Issue Brief
Updated February 2003
Pregnant women and mother-to-child transmission
| Persons at highest risk for acquiring HIV, or most in need of care and support if they are infected, fall into three major groups. |
The first group includes youth, women (including commercial sex workers and pregnant women), and orphans/street children, all at risk due to a mix of biological factors and lack of information or power to protect themselves or obtain care. The second group includes the military, migratory laborers, and internally displaced persons (IDPs), all highly mobile, under stress, and separated from family for long periods. The last group includes farmers and the general workforce, comprising the core of Ethiopia's primarily agrarian economy, largely unprotected by HIV awareness and protective policies.
Comprising more than half of the Ethiopian population, youth 24 years of age and younger are a high priority group for HIV/AIDS education (DHS 2000). In- and out-of-school youth between the ages of 15 and 24 comprise about 30 percent of the population in the country, and account for the highest percentage of new HIV cases in Ethiopia (MOH/NACS, 2001). Educating youth and children about HIV and sexual health must start early to curb the high HIV incidence in this age group.
Natural curiosity and widespread peer pressure about sex exist among youth. However, cultural and societal taboos associated with open and frank discussion about sexual matters tend to prevent information about the risks of sexual activity from reaching young people. Lack of appropriate information and guidance can fuel early and unprotected sexual activity.
Despite evidence that the majority of Ethiopian youth is sexually active, availability of accurate information about sexual matters at home or at school is rare. To protect themselves from HIV, other STDs, and unwanted pregnancies, youth need answers to their common questions of 'if and when' to initiate sex, how to talk about sexual decision-making with a partner, and contraceptive use. They also need to be able to identify myths and other misinformation that can encourage risky sexual experimentation. Accurate and relevant information helps young people make important decisions about their sexuality using facts, not guesswork or popular opinion. Access to creative and salient messages and services tailored to their needs, lives, and culture is essential. Sex and AIDS education and counseling can delay sexual debut for many, and encourage responsible decision-making and safer sexual behaviors among those youth who choose to be sexually active.
The estimated 1.2 million children in Ethiopia who have lost their mother or both parents to HIV/AIDS suffer from a lack of financial, emotional, educational, and moral support (MOH 2002). Very often after the death of a parent, they find they have no caregiver. Endemic poverty and the all-too-common financial and emotional burden of caring for HIV-infected individuals often prohibit relatives from taking these children in. Many AIDS orphans resort to life on the streets, begging or rummaging through trash to survive. Orphaned young girls frequently are led into child prostitution to generate income for their basic needs. Many children engage in substance abuse at an early age, which makes them especially vulnerable to HIV.
Orphanages are overwhelmed with orphans, and rarely provide a viable option for children recently orphaned by HIV/AIDS. Orphan care programs can be initiated by schools and community organizations to help extended families overwhelmed by orphans and reduce the number of children who resort to living on the streets. Outreach programs targeting street children and facilitating payment of school fees may also alleviate the burden somewhat. Above all, protective policies must be implemented to assure orphans of the right to go to school, and to meet their basic needs.
HIV/AIDS disproportionately affects women, especially younger women, in Ethiopia. This is due to a number of factors unique to women that increase their risk of acquiring HIV relative to men:
Rates of HIV infection are high among pregnant women in the general population in Ethiopia, as monitored through sentinel surveillance sites at antenatal clinics. This measurement is considered the best available proxy measurement for HIV prevalence in a population. In 2001, 15.6% of pregnant women tested for HIV in Addis Ababa were HIV-positive. Rates of HIV infection among pregnant women, measured in other cities in Ethiopia, ranged from 3.1% in Ginir (Oromia), to 21.4% in Bahir Dar (weighted average of hospital and health center data, MOH 2002). An age pattern of HIV prevalence has been detected among pregnant women ages 15-49: with prevalence of 12.1% overall, women ages 15-24 years have the highest average HIV prevalence (MOH 2002). Most of these young women have been sexually active for a short time and so represent relatively new infections of great public health importance. Still, testing for HIV is not routine for pregnant women.
Approximately one-third of HIV-positive women pass HIV on to their children, either while pregnant, during the birth of the child, or while breastfeeding. This mother-to-child transmission (MTCT) accounts for a vast majority (some estimate 90%) of the 200,000 HIV infections in Ethiopia among children under five (MOH 2002). To reduce MTCT and improve maternal health, a woman who is HIV-positive needs sensitive and appropriate counseling to make decisions about future childbearing, how to maintain or improve her own health, and whether or not to choose replacement feeding instead of breastfeeding. If she is pregnant, the risk of HIV transmission can be reduced through improved nutrition, good care during and after pregnancy, early diagnosis and treatment of other STDs, and antiretrovirals where available. HIV-positive women can also prolong and improve the quality of their lives with their children by utilizing family planning services and living positively.
Frequency of sex with multiple partners and a high burden of other STDs place a specific subgroup of women - commercial sex workers - at very high risk of HIV infection. An upsurge in HIV prevalence has been reported among commercial sex workers in Addis Ababa, from less than 1 percent in 1985 to 74 percent in 1998 (Aklilu et al 1998). Similar increases in HIV prevalence among sex workers have been noted in other cities, including Bahir Dar, Dire Dawa, and Nazret.
Since many of these women have resorted to sex work for financial survival, providing them with alternative income-generating opportunities can drastically reduce their risk of contracting HIV. In cases where alternatives to sex work do not exist, harm reduction programs encouraging condom use, increasing availability of condoms, and providing quality STD diagnosis and treatment for these women can minimize their risk of becoming HIV-positive or transmitting the virus to their clients. Because male clients fuel the commercial sex trade, including them as a target audience in any intervention involving commercial sex workers is essential.
High mobility, frequent long periods away from family, a predominantly single-sex environment, and stressful work conditions characterize the lives of uniformed military personnel. In concert, these factors place military and police personnel at high risk for infection with HIV. In particular, demobilized soldiers in Ethiopia have been reported to engage in unsafe sexual behaviors, including unprotected sex with sex workers or casual contacts (Shabbir and Larson 1995).
This high-risk subgroup is easier to reach with interventions than others because of the military tradition of discipline and receptivity to training. However, once demobilized, this group can be hard to track. The Ethiopian armed forces have been at the forefront of the national battle against HIV/AIDS, providing condoms, testing opportunities, widespread training for all levels, surveillance, and research to reduce the spread of HIV through its ranks. The example of the military, though difficult to translate to less structured environments, could guide the response of other sectors.
Seasonal workers and truck drivers are frequently away from home for long periods of time, and the social disruption and loneliness resulting from their migration is associated with higher incidence of casual sexual partners. While away from home, loneliness and stress drive many of these migratory laborers to frequent commercial sex workers. Conversely, women whose partners are migratory workers may resort to commercial sex work while their partners are absent for economic survival. A number of Ethiopia's internally displaced persons and refugees from war are also at high risk of HIV infection. Frequently separated for long periods from their families, these persons are often confined to camps where lack of employment and activity lead to increased sexual activity.
Mobile populations, including some groups of IDPs, can sometimes be targeted with BCC strategies, condom distribution, and interpersonal communication while in semi-permanent camps or settlements. However, mobile refugee populations and nomadic agriculturalists pose unique problems to HIV prevention, testing, and treatment programs, and often necessitate brief interventions at checkpoints, or in-depth training of trainers within the mobile group.
Most farmers, like the majority of Ethiopia's population, live in rural areas. Like migratory laborers, rural commercial farmers often visit local towns for social and business purposes. Farmers may frequent female commercial sex workers while visiting towns to bring their harvest to market or distribution points, indicating this group could include carriers of HIV into rural areas (Shabbir and Larson 1995). Education levels tend to be very low in rural areas, and HIV/AIDS awareness and knowledge of prevention methods tend to be dangerously low among this group. Economic pressure, famine, and illness (especially AIDS-related) yield less nourishing crops, smaller harvests, and an exhausted workforce that is at even greater risk of HIV/AIDS.
Because of geographic isolation and poor transportation infrastructure, farmers are among the most difficult group to target with behavior change communication. Some potential strategies to reach farmers include producing and distributing HIV/AIDS education materials specifically for rural audiences (particularly farmers), encouraging nutrition education programs to discourage non-nutritive crop planting, mobilizing social networks (including spiritual leaders, leaders of farmers' associations, and agricultural extension workers), and advocating for rural outreach among authorities at higher government levels.
Because HIV/AIDS strikes primarily those in their most economically productive years, businesspeople are an especially important group to target with HIV/AIDS behavior change communication approaches. The workplace provides an ideal organized context in which to launch behavior change communication programs and encourage appropriate responses toward those who are infected. Designing appropriate workplace HIV/AIDS prevention and care packages, including comprehensive policies and services to reduce HIV risk behaviors and discrimination towards those who are infected, is one of the most effective best practices toward reaching persons in this vulnerable group.
Aklilu, M., T. Messele, T. Biru, et al. 1999. Factors Associated with HIV Infection among sex workers of Addis Ababa, 1998. XI International Conference on AIDS and STDs in Africa, Lusaka, Zambia, 9/12-16, Abstract 15Dt3-4.
Ethiopia Central Statistical Authority and ORC Macro. 2001. Ethiopia Demographic and Health Survey 2000. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Authority and ORC Macro.
Ethiopia Ministry of Health, Disease Prevention and Control Department. 2002. AIDS in Ethiopia. 4th Edition. Addis Ababa: Ministry of Health.
Ethiopia Ministry of Health, Disease Prevention and Control Department. 2000. AIDS in Ethiopia. 3rd Edition. Addis Ababa: Ministry of Health.
Ethiopia Ministry of Health, Program and Planning Department. 2001. Health and Health Related Indicators. Addis Ababa: MOH.
Ethiopia Ministry of Health. 2001. Guidelines for Prevention of Mother-to-Child Transmission of HIV. Addis Ababa: MOH.
Ethiopia National AIDS Council. 2001. Strategic Framework for the National Response to HIV/AIDS in Ethiopia (2001-2005). Addis Ababa: National HIV/AIDS Council Secretariat.
Shabbir and Larson. 1995. Urban to rural routes of HIV infection spread in Ethiopia. J Trop Med Hyg. 98:338-342.