Distribution of Most-At-Risk Population Groups and Their Perceptions

DISTRIBUTION OF MOST-AT-RISK POPULATION GROUPS AND THEIR PERCEPTIONS TOWARDS HIV/AIDS: A BASELINE SURVEY IN AMHARA REGION FOR THE IMPLEMENTATION OF MOBILE HIV COUNSELING AND TESTING

February 2009

This publication was produced for review by the United States Agency for International Development. It was prepared by Amare Deribew for the Private Sector Program-Ethiopia.

Recommended Citation: Deribew, Amare. February 2009. Distribution o Most-at-risk Population Groups and Their Perceptions Towards HIV/AIDS: A Baseline Survey in Amhara Region for the Implementation of Mobile HIV Counseling and Testing. Bethesda, MD: Private Sector Program-Ethiopia, Abt Associates Inc.

Contract/Project No.: GPO-I-00-04-00007-00 TO # 807

Submitted to: Bradley Corner, CTO Office of Health, Population, and Nutrition United States Agency for International Development/Ethiopia Addis Ababa, Ethiopia

Abt Associates Inc. 4550 Montgomery Avenue, Suite 800 North Bethesda, Maryland 20814 Tel: 301.347.5000. Fax: 301.913.9061 www.PSP-One.com www.abtassociates.com

In collaboration with: Banyan Global IntraHealth International Population Services International

DISTRIBUTION OF MOST-AT-RISK POPULATION GROUPS AND THEIR PERCEPTIONS TOWARDS HIV/AIDS: A BASELINE SURVEY IN AMHARA REGION FOR THE IMPLEMENTATION OF MOBILE HIV COUNSELING AND TESTING

DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government

CONTENTS

Acronyms...... v

Definition of Terms...... vii

Acknowledgments...... ix

Executive Summary...... xi

1. Introduction...... 1 1.1 Background...... 1 1.2 Objectives of the assessment ...... 1 1.3 Methodology...... 2 1.3.1 Study areas ...... 2 1.3.2 Study Design ...... 2 1.3.3 Data Collection, Data Management, and Analysis ...... 3 1.3.4 Ethical considerations ...... 3 1.3.5 Limitations ...... 3 2. Results ...... 5 2.1 Debretabor ...... 5 2.1.1 Most-At-Risk Populations ...... 5 2.1.2 Health Services...... 8 2.1.3 Organizations Providing HIV/AIDS Services ...... 8 2.1.4 Counseling and Testing Services...... 9 2.2 Dangila...... 9 2.2.1 Most-At-Risk Populations ...... 9 2.2.2 Health Services...... 11 2.2.3 Organizations Providing HIV/AIDS Services ...... 12 2.2.4 Counseling and Testing Services...... 12 2.3 Engibara...... 12 2.3.1 Most-At-Risk Populations ...... 12 2.3.2 Health Services...... 14 2.3.3 Organizations Providing HIV/AIDS Services ...... 15 2.3.4 Counseling and Testing Services...... 15 2.4 Fenote-Selam ...... 15 2.4.1 Most-At-Risk Populations ...... 15 2.4.2 Health Services...... 17 2.4.3 Organizations Providing HIV/AIDS Services ...... 18 2.4.4 Counseling and Testing Services...... 18

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3. Discussion and Conclusions...... 19

4. Recommendations ...... 21

References...... 23

LIST OF TABLES

Table 1: Description of the four study towns in Amhara National Regional State...... 2 Table 2: Size of target populations in Debretabor ...... 5 Table 3: Locations in Debretabor where female sex workers operate...... 6 Table 4: Information on trucks and long-distance buses passing through Debretabor...... 6 Table 5: Distribution of in-school adolescents and youths in Debretabor...... 7 Table 6: Availability of health services in Debretabor ...... 8 Table 7. Non-governmental and community-based organizations providing HIV/AIDS care and support activities in Debretabor .8 Table 8: Size of target populations in Dangila...... 9 Table 9: Locations in Dangila where female sex workers operate...10 Table 10: Information on trucks and long-distance buses passing through Dangila...... 10 Table 11: Distribution of in-school adolescents and youths in Dangila...... 11 Table 12: Availability of health services in Dangila ...... 11 Table 13: Non-governmental and community-based organizations providing HIV/AIDS care and support activities In Dangila...... 12 Table 14: Size of target populations in Engibara...... 13 Table 15: Locations in Engibara where female sex workers operate...... 13 Table 16: Information on trucks and long-distance buses passing through Enjibara...... 13 Table 17: Distribution of in-school adolescents and youths in Engibara...... 14 Table 18: Availability of health services in Engibara ...... 15 Table 19: Size of target populations in Fenote-Selam...... 15 Table 20: Locations in Fenote-Selam where female sex workers operate...... 16 Table 21: Information on trucks and long-distance buses passing through Fenote-Selam...... 17 Table 22: Distribution of in-school adolescents and youths in Fenote-Selam...... 17 Table 23: Availability of health services in Fenote-Selam...... 18 Table 24: Non-governmental and community-based organizations providing HIV/AIDS care and support activities in Fenote-Selam...... 18

ACRONYMS

AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral therapy BCC Behavior change communication BSS HIV/AIDS Behavioural Surveillance Survey CBO Community-based organization FGD Focus group discussion FSW Female sex worker HAPCO HIV/AIDS prevention and control offices HBC Home-based care HCT HIV counseling and testing HIV Human Immunodeficiency Virus IEC Information, education, and communication IGA Income-generating activities MARP Most-at-risk populations NGO Non-governmental organization OI Opportunistic infection PLWHA People living with HIV/AIDS PMTCT Prevention of mother-to-child transmission RHB Regional Health Bureau STI Sexually transmitted infection TB Tuberculosis USAID United States Agency for International Development WoHO Woreda heath offices

DEFINITION OF TERMS

Areki: Strong alcohol (about 75 percent) made by a local distillation system

Consistent condom use: Utilization of a condom during every sexual encounter

Cross-generational sex: When a woman age 15 to 24 has non-marital intercourse with a man who is 10 years older than her or greater

Female sex workers (FSWs): A female who sells sex for money or goods

Iddir: A community-based organization established by people who live in the same community with the primary aim of helping members to cope with the loss of family members. Also referred to as funeral insurance, iddirs provide physical, emotional, and financial support during the burial ceremony. Elders who have the respect of the community usually lead iddirs.

Kebele: The smallest unit of local government in Ethiopia (urban and rural), equivalent to a neighborhood association. Kebeles are accountable to the woreda (district), subcity, or city administrations.

Kimit: A woman who serves as a sexual partner for a man who usually has a legal wife

Medea: Houses where FSWs work and local brews, khat (leaves chewed as a stimulant), and shisha (tobacco or other substances smoked through a water pipe) are served

Region: Ethiopia is divided into nine ethnically based regional states and two federal city administrations (Addis Ababa and Dire Dawa), each with its own government directly accountable to the federal government

Risky sex: Unprotected sex (without a condom) with a non-regular partner

Shisha: A mixture of ingredients that is smoked though a water-filled pipe

Substances: For the purposes of this study, stimulants other than alcohol. These include khat (Catha edulis), shisha, and hashish (marijuana).

Transactional sex: The exchange of sex for money or goods

Tella: Locally brewed beer with an alcohol content of 5 to 10 percent

Town: Often the capital of a woreda administration, it has its own local government

Woreda: An administrative division of a zone managed by a local government, equivalent to a district. Woredas are important political and administrative units with legal recognition and authority, including the delivery of services such as education and health, budget allocation, and management.

Zone: A subdivision of a region with varying political and legal recognition as well as authority. A zone is divided into woredas.

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ACKNOWLEDGMENTS

Thank you to the regional, zonal, and woreda health offices and HIV/AIDS prevention and control offices; health institutions; and non-governmental and community-based organizations that provided information essential to this report. My deepest gratitude goes to the informants, focus group participants, and interview subjects for their willingness to help. My sincere thanks goes to the staff of PSP-Ethiopia, especially Kathleen Poer, Wasihun Andualem, Abenet Leykun, Faris Hussen, Sileshi Kassa, Saba Amdemariam, Michael Biru, and Abinet Tekabe, for its support designing the instrument and organizing the data-collection process. Also thank you to Ato Tsegaye G/Medhin for arranging comfortable transportation on quick notice.

In addition, the authors wish to thank Parsa Sanjana for her technical review of the assessment report, and Zach Everson and Ricky Merino for editing, formatting, and finalizing the document. Finally, the author thanks the United States Agency for International Development for its support of PSP-E in general, and, in particular, of this assessment.

EXECUTIVE SUMMARY

The Private Sector Program-Ethiopia (PSP-Ethiopia) conducted this HIV counseling and testing (HCT) assessment in collaboration with Amhara Regional Health Bureau in four towns in the Amhara National Regional State to inform the design of mobile HCT services. PSP-Ethiopia, led by Abt Associates Inc. and funded by the United States Agency for International Development, is the leader in implementing and expanding access to HCT through mobile services in Ethiopia.

Amhara is the second most populous region in Ethiopia. Amhara has a high rate of HIV/AIDS infection with an adult HIV prevalence of 2.7 percent (male 2.2 percent and females 3.3) in 2008. The urban HIV/AIDS prevalence of the region is 9.9 percent (males 7.9 percent and females 11.9), which is among the highest in the nation.1 This statistic indicates that joint efforts are essential to stop the transmission of HIV/AIDS. Among others strategies, HCT and condom-promotion services must be accessible to the most-at-risk population (MARPs).

This assessment aims to identify the magnitude and concentration of MARPs in these towns and develop recommendations to design mobile HCT services targeting them. The assessment was conducted in four towns located in West Gojjam, Awi, and South Gondar zones of Amhara National Regional State. Fenote-Selam, Enjibara, and Dangila are situated along the Addis Ababa-to-Metema route. The fourth town, Debre-Tabor, is located along the Woreta-to-Woldya route.

The assessment used quantitative and qualitative methods. Interviews and service mapping were conducted in each town. The information solicited from the different sources was triangulated to learn about the knowledge and attitude of the MARPs about HIV preventive methods, especially HCT and use of condoms.

This findings indicate that the studied towns host a large number of government employees, migrant workers, female sex workers (FSWs), and secondary and college students as well as transient populations that temporarily reside in the towns (such as truckers and their assistants, migrant workers, and businessmen).

Transactional and cross-generational sexual practices are common in all study towns. According to informants, secondary school and college girls establish sexual networks with older men in return for money and gifts. Consistent condom use is low among FSWs operating in local brew-selling houses, adolescents, and youths in almost all towns. Use of substances like alcohol, khat, and shisha is high among in- and out-of school youth. There are widespread wrong beliefs and misconceptions that adversely affect the use of condoms.

In all study towns, there is at least one public health facility with comprehensive HIV/AIDS care and treatment services. The informants, however, noted target groups’ low utilization of services like HCT and sexually transmitted infection treatment for fear of stigma and discrimination that originates from the perceived lack of confidentiality and privacy. All respondents and target groups strongly believe that mobile HCT creates access to HCT for the MARPs.

1. INTRODUCTION

1.1 BACKGROUND

The national adult HIV prevalence in Ethiopia in 2008 is 2.2 percent (1.8 percent for males and 2.6 for females). There is an estimated 1.3 million people living with HIV/AIDS (PLWHA), including 68,136 children under 15 years old.1 The highest rate of infection is registered among the 15-to-24 age groups with 58 percent of the new infections occurring among women.2

Demographic, occupational, behavioral, and social factors place people at various risks for contracting HIV.3 Certain population segments are at higher risks of contracting HIV because of their sex, mobility, economic and social vulnerabilities. The frequently cited most-at-risk population (MARP) groups in Ethiopia include female sex workers (FSWs), youths (people 14 to 24 years old), truck drivers, uniformed men, migrant workers, and day laborers.3,4,5

Amhara National Regional State is the second most populous region in Ethiopia. Amhara has a high rate of HIV/AIDS infection with an adult HIV prevalence of 2.7 percent (males 2.2 percent and females 3.3) in 2008.1 The Amhara Region has large number of most-at-risk populations (MARPs), such as truckers, migrant day laborers, and female sex workers (FSWs). The region hosts large numbers of sexually active youths, men, and women. Unemployment among youths is high, causing frustration, shortsightedness, and alcohol and khat abuses.3,4,5 There also are widespread traditional practices that disproportionately increase the risk of HIV among girls, for instance early marriage. The widespread concurrent sex among better-off married men and economically disadvantaged young women (referred to as kimit and wushima) fuel HIV transmission in urban areas of Amhara region.3,4,5

Cognizant of those facts, the Private Sector Program-Ethiopia (PSP-Ethiopia) in collaboration with Amhara Regional Health Bureau (RHB) conducted this assessment in four towns in Amhara Region to inform the design of mobile HCT services. The aim of the assessment is to identify the magnitude and concentration of MARPs in these towns and develop recommendations to design mobile HCT services targeting MARPs.

This assessment’s findings are summarized to develop recommendations to design more accessible and accepted HCT services targeting MARPs. The data from this assessment will enable PSP-Ethiopia to identify target groups for mobile HCT services, organizations to support mobile services, times and locations for services, and partners for social mobilization and referral linkages.

1.2 OBJECTIVES OF THE ASSESSMENT

The overall objective of this assessment is to collect and analyze data to develop recommendations to design effective mobile HCT services targeting MARPs in the study towns.

The study’s specific objectives are to

• identify the MARPs in the study sites in Amhara regional state and determine their distribution, estimate the density of target populations, and pinpoint specific localities where these target population subgroups reside

• identify and document the health facilities and organizations providing HIV/AIDS services in each town, including facility-based services as well as community care and support services, to establish a referral network for mobile HCT follow-up

• identify the behaviors of MARPs, particularly HIV risk behaviors and HCT service utilization

• collect information to design and plan mobile HCT services for each town, including the acceptability of services to target population and local stakeholders, recommended hours and locations, and potential partners to assist with implementation

1.3 METHODOLOGY

1.3.1 STUDY AREAS

The study was conducted in four towns located in West Gojjam, Awi, and South Gondar zones of Amhara National Regional State. Three of four towns (Fenote-Selam, Enjibara, and Dangila) are along the Addis Abada-to-Metema route. The fourth town, Debre-Tabor, is located along the Woreta-to- Woldya route.

The study sites are home to large numbers of government employees, migrant workers, FSWs, and secondary and college students as well as transient populations that temporarily reside in these towns (truckers and their assistants, migrant workers, and businessmen).

All of study sites are marketplaces for the surrounding rural communities. The rural men and women frequently visit these towns to sell their agricultural products and buy commodities for their household’s consumption. The study towns have several hotels, bars, and local brew-selling houses (areki and tella bets) where FSWs operate.

TABLE 1: DESCRIPTION OF THE FOUR STUDY TOWNS IN AMHARA NATIONAL REGIONAL STATE

Town’s name Name of route Zone Distance from Addis Ababa (km) Finote Selam Addis Ababa-to- Metema West Gojam 374 Engibara Addis Ababa-to- Metema Awi 452 Dangila Addis Ababa-to- Metema Awi 480 Debretabor Woreta-to-Woldiya South Gondar 660

1.3.2 STUDY DESIGN

The study used a cross-sectional design using qualitative and quantitative methods, including interviews and institutional mapping. Interviews were conducted with representatives from woreda health offices (WoHO), HIV/AIDS prevention and control offices (HAPCOs), non-governmental organizations (NGOs), community-based organizations (CBOs), and faith-based organizations in each town. Other informants in the study included FSWs, in-school youths, migrant workers, and day laborers.

1.3.3 DATA COLLECTION, DATA MANAGEMENT, AND ANALYSIS

In this study, data was obtained from informants via pre-tested semi-structured questionnaires and focus group discussion (FGDs). The questionnaires and FGD guides included questions about the status of HIV/AIDS in the community, factors that contribute to the spread of HIV/AIDS, identification of the MARPs for HIV, condom use, availability of HIV/AIDS services (including HCT), and recommendations to improve the services

Three FGDs were held in Debretabor with youths, adult women, and day laborers. In addition, 20 informants were interviewed from the WoHO and woreda HAPCO, NGOs, CBOs, and people living with HIV/AIDS (PLWHA) associations in the four towns. 10 in-depth interviews were conducted with FSWs.

An interview guide was used to map the available HIV/AIDS services in the towns. This guide facilitated the collection of the number of MARPs in the town by subgroup and the availability of health services in the area.

Trained data collectors with a second degree in public health collected the data under the supervision of a consultant and PSP-Ethiopia staff. The data collectors transcribed the qualitative information immediately after the interviews. The principal investigator reviewed this transcribed data and, if needed, followed up promptly with the data collectors for clarification. The final transcription was used to identify and develop categories and themes for data analysis. Finally, the data were interpreted and presented by using respondents’ own words as illustrations. The quantitative data were analyzed using Microsoft Excel and are presented as tables throughout this report.

1.3.4 ETHICAL CONSIDERATIONS

Prior to data collection, PSP-Ethiopia and the Amhara Regional Health Bureau (RHB) jointly agreed to conduct mobile HCT in the selected towns. RHB and PSP-Ethiopia wrote letters asking for support to the study towns before the assessment.

The data collectors explained the objective of the assessment and obtained verbal consent from participants before proceeding with the interviews.

1.3.5 LIMITATIONS

Incomplete data regarding out–of-school youth and uniformed men reduced the comprehensiveness of this assessment. The FGD and in-depth interviews did not include truckers and informal traders, both important MARP groups. Therefore, the behaviors of these groups could not be assessed in detail.

2. RESULTS

This assessment was conducted in Fenote-Selam, Enjibara, Dangla, and Debretabor. The detailed assessment findings for each town are discussed in the following sections.

2.1 DEBRETABOR

Debretabor, located along the Woreta-to-Woldiya route 660 kilometers from Addis Ababa, has a population of 38,932 people (20,037 males and 18,895 females). Debretabor is a site for South Gondar zone administration and, therefore, hosts government offices with a large number of employees. HIV/AIDS, tuberculosis (TB), malaria, pneumonia, trachoma, and kal-azar are the major health problems.

2.1.1 MOST-AT-RISK POPULATIONS

There are a number of at-risk populations in the town, including FSWs, in and out-ofschool youth, migrant day laborers, and truck drivers. Cross-generational and transactional sex are common. There is widespread tradition of concurrent sex between married men and married, single, or widowed women known as “wushima.” The other common form of concurrent sex is called “kimit” in which economically better-off men establish long-term hidden affairs with young women to whom they provide all economic support. The town also hosts more than 1,600 FSWs who operate in hotels, bars, and local brew-selling houses.

TABLE 2: SIZE OF TARGET POPULATIONS IN DEBRETABOR

Target population Estimated number College students (private and public) 464 Construction workers 1,275 FSWs 1,632 Informal traders and market sellers (such as suq bederete, lottery 1,430 azuari, and unregistered street traders) In-school youths (excluding college students) 16,539 Migrant day laborers 2,736 Out-of-school youths Data not available Truck drivers 75 Uniformed government workers (such as customs officers, police, Data not available soldiers, and immigration agents)

Female Sex Workers

The woreda HAPCO officials estimated that 1,632 FSWs operate in hotels, bars, and areki bets in kebele 02, 03, and 04. According to informants, there are three types of FSWs in the town based on where they work and how they meet with their clients: hotel- and bar-based FSWs (formal FSWs), informal FSWs who work in areki and tella bets (covertly), and students who work through brokers or pick up clients on the street at night. For instance, men who have money, truck drivers, and government employees are the main clients for the hotel-based FSWs. Low-paid workers (such as migrant day laborers) and students are the main clients for FSWs in local brew-selling houses. Students target transient men, such as truckers and their assistants and local businessmen.

According to FSWs, condom use among informal sex workers is low due to their lower awareness about the benefits and the unwillingness of their clients, primarily migrant workers, to use them. Some men offer to pay more for sex without a condom (100 to 150 birr compared to 40 birr with a condom). The frequently cited reasons for inconsistent use of condoms were alcohol and khat use and the misconception that condoms are infected with HIV.

Most FSWs claimed that they have been tested for HIV at least once. The women have to travel more than 50 kilometers to Gondar and Bahir Dar, however, for HCT. These FSWs were scared to get tested in their local health facilities because they were afraid of their clients seeing them and also feared a lack of confidentiality at the facility. All interviewed FSWs appreciate the idea of mobile HCT and suggested locating the services at Tewodros Square or Kebeles Hall in the morning (10 to 11 a.m.) and afternoon (1 to 4 p.m.).

TABLE 3: LOCATIONS IN DEBRETABOR WHERE FEMALE SEX WORKERS OPERATE

Category Name and location Hotels and bars • Sodere Bar, 02 Kebele • Frick Bar, 02 Kebele • Eyerusalem Bar, 03 Kebele • Nice Bar, 04 Kebele Streets • Nega Biru Sefer, 02 Kebele • Akilay Sefer, Kebele 04 • Kebele 03 Areki, tella, and tej bets • Kebele 02, 03, and 04

Informal Traders and Market Sellers

An estimated 1,430 informal traders in Debretabor operate mainly in Segno Gebeya, Tewodros Adebabay, and Millenium Sefer. Most of petty traders are adolescents who peddle small items in the town’s main street, Suk Bederetie). Many of these adolescents, especially girls, have their sexual debut at 13 to 14 years old. Most of these economically disadvantaged girls get paid for sex, often by migrant day laborers, to supplement their income. Some older informal traders establish longer-term concurrent sexual relationships with married men and local businessmen. Condom use in these relationships is low because of the emotional ties with men partners and the association of condom use with commercial sex work.

Truckers and Intercity Bus Drivers

On average, 75 truck and intercity buses entering and leave Debretabor each day. Approximately 40 park overnight at Tewodros Adebabay, Millenium Sefer, and the bus station. Truck drivers usually meet FSWs in hotels and bars located in Kebele 02 and 03. According to FSWs, consistent condom use among truckers is common.

TABLE 4: INFORMATION ON TRUCKS AND LONG-DISTANCE BUSES PASSING THROUGH DEBRETABOR

Selected information Details Times • Morning (19) • Mid-day (37) • Night (19) • Staying overnight (40) Overnight parking locations • Tewdros Adebabay • Around the bus station • Millenium Sefer

Selected information Details Bars, clubs, and inns visited • Sodere Bar, 02 Kebele • Frick Bar, 02 Kebele • Eyerusalem Bar, 03 Kebele • Nice Bar, 04 Kebele • Areki Bet, Nega Biru Sefer • Areki Bet, 03 Kebele • Areki Ber, Akilay Sefer Truck and bus companies • Tikur Abay • Construction cars (Saba, Sure, and Satcon)

Adolescents and Youths

Most of youths who participated in FGDs perceived themselves as part of an at-risk population group because of the lack of job opportunities, khat and alcohol abuse, and low use of condom. As FGD participants noted, most youth spend their time in areki and tella houses. A 40-year-old divorced women said, “Nowadays, there are so many areki, tella, and khat houses where many youth spend most of their time where they initiate unsafe sex practices. Something has to be done to solve this crisis.”

Respondents noted that adolescents start having sex as early as 12 or 13 years old for girls and 15 years for boys, first with their peers. Girls also have sexual relations with older men in return for money and gifts, especially with drivers and government employees. Condom use among adolescents is low, explained by trust in boyfriends and the belief that condoms are infected with HIV. Most of the respondents noted the presence of high demand for HCT among youths and adolescents.

TABLE 5: DISTRIBUTION OF IN-SCHOOL ADOLESCENTS AND YOUTHS IN DEBRETABOR

Number of schools by type Student enrollment School level Private Public NGO Private Public NGO Total Primary (grades 18) 3 7 0 521 10,242 0 10,763 Secondary (grades 910) 0 2 0 0 5,776 0 5,776 Tertiary (college and 0 1 0 0 464 0 464 higher) Total 3 10 0 521 16,482 0 17,003

Day Laborers and Construction Workers

An estimated 2,736 migrant day laborers and 1,275 construction workers reside in Debretabor. These day laborers and construction workers spend their leisure time drinking heavy local brews, especially areki. Most areki houses are located in Kebele 02 and 03. Consistent use of condom among these groups is low. Of the FGDs participants, only a few claimed that they ever had been tested for HIV. Many FGD participants have an interest in knowing their HIV status though. A 20- year-old day laborer said, “I never had voluntary counseling and testing since I did not perceived myself as at risk of contracting HIV. From discussion we had now, I understand that everybody is at high risk of having HIV and I will be tested soon.” Most day laborers welcomed the idea of mobile HCT services, and considering the nature of their work, suggested having mobile HCT on the weekends at the marketplace.

2.1.2 HEALTH SERVICES

According to the WoHO and HAPCO, HIV/AIDS, TB, malaria, pneumonia, trachoma, and kal-azar are among the major public health problems in Debretabor.

There are two public health facilities, a health center and hospital, with comprehensive HIV care and treatment services. These two public health facilities provide a wide range of HIV and sexually transmitted infection (STI) services, such as information education and communication (IEC); HCT; antiretroviral therapy (ART); opportunistic infection (OI) treatment; STI treatment, TB diagnosis and treatment; and condom distribution.

Because of the cost for treatment and the perceived lack of confidentiality, most STI patients seek treatment from traditional healers rather than health facilities, according to informants.

TABLE 6: AVAILABILITY OF HEALTH SERVICES IN DEBRETABOR

Services provided Name of facility Type HCT TB TB ART PMTCT STIs OIs of diagnosis treatment facility Debretabor Zonal Public √ √ √ √ √ √ √ Hospital Debretabor Health Public √ √ √ √ √ √ √ Center St. Merry Medium Private √ √ Clinic Felegehiwot Lower Private √ √ Clinic

2.1.3 ORGANIZATIONS PROVIDING HIV/AIDS SERVICES

Two local and one international NGO provide HIV/AIDS care and support activities. These NGOs primarily focus on awareness creation and behavior change communication (BCC). They provide community and home-based care and supports to PLWHA and their families.

TABLE 7. NON-GOVERNMENTAL AND COMMUNITY-BASED ORGANIZATIONS PROVIDING HIV/AIDS CARE AND SUPPORT ACTIVITIES IN DEBRETABOR

HIV/AIDS-related services provided Name of BCC HCT PMTCT ART OI STI Income- Nutrition HBC OVC Target organization generating groups activities Community √ General Volunteers population for the World and PLWHA Ethiopian √ √ √ √ PLWHA Orthodox and their Churches families Hiwot Chora √ √ √ PLWHA PLWHA and their Association families

2.1.4 COUNSELING AND TESTING SERVICES

As informants noted, educated people and government employees travel as far as Gondar and Bahir Dar for HIV testing. There seems to be low use of public facility-based HCT services by at-risk populations. This conclusion is supported by the HAPCO official who said, “Last year the woreda HAPCO conducted two rounds of mobile counseling and testing campaigns. Many [of] the surrounding rural communities were happy and utilized the service; however, most government employees in Debretabor did not show up for the services.” Fear of stigma was the most frequently cited reasons for low use of HCT services by educated and government employees.

Informants and interviewed target groups welcomed the idea of mobile HCT. Most of them felt that mobile HCT would create access to HCT services for different population segments if they are provided with confidentiality to avoid stigmatization for those who decide to get tested. Weekend service was suggested to reach different target groups. Informants suggested places like Tewodros Adebaby or Meskel square for mobile HCT services. FSWs preferred mobile HCT to be held at Kebele hall in the morning (from 10 to 11 a.m.) or early afternoon from (1 to 4 p.m.).

2.2 DANGILA

Dangila is in the West Gojjam zone, 480 kilometers northwest of Addis Ababa along the Addis Ababa-to-Metema route. The town has a population of 49,312 people (24,567 males and 24,745 females). The town has a high school, college, public health center, and private clinic. The common public health problems include HIV/AIDS, TB, and waterborne diseases.

2.2.1 MOST-AT-RISK POPULATIONS

Dangila is the hometown for different population segments that have increased risk of HIV, including FSWs, day laborers, truck drivers, and uniformed men. There are large numbers of informal FSWs who operate in local brewhouses. Uniformed men are concentrated at a military camp 10 kilometers from town. Transactional and cross-generational sex is common. Students and out-of-school girls have sexual networks with uniformed men. Married men and local businessmen commonly establish long-term concurrent relationships with women in town. The presence of this large pool of MARPs and multiple sexual networking contributes to HIV transmission in Dangila.

TABLE 8: SIZE OF TARGET POPULATIONS IN DANGILA

Target population Estimated number College students (private and public) 1,374 FSWs 2,104 Informal traders and market sellers (such as suq bederete, lottery 400 azuari, and unregistered street traders) In-school youths (excluding college students) 15,401 Migrant day laborers 200 Out-of-school youths Data not available Truck drivers 85 Uniformed government workers (such as customs officers, police, Data not available soldiers, and immigration agents)

Female Sex Workers

Approximately 2,104 FSWs operate in hotels, bars, and local brew-selling houses. FSWs were concentrated in Kebele 01, 03, and 05. Most FSWs operate in small areki and tella houses. The clients for FSWs include uniformed men, day laborers, and students. Most of the hotels and bars are

concentrated along the main road in Kebele 05. Condom use by FSWs operating in hotel and bars is said to be high compared with FSWs working in local brew-selling houses. Condom use among some FSWs is believed to be low because of the widespread misconceptions that the widely circulated condom brand (Hiwot Trust) is of low quality in preventing HIV transmission.

TABLE 9: LOCATIONS IN DANGILA WHERE FEMALE SEX WORKERS OPERATE Category Name and location Hotels and bars • Special Bar, 05 Kebele • Chachi Bar and Nightclub, 05 Kebele • Abugida Bar and Nightclub, 05 Kebele • Seraye Bar and Nightclub, 05 Kebele Streets • 01 Kebele • 03 Kebele • 04 Kebele • 05 Kebele Areki, tella, and tej bets • Dangla Areki bet • Taitu Areki bet • Birhan Areki bet • Other areki bet around Kebele 01, 03, and 04

Informal Traders and Market Sellers

The town hosts approximately 400 informal traders who operate in an open market along the main road in Kebele 03, 04, and 05. The informal traders are engaged in selling small items like candy. According to informants, uniformed men have sexual networks with informal traders.

Truckers and Intercity Bus Drivers

An estimated 85 truck and intercity buses enter and leave Dangila daily. Many truckers park for the night at Kebele 05. Truckers and their assistants frequent hotels, bars, and nightclubs where they meet with FSWs.

TABLE 10: INFORMATION ON TRUCKS AND LONG-DISTANCE BUSES PASSING THROUGH DANGILA

Selected information Details Times • Morning (9) • Mid-day (9) • Night (24) • Staying overnight (42) Overnight parking locations • Special Bar, 05 Kebele Main Road • Chachi Bar and Nightclub, 05 Kebele Main Road • Abugida Bar and Nightclub, 05 Kebele Main Road • Nice Bar and Nightclub, 05 Kebele Main Road • Seraye Bar and Nightclub, 05 Kebele Main Road • Hahu Hotel, 05 Kebele Main Road • Adugna Hotel, 05 Kebele Main Road Bars, clubs, and inns visited • Special Bar, 05 Kebele • Chachi Bar and Nightclub, 05 Kebele • Nice Bar and Nightclub, 05 Kebele • Abugida Bar and Nightclub, 05 Kebele Truck and bus companies • Tikur Abay Transportation • Salini Construction Company • Tana Transportation

Adolescents and Youths

More than 16,000 in-school youths live in Dangila. Adolescent girls begin having sex as early as 14 to 15 years old, according to informants. Students and out-of-school youth have sexual network with uniformed men. Condom use among youths is said to be low because of their safe sex negotiation skills and the belief that buying a condom is embarrassing.

TABLE 11: DISTRIBUTION OF IN-SCHOOL ADOLESCENTS AND YOUTHS IN DANGILA

Number of schools by type Student enrollment School level Private Public NGO Private Public NGO Total Primary (grades 18) 0 10 0 0 9,343 0 9,343 Secondary (grades 910) 0 1 0 0 6,058 0 6058 Tertiary (college and 0 1 0 0 1,374 0 1,374 higher) Total 0 12 0 0 16,775 0 16,775

Migrant Day Laborers

An estimated 200 migrant day laborers work in Dangila, concentrated in Kebele 03. Day laborers often visit local brew-selling houses situated in Kebele 05 where they meet with FSWs.

2.2.2 HEALTH SERVICES

Dangila has one public health center and two private medium clinics. The public health center has comprehensive HIV/AIDS-related services including BCC, HCT, ART, OI, TB, and STI treatment. It also distributes free condoms. The two private medium clinics provide TB diagnosis and STI treatment services.

According to WoHO officials, there is a wait to receive STI treatment at health facilities. As a result, STI patients show up at public health facilities at the late stages of their diseases. An informant further noted those people who can afford to often seek STI treatment in private clinics or travel to other town (like Bahir Dar) for it.

TABLE 12: AVAILABILITY OF HEALTH SERVICES IN DANGILA

Services provided Name of facility Type HCT TB TB ART PMTCT STIs OIs of diagnosis treatment facility Dangla Health Public √ √ √ √ √ √ √ Center Dangila Medium Private √ √ Clinic St. Mary Medium Private √ √ Clinic Medhanyalem Drug Private N/A N/A N/A N/A N/A N/A N/A Store Nahom Drug Vendor Private N/A N/A N/A N/A N/A N/A N/A St. Mary Drug Store Private N/A N/A N/A N/A N/A N/A N/A

2.2.3 ORGANIZATIONS PROVIDING HIV/AIDS SERVICES

There are few NGOs providing HIV/AIDS services in Dangila, as indicated in Table 13.

TABLE 13: NON-GOVERNMENTAL AND COMMUNITY-BASED ORGANIZATIONS PROVIDING HIV/AIDS CARE AND SUPPORT ACTIVITIES IN DANGILA

HIV/AIDS-related services provided Name of BCC HCT PMTCT ART OI STI Income- Nutrition HBC OVC Target organization generating groups activities Ethiopian √ √ √ Orthodox Church Management √ √ General Sciences for population, Health PLWHA and their families PLWHA √ √ association

2.2.4 COUNSELING AND TESTING SERVICES

Fear of stigma and discrimination is among the frequently cited reasons for low utilization of existing HCT at public health facilities, according to respondents. Most informants noted that the town’s better educated and government employees travel to bigger towns like Bahir Dar and Gondar to get HIV testing. All of respondents acknowledge the high potential for mobile HCT services to reach the target population if—and only if—people become confident about their confidentiality and privacy. They also suggested using weekends and market days to access special target groups, such as day laborers, students, and government employees.

2.3 ENGIBARA

Engibara, the site of Awi zone administration, is 459 kilometers northwest of Addis Ababa along the Addis-to-Metema route. Engibara has a population of 25,729 people (12,474 males and 13,255 females). It has one health center with comprehensive HIV care and treatment services. The most frequently observed public health problems include malaria, TB, HIV/AIDS, and typhoid.

2.3.1 MOST-AT-RISK POPULATIONS

FSWs, students, construction workers, and truck drivers are among the MARP groups identified in Engibara. Transactional and cross-generational sex is common as is a high level of alcohol use. Respondents attribute unplanned and unprotected casual sex among youths to pornographic films shown in illicit video houses. The widespread misconception that condoms are infected with HIV adversely affects their use.

TABLE 14: SIZE OF TARGET POPULATIONS IN ENGIBARA

Target population Estimated number College students (private and public) 1,646 Construction workers 315 FSWs 550 Informal traders and market sellers (such as suq bederete, lottery 85 azuari, and unregistered street traders) In-school youths (excluding college students) 8,964 Migrant day laborers 250 Out-of-school youths Data not available Truck drivers 55 Uniformed government workers (such as customs officers, police, Data not available soldiers, and immigration agents)

Female Sex Workers

An estimated 550 FSWs (400 permanent and 150 transient) operate in hotels, bars, and local brew- selling houses in Katanga Sefer, the Menaharia area, and in hotels and bars along the main road. Truckers, students, and migrant workers meet the FSWs at hotels and bars and areki bets. Inconsistent condom use is said to be more common with FSWs operating in local brew-selling houses than among hotel- and bar-based FSWs. The demand for mobile HCT is high among FSWs.

TABLE 15: LOCATIONS IN ENGIBARA WHERE FEMALE SEX WORKERS OPERATE

Category Name and location Hotels and bars • Bar Beza, around Katanga Sefer • Walia Hotel, around Katanga Sefer • Tebota Hotel, around Katanga Sefer Streets • Katanga Sefer • Menahria Sefer Areki, tella, and tej bets • Along the main road

Informal Traders and Market Sellers

Generally 85 petty traders operate in open markets in Kosober Sefer and Chagni Mewcha along the main road. Most of these traders are adolescents and young girls who engage in sex with older men to supplement their meager income.

Truckers and Intercity Bus Drivers

An estimated 55 trucks enter and leave Engibara daily. Most trucks that stay overnight park at Waliya and Agew Midir hotels in Katanga Sefer. These truckers usually meet FSWs in Menaharia and Katanga Sefer. It was reported that truckers commonly use condoms while having sex with FSWs.

TABLE 16: INFORMATION ON TRUCKS AND LONG-DISTANCE BUSES PASSING THROUGH ENJIBARA

Selected information Details Times • Morning (10) • Mid-day (35) • Night (10) • Staying overnight (20) Overnight parking locations • Around Walia Hotel • Around Agew Mider Hotel

Selected information Details • Tebota Hotel Bars, clubs, and inns visited • Bar Beza, around Katarya Sefer • Tebota Hotel, around Katarya Sefer • Agew Mider Hotel, around Katarya Sefer • Walia Hotel, around Katarya Sefer Truck and bus companies • Tana Transportation • Tikur Abay Transportation • China Wanbo Transportation • Salini Transportation • Mesfin Engineering Transportation • Kaju Transportation

Adolescents and Youths

The widespread pornographic video films shown in illicit video houses were mentioned as a reason for early sexual initiation among urban adolescents and youths. Condom use among in-school youths is high compared with out-of-school youths because of the better information available to in-school youth. Prevailing widespread misconceptions, however, negatively affect condom use in general. As WoHO representatives said, “Most people in town believe that condom lubricants contain the HIV virus.” The demand for HCT among adolescents and youths is high.

TABLE 17: DISTRIBUTION OF IN-SCHOOL ADOLESCENTS AND YOUTHS IN ENGIBARA

Number of schools by type Student enrollment School level Private Public NGO Private Public NGO Total Primary (grades 18) 3 5 0 209 6,390 0 6,599 Secondary (grades 910) 0 1 0 0 2,365 0 2,365 Tertiary (college and 2 2 0 183 1,463 0 1,646 higher) Total 5 8 0 392 10,218 0 10,610

Migrant Day Laborers and Construction Workers

About 250 day laborers and 315 construction workers are in Engibara. The number of construction workers increases from time to time because of the construction of condominiums. Many of the day laborers and construction workers are found in Katanga Sefer where there are a lot of local brew- selling houses in which they meet with FSWs.

2.3.2 HEALTH SERVICES

Engibara has one public health center that provides comprehensive HIV/AIDS care and treatment services, such as HCT, ART, TB treatment and diagnosis, STI treatment, prevention of mother-to- child transmission (PMTCT), and free condom distribution. There are three drug vendors in the town. Because of the stigma associated with STIs, many patients seek treatment at a late stage from the public health center. Those people who go to health facilities often hide their symptoms until they develop confidence about providers, which make the diagnosis difficult according to informants.

TABLE 18: AVAILABILITY OF HEALTH SERVICES IN ENGIBARA

Name of facility Type Services provided of HCT TB TB ART PMTCT STIs OIs facility diagnosis treatment Injibara Health Public √ √ √ √ √ √ √ Center Koso Ber Drug Private N/A N/A N/A N/A N/A N/A N/A Vendor Tsion Drug Vendor Private N/A N/A N/A N/A N/A N/A N/A Buya Drug Store Private N/A N/A N/A N/A N/A N/A N/A

2.3.3 ORGANIZATIONS PROVIDING HIV/AIDS SERVICES

The WoHO and HAPCO organize community-level care and support activities. There are no NGOs that provide HIV prevention, care, or support activities in Engibara.

2.3.4 COUNSELING AND TESTING SERVICES

People in Engibara are reluctant to access HCT at the town health center because most residents know each other in this small town. All respondents appreciated the idea of mobile HCT to target at-risk populations. A woreda HAPCO representative said, “If we bring in providers from other towns in mobile HCT, most of people in town will be confident enough in using the services as fear of stigma and discrimination is the main reasons for low use of voluntary counseling and testing at [the] public health center.”

2.4 FENOTE-SELAM

Fenote-Selam, located in West Gojjam zone 376 kilometers northwest of Addis Ababa along the Addis-to-Metema route, has a population of 31,141 (14,294 male and 16,847 female). The town has one college, a zonal hospital, and two private drug vendors. The most common public health problems include malaria, HIV/AIDS, TB, and typhoid fever.

2.4.1 MOST-AT-RISK POPULATIONS

Army forces based in Birshelko/Tatek Military camp frequently visit the town. Fenote-Selam is a marketplace and frequently visited by local businessmen and farmers from the neighboring woredas. In addition, truckers and their assistants enter and leave the town every day. The town also hosts large numbers of FSWs operating in hotels, bars, and local brew-selling houses. Cross-generational and transactional sex is common, especially among secondary and college students with uniformed men, local businessmen, and government employees. Alcohol and khat use and inconsistent condom use are among frequently cited reasons for the town’s unchecked HIV transmission.

TABLE 19: SIZE OF TARGET POPULATIONS IN FENOTE-SELAM

Target population Estimated number Fishermen/women 18 College students (private and public) 1,827 Construction workers 389 Farm plantation workers 30

Target population Estimated number FSWs 350 Uniformed government workers (such as customs officers, police, 494 soldiers, and immigration agents) Informal traders and market sellers (such as suq bederete, lottery 75 azuari, and unregistered street traders) In-school youths (excluding college students) 10,572 Migrant day laborers 350 Out-of school youths Data not available Truck drivers 70

Female Sex Workers

An estimated 350 FSWs operate in hotels and bars located along the main road. FSWs in local brew- selling houses are concentrated in Giga, Korit, and Gebya Sefer neighborhoods. The clients of the FSW include uniformed men, truck drivers, construction workers, students, and farmers. According to the interviewed FSWs, inconsistent condom use is common among FSWs working in areki and tella houses.

TABLE 20: LOCATIONS IN FENOTE-SELAM WHERE FEMALE SEX WORKERS OPERATE

Category Name and location Hotels and bars • Lemech Hotel, around Finoteselam Bus Station • Tseday Hotel, around Finoteselam Bus Station • Abeba Hotel, along the main route • Addis Hotel, along the main route • Exterm Hotel, along the main route • Axum Hotel, along the main route Streets • Giga Sefer in front of Educational Office • Around Georges Church and Gebeya Sefer • On the way to Bakel • On the way to Bahirdar along the route Areki, tella, and tej bets • Giga Sefer • Korit Sefer • Gebya Sefer • Near the bus station (or Menaharia)

Informal Traders and Market Sellers

An estimated 75 informal traders engage in petty trading in open marketplaces in Kebeles 01 and 02. Young women who sell small items and roasted grains (kollo) constitute a large share of the petty traders. These economically vulnerable young women are said to engage in sex to supplement their meager income.

Truckers and Intercity Bus Drivers

On average, 70 trucks and intercity buses enter and leave Finote Selam daily. At least 25 trucks stay overnight in the town. Truckers and their assistants are the main clients for FSWs operating in hotels around Menaharia Sefer. According to FSWs, truckers are known for consistent condom use.

TABLE 21: INFORMATION ON TRUCKS AND LONG-DISTANCE BUSES PASSING THROUGH FENOTE-SELAM

Selected information Details Times • Morning (15) • Mid-day (35) • Night (20) • Staying overnight (25) Overnight parking locations • Around Extrem Hotel along the route Bars, clubs, and inns visited • Lemech Hotel, along the route (Menahria) • Extrem Hotel, along the main route • Tseday Hotel, along the main route (Menahria) • Abeba Hotel, along the main route • Addis Hotel, along the main route • Axum Hotel, along the main route Truck and bus companies • Tikur Abay Transportation • Tana Transportation • Mesfin Engineering Transportation • Salini Transportation • Caju Transportation • China Wanbo Transportation

Adolescents and Youths

There are more than 1,500 college students and 4,000 secondary school students in the town. Informants noted that in- and out-ofschool youths have sexual networks including fellow students, uniformed men, and local businessmen. Khat and alcohol abuse is common, particularly among male students. Students do not use condoms consistently, citing alcohol and khat abuse and embarrassment to obtain condoms from the public hospital, shops, or kiosks as the main reasons.

TABLE 22: DISTRIBUTION OF IN-SCHOOL ADOLESCENTS AND YOUTHS IN FENOTE-SELAM

Number of schools by type Student enrollment School level Private Public NGO Private Public NGO Total Primary (grades 18) 3 6 0 339 5,921 0 6,260 Secondary (grades 910) 0 1 0 0 4,312 0 4,312 Tertiary (college and 1 1 0 649 1,178 0 1,827 higher) Total 4 8 0 988 11,411 0 12,399

Migrant Day Laborers and Construction Workers

There are about 350 migrant workers and 389 construction workers in the town. These workers are concentrated along the main roads and in front of Kebele 01 administration hall. Migrant workers usually meet FSWs in local brew-selling houses in Giga Sefer. Consistent condom use is said to be low among migrant workers.

2.4.2 HEALTH SERVICES

Finote-Selam has one zonal hospital that provides comprehensive HIV/AIDS care and treatment services. According to informants, most STI patients seek treatment from traditional healers rather

than the public hospital. They further noted that some people do not know about the availability of STI treatment in the hospital.

TABLE 23: AVAILABILITY OF HEALTH SERVICES IN FENOTE-SELAM

Name of facility Type of Services provided facility HCT TB TB ART PMTCT STIs OIs diagnosis treatment Finoteselam Zonal Public √ √ √ √ √ √ √ Hospital Bata Drug Store Private N/A N/A N/A N/A N/A N/A N/A Grar Drug Store Private N/A N/A N/A N/A N/A N/A N/A

2.4.3 ORGANIZATIONS PROVIDING HIV/AIDS SERVICES

Table 24 provides information on the NGOs and CBOs that provide HIV/AIDS-related services in Finote-Selam. Addis Hiwot PLWHA Association provides IEC and income-generating activities (IGA) for PLWHA and their families.

TABLE 24: NON-GOVERNMENTAL AND COMMUNITY-BASED ORGANIZATIONS PROVIDING HIV/AIDS CARE AND SUPPORT ACTIVITIES IN FENOTE-SELAM

HIV/AIDS-related services provided Name of BCC HCT PMTCT ART OI STI IGA Nutrition HBC OVC Target organization groups Addis Hiwot PLWHA √ √ PLWHA and Association their families Idirs √ PLWHA and their families, OVC I-TECH √ √ PLWHA and their families, MSH √ √ PLWHA and their families

2.4.4 COUNSELING AND TESTING SERVICES

According to informants, there is low use of the HCT services offered at the hospital because of the potential stigma. There are no NGOs that provide HCT in this town. The informants and interviewed target population appreciate the idea of mobile HCT. They proposed marketplaces as good sites for mobile HCT services. Weekend service is recommended by respondents to create access to HCT services for the MARP.

3. DISCUSSION AND CONCLUSIONS

This study found a large, diversified at-risk population in study towns. This assessment also discovered multiple sexual networks among these at-risk population that contribute to unchecked HIV transmission. All of the study towns are marketplaces for the surrounding rural communities. Their economic activities attract large pools of mobile workers, including truckers, migrant day laborers, and businessmen. The town also hosts large numbers of farmers, especially on the weekly market days. FSWs are concentrated in hotels, bars, and local brew-selling houses. All of the study towns have secondary schools that enroll not only students from the town but also large number of students from the neighboring rural woredas. Fenote-Selam has one public college and a large number of students from different parts of the Amhara region. This study also identified students who practice sex work with the help of brokers and those who have sex with older men in return for money and gifts. The same findings were noted in PSP-Ethiopia’s HCT assessments that were conducted in 18 towns in Amhara.4,5 The other important at-risk population, especially in Fenote- Selam, is the army forces that are based in Birshelko/Tatek Military camp, which is close to the town. The army forces’ sexual networks extend from FSWs to students and out-of-school youth.

This study also found the high presence of cross-generational sex and widespread concurrent sex between married men and a women irrespective of her marital status, which is commonly called “wushima.” The other common concurrent sex noted was included better-off men who establish long-term sexual networks with younger ladies to whom they provide economic supports (kimit). Encouraging the use of condoms in this type of network is difficult as the relationship involves emotional ties. This study also noted that alcohol and khat abuse is common among in- and out- ofschool youth, and it is said to be one of the main factors for inconsistent condom use. Male students have sexual networks with low-paid FSWs who operate in local brew-selling houses. Similarly, migrant workers are known for their heavy use of areki and are among the main clients for FSWs operating in local brew-selling houses.

Consistent use of condom is low particularly, among youths, students, and areki bet- and tella bet- based FSWs. The 2005 HIV/AIDS Behavioural Surveillance Survey (BSS) report showed that home- based FSWs were less likely to use condoms compared to bar- and hotel-based ones. The BSS also indicated that condom use among youths was lowest (24 percent) in the Amhara Region as compared to other regions. Previous mobile HCT assessments had similar findings about the low and inconsistent condom use among youths and migrant day laborers.3, 4 This study found the presence of widespread wrong beliefs and misconception that adversely affect condom use; the main ones include the belief that condom lubricant has HIV in it.

In all of the study towns, there is at least one public health facility with comprehensive HIV/AIDS care and treatment services. Though few NGOs provide community care and support activities, woreda HAPCO is strengthening it indigenous organization, especially PLWHA support associations to create community awareness and IGA support for PLWHA and their families. This study is in full agreement with two other PSP-Ethiopia HCT assessments with regard to the low utilization of HCT and STI services in public health facilities.(3,4) Fear of stigma and discrimination was among the frequently cited reasons for this low use. Similar findings were noted in other African countries where stigma about HIV is pervasive and is the main reason for the reluctance to be tested, to disclose HIV status, or to take antiretroviral agents.7,8,9,10 This finding underscores the importance of confidentiality and privacy in building the at-risk population’s confidence to seek HCT services.

The demand for HCT services is high in all study towns. The use of existing fixed HCT services at public health facilities is low, especially by at-risk populations for fear of stigma and discrimination. Most of the respondents have noted that at-risk groups in town choose places where no one knows them to get HIV testing, mostly as far as 50 kilometers away in largest towns, such as Gondar and Bahir Dar. The existence of at least one public health facility with continuum of HIV/AIDS care and support enables the referral linkage for on-going counseling, pre-ART registration, ART, and other related services.

4. RECOMMENDATIONS

WoHO and HAPCO

• Strong IEC and BCC are recommended to bring about consistent condom use. In particular, the IEC and BCC strategy must address the widespread misconception that condoms are infected with HIV. Education also should be given about HCT and its benefits to the population and special target groups.

• The WoHO should take the initiative in talking with providers at public health facilities to identify gaps and improve confidentiality and privacy to increase HCT and STI treatment service utilization by the target population.

• The WoHO and HAPCO need to coordinate and mobilize resources to support economically vulnerable women, especially those working at local brew-selling houses and informal traders. IGAs could prevent these economically disadvantaged and vulnerable women from engaging in sex work.

PSP-Ethiopia

• PSP-Ethiopia has to start mobile HCT service in the study towns. Mobile HCT should be organized in partnership with local actors, especially WoHOs and HAPCO.

• Even though there are similarities in the at-risk populations residing in each study town, more focus should be given to target groups in each town. There is marked difference in the location and timing similar target groups residing in different towns suggest. The timing and location of services must be tailored to meet the needs of each town.

• Condom education and distribution must be emphasized during the mobile HCT services.

• Most of the respondents recommend weekend services for migrant workers and government employees. FSWs suggested morning time (10 to 11 a.m.) and early afternoon (1 to 4 p.m.).

• All informants and interviewed target groups said that target groups in their towns are reluctant to receive HIV testing from providers known to the community. PSP-Ethiopia has to bring in providers from other towns to conduct HCT services.

REFERENCES

1. Ministry of Health Ethiopia and Federal HIV/AIDS Prevention and Control Office. 2007. Single Point HIV Prevalence Estimate. Addis Ababa, Ethiopia: Ministry of Health Ethiopia and Federal HIV/AIDS Prevention and Control Office.

2. Ministry of Health Ethiopia. 2005. HIV/AIDS Behavioural Surveillance Survey (BSS).

3. Federal Democratic Ethiopia, HIV/AIDS Prevention and Control Office and Global AIDS Monitoring & Evaluation Team. 2008. HIV/AIDS in Ethiopia: An Epidemiologic Synthesis. Washington, DC: The International Bank for Reconstruction and Development/The World Bank.

4. Habte, D. 2008. Assessment on the Distribution of At Risk population and HIV/AIDS Referral Services: Baseline Assessment for MCT Program in Afar Regional State.

5. Yilma, M. 2008. Assessment on the Distribution of At Risk population and HIV/AIDS Referral Services: Baseline Assessment for MCT Program in Afar Regional State.

6. Andualem, W. and K. Gilbert. 2000. Implementation of Mobile Counseling and Testing in Ethiopia: Preliminary lessons from the Oromiya Region. Bethesda, MD: Public-Private Partnerships for HIV and TB in Ethiopia project, Abt Associates Inc.

7. Herek, G., J. Capitanio, K. Widaman. 2003. Stigma, social risk, and health policy: Public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology 22:533– 540.

8. Herek, G., and J. Capitanio. 1999. AIDS stigma and sexual prejudice. American Behavioral Science 42:1130–1147.

9. Day, J., K. Miyamura, A. Grant, et al. 2003. Attitudes to HIV voluntary counseling and testing among mineworkers in South Africa: will availability of antiretroviral therapy encourage testing? AIDS Care. 15:665–672.

10. Ford, K., D. Wirawan, G. Sumantera, A. Sawitri, and M. Stahre. 2004. Voluntary HIV testing, disclosure, and stigma among injection drug users in Bali, Indonesia. AIDS Education Prevention. 16(6):487–498.