3. Quantitative Results

Interviews were conducted with a total of 14,224 out-of-school youth (OSY) from the ten regions and Dire Dawa Administrative Council (AC). Of the 15- to 19-year-old OSY (constituting 51.1% of all OSY interviewed), 3607 (25.4% of all OSY) were male and 3660 (25.7% of all OSY) were female. Of those between 20 and 24 years old (48.9% of all OSY interviewed), 3503 (24.6%) were male and 3454 (24.3%) were female. For the remainder of this document, the 15- to 19-year-old OSY is referred to as younger OSY and the 20– to 24-year-old group as older OSY.

Interviews were conducted with a total of 6210 in-school youth (ISY) from six regions (Amhara, Oromia, Somali, Harari, Addis Ababa and Dire Dawa). Amongst ISY, 3089 (49.7%) were males and 3121 (50.3%) females were interviewed.

Age

For the younger OSY, mean age was 17.3 years for the males and 17.2 years for the females. For the older OSY, mean age was 21.9 and 21.8 years for males and females, respectively. For ISY, mean ages for males and females were 17.5 and 17.1 years, respectively.

Education

The median number of years of schooling for ISY, 10 years, was the same for both genders. In most cases (51.4%), parents paid the children’s school fees. The majority (89.4%) of male and female in-school respondents reported that they were never absent during school days.

The majority (87.2%) of OSY had at some time in the past attended school. Amongst those who had previously been to school, the median number of years of schooling was 9 years. More males than females reported ever having attended school; this seemed to be the case for both age groups (younger and older). Levels of literacy amongst male and female OSY reflected this trend (see Figure 3.1.1).

Figure 3.1.1 Levels of literacy by age and gender – OSY.

OSY who did not complete 12^th Grade were asked their reason for dropping out of school. The most common reasons given, by both genders, were shortage of money to continue school (19.7%), health problems (12.6%), failed/academic dismissal (11.8%) and refusal to continue school (11.0%). Amongst females, 5.8% discontinued schooling because of pregnancy.

Residence

Amongst the OSY, the majority of respondents (48.4%) reported that they lived with their parents. Amongst female younger OSY, 18.4% reported that they lived with their employer; in contrast, this was reported by only 5% of their male counterparts. A similar pattern was observed amongst the older OSY, with slightly more females (11%) than males (3%) reporting living with their employer. The majority (70.0%) of ISY (males and females) reported that they lived with their parents; considerable numbers (22.6%) also lived with other relatives.

Employment

OSY were often engaged in informal employment. They were commonly involved in buying and selling (23.3%) or domestic work (18.8%), or were employed as shop/tea/pastry workers (15.3%). The majority (64.7%) of respondents with informal employment kept most of their earnings for their own use.

Support

Around 40% of OSY reported that they were supporting other people. Amongst this group, 71.4% were supporting 1-2 adults, 15% supported 3-5 adults, and 1.9% supported more than 5 adults. Moreover, 45% supported 1-2 children, 21.6% supported 3-5 children and 3.2% supported more than 5 children.

Mobility

Most OSY and ISY had lived in the same area for many years; indicating some degree of stability amongst both groups. Only 1523 (10.9%) of OSY had lived in the area for one year or less and 24.7% for less than five years, whilst 438 (7%) of the ISY had lived in the area for one year or less and 21.8% for less than five years. Greater levels of mobility were observed amongst the female OSY than their male counterparts; the females were more likely to have lived in the area for less than one year (P<0.001); this was the case in both age categories.

Religion

The majority (72.6%) of OSY was Christian and 26.1% was Muslim. Similarly, 71.4 and 27.2% of the ISY were Christian and Muslim, respectively.

Circumcision

Amongst the OSY, 82% of males and 68% of females were circumcised; amongst ISY, 97% of males and 51% of females were circumcised. Of the circumcised OSY females, 63.2% had undergone the non-infibulating type of circumcision while 11.2% had been infibulated. Of the ISY, 43 and 11% had undergone non-infibulating and infibulating type of circumcision, respectively. There was regional variation in the prevalence of circumcision for both genders. Male circumcision was common in all regions except in Beneshangul-Gumuz (44.2%) and Gambella (45.9%). Female circumcision was common in all regions except Beneshangul-Gumuz (14.5%) and Amhara (30.8%). The infibulating type of female circumcision was common in the Somali (55.3% of circumcised OSY and 38.5% of ISY) and Afar (14.4% of OSY) regions.

3.1.2 STI/HIV/AIDS related knowledge

Knowledge of STIs

A large majority of OSY (81.5%) and ISY (95.5%) said they had heard of STIs. Knowledge of the existence of sexually transmitted infections (STIs) was slightly higher amongst males than females. A higher proportion of the older OSY respondents (92% of males and 84% of females) than the younger OSY respondents (80% of males and 71% of females) said they had heard of STIs. Amongst the ISY, 97% of males and 94% of females had heard of STI.

All respondents who had heard of STIs were asked which female and male STI symptoms they knew. The most frequently mentioned female STI symptoms were a burning pain on urination and genital discharge, followed by genital ulcers. The most commonly mentioned male STI symptoms were genital ulcers/sores and a burning pain on urination.

Knowledge and misconception about HIV/AIDS

Knowledge of HIV prevention methods and absence of incorrect beliefs about HIV transmission are the two major indicators presented in this subsection.

Amongst the OSY, over 95% of respondents in both age and gender groups reported that they had heard of HIV/AIDS. The proportion of ISY who had heard of HIV/AIDS was 99.9%.

Respondents were asked whether they knew of anyone who was infected with HIV or had died of AIDS. Amongst respondents who said they had heard of HIV/AIDS, over half of the younger OSY respondents knew of someone who was HIV infected or had died of AIDS. More than two thirds of the older OSY said they knew someone who was infected with HIV or had died of AIDS. A similar pattern was observed amongst the ISY where 76% of males and 81% of females knew someone who was infected with HIV or had died of AIDS.

Those who said they knew someone who was HIV infected or had died of AIDS were asked whether it was a close friend or a relative. Only a very few respondents said it was either of these. About 10 and 12% of OSY and ISY, respectively, responded that they had a relative who was infected with HIV or had died of AIDS whilst about 7% of each group had a close friend in the same situation.

Overall, 57.7% of all youth (OSY and ISY combined) knew the three major preventive methods for HIV/AIDS. When disaggregated, around half of the younger OSY (55% of males and 45% of females) knew the three preventive methods; amongst older OSY, 65% of males and 53.7% of females were aware of the three methods. More than two-thirds (70%) of male and 62% of female ISY knew the three major preventive methods.

The proportion of younger OSY who knew that people could protect themselves from HIV by always using a condom when having sex tended to be slightly higher amongst male compared with female respondents (67% for males and 61% for females). A slightly higher proportion of male (83%) than female (71%) younger OSY replied correctly that people could protect themselves from HIV by being in a ‘one-to-one’ relationship (faithfulness). Likewise, more male (81%) than female (70%) younger OSY agreed with the statement that ‘people could protect themselves from HIV by abstaining from sex’. Similar knowledge patterns with slightly higher proportions were seen amongst the older OSY (see Annex 2F).

About 74% of male and 68.1% of female ISY agreed that consistent and correct use of condoms when having sex could protect people from HIV infection. Having one uninfected faithful sex partner was recognized as one of the prevention methods of HIV/AIDS transmission by 93.5 and 87.0% of male and female ISY, respectively. The proportion of ISY who responded that abstaining from sexual intercourse could protect people from HIV was similar between male and female respondents (94.4% for males and 93.5% for females).

Knowledge level, by region, is shown in the summary indicator table (Annexes 2B, 2D and 2F). Knowledge of the three preventive methods amongst ISY was lowest in the Somali region. Amongst OSY, knowledge level was high in Amhara, Tigray and Harari but relatively low in the Gambella, Somali and Afar regions.

Figure 3.1.2 Percentage of ISY (15-19 years old) and OSY (15-24 years old) with commonly observed misconceptions.

People’s beliefs or myths about HIV/AIDS play an important role in determining their attitudes towards people living with HIV/AIDS (PLWHA) and practice of preventive methods. Various statements were read out to respondents and they were asked to agree or disagree with each statement (see Annexes 2A-F). Those respondents with at least one incorrect response were identified as having misconceptions.

More than three quarters (76.5%) of all youth had at least one misconception about HIV/AIDS transmission (72.1% of males and 81% of females). More OSY (82.2%) than ISY (63.7%) were found to have at least one misconception. Figure 3.1.2 shows the frequency of each misconception amongst the OSY and ISY.

Regional differences were observed in the distribution of misconceptions relating to HIV/AIDS. The proportion of OSY with at least one misconception was highest in Afar (90.4%), Tigray (89.9%) and Addis Ababa (89.6%). Amongst ISY, in Addis Ababa (78.8%), Amhara (74.6%) and Somali (73.8%) were found to have the highest levels of misconceptions. (see Figure 3.1.3).

Figure 3.1.3 Percentage of OSY and ISY who, when prompted, voiced at least one misconception about HIV/AIDS transmission. (Note: ISY was surveyed only in the Amhara, Oromia, Somali, Harari and Addis Ababa regions and the Dire Dawa AC).

In terms of the ‘no incorrect beliefs’ indicator used by United Nations Program on HIV/AIDS (UNAIDS), which is based on the three most common misconceptions, about half of the OSY and just over half of the ISY respondents correctly rejected all three statements (See Annexes 2A, 2C and 2E).

In this study, a combination of composite indicators, knowledge of the three preventive methods and no incorrect belief about HIV/AIDS transmission was used to examine comprehensive knowledge amongst the youth (see Annexes 2A, 2C and 2E). Overall 35.8% of youth had comprehensive knowledge. Comprehensive knowledge was higher in ISY (45%) than in younger OSY (27.2%). Males (41.2%) were more knowledgeable than females (30.5%).

Knowledge about condoms

Condom use remains one of the key methods to prevent HIV transmission. Over the past years, both government and non-governmental organization (NGO) partners in the response to HIV/AIDS have been involved actively in the promotion of condom use for HIV and STI prevention, and contraception. Knowledge about condoms is an important indicator of HIV/AIDS-related behaviors.

A significant proportion of OSY (94.4%) in both age groups reported having heard of male condoms. For the younger OSY a slightly higher proportion of males (96%) than females (87%) had heard of male condoms. An almost equal proportion of males (98%) and females (95%) in the older OSY reported ever having heard of male condoms. Similarly, equal proportions of males and females (>98%) amongst the ISY had heard of male condoms.

In comparison, the proportion of youth who reported ever having heard of female condoms was low: 57% of males and 43% of females amongst ISY; 27% of males and 21% of females amongst the younger OSY; and 41% of males and 25% of females amongst the older OSY.

Most ISY (94.5%) and OSY (84.2%) knew where to obtain condoms. More males than females knew places where they could obtain condoms. The most frequently mentioned sources of male condoms were shops, pharmacies and hospitals/health centers (see Figure 3.1.4).

The majority (>90%) of respondents (ISY and OSY, and both genders) reported that it took less than 30 minutes to obtain a male condom.

Figure 3.1.4 Locations where youth obtain male condoms.

Stigma and discrimination

Questions were asked to determine the acceptance of PLWHA and levels of stigma and discrimination. Stigma and discrimination against PLWHA was widespread amongst youth with 97.8% of all youth (98.7% of males and 96.9% of females) expressing at least one stigmatizing attitude.

Amongst OSY the large majority of males (98%) and females (95%) demonstrated at least one stigmatizing attitude; likewise, the proportion of ISY who expressed at least one stigmatizing attitude was 95% for males and 99% for females. About 24.7% of OSY and 9.1% of ISY believed that a person who was infected with HIV should be quarantined in health care facilities. Furthermore, 79.6% of OSY and 90% of ISY believed that infected students should not continue at school. In fact, the very high levels of stigmatizing attitudes amongst youth revealed by the overall composite indicator were a direct result of the stigmatized responses regarding continuation of schooling. Analysis of results by region showed that stigmatization was widespread in all regions; however, youth in the Beneshangul-Gumuz region had slightly lower levels of stigmatizing attitudes (88.5%).

Mother-to-child transmission of HIV/AIDS

Most OSY and ISY recognized that HIV could be transmitted from an infected mother to her unborn child (81 and 88%, respectively) and from an infected woman to a child she was breastfeeding (71 and 70%, respectively). Female youth was slightly more knowledgeable than male youth.

Individuals, who were aware that HIV could be transmitted to an unborn child, were asked a further question relating to the actions a pregnant woman could take to reduce the risk of HIV transmission to the unborn child. Only 17% of ISY and OSY (20% of males and 13.9% of females; P<0.001) knew that the risk for mother-to-child HIV transmission could be decreased by antiretroviral therapy. When asked to select possible ways that mother-to-child HIV transmission could be reduced (from a list of options), 6% of ISY and 10% of OSY selected ‘abortion’. About 29 and 30% of ISY and OSY, respectively, thought that nothing could be done to prevent the transmission.

3.1.3 Alcohol and drug use

In the four weeks preceding interview, 9% of ISY and 29.1% of OSY (22.9% of the younger and 35.6% of the older) had consumed drinks containing alcohol. Regular consumption of alcohol (consumption at least once a week) was reported by 19.5% of the younger OSY (24% of males and 15% of females) and 32.7% of the older OSY (42.8% of males and 22.5% of females). Amongst ISY, 8.9% (10% of males and 7.8% of females) were regular alcohol users.

For the OSY, the highest percentages of regular alcohol users were found in the Amhara (48.1%) and Tigray (37.2%) regions and lowest percentages in the Somali (11.8%) and Afar (12.3%) regions. Amongst ISY, the highest and lowest percentages of regular alcohol users were found in the Amhara (19.5%) and Addis Ababa (2.4%) regions, respectively.

Figure 3.1.5a Regular alcohol and khat use amongst ‘ever users’ by region – ISY.

Figure 3.1.5b Regular alcohol and khat use amongst ‘ever users’ by region – OSY.

Overall, 9.7% of ISY (16.4% of males and 3% of females) and 28.5% of OSY (42.2% of males and 14.9% of females) had ever used drugs. Amongst OSY, ‘ever drug use’ was highest in the Somali (48.4%) and Harari (45.1%) and lowest in the Tigray (12.3%) and Amhara (13.2%) regions. For ISY, ‘ever drug use’ was highest in the Harari region (21.2%) and lowest in the Addis Ababa region (3.1%). The proportion of ISY and OSY who had ever used specific types of drugs is shown in Table 3.1.1. Khat was the major drug used by the youth.

Table 3.1.1. ‘Ever use’ of specific types of drugs by the youth.

Target group

Number (%)

Khat

Shisha

Benzene

Hashish

Mandrax

Cocaine

Crack

IDU*

Males

Females

Total

ISY

507 (16.4)

92 (2.9)

599 (9.69)

55 (0.9)

11 (0.2)

1 (0.0)

0 (0.0)

0 (0.0)

8 (0.1)

36 (0.6)

Younger OSY

1131 (31.5)

393 (11.0)

1524 (21.2)

280 (3.9)

23 (0.3)

23 (0.3)

4 (0.1)

4 (0.1)

5 (0.1)

59 (0.8)

Older OSY

1837 (52.6)

637 (18.7)

2474 (35.9)

483 (7.0)

10 (0.1)

28 0.4)

2 (0.0)

1 (0.0)

1 (0.0)

49 (0.7)

*IDU = injecting drug user

Amongst ‘ever khat users’, 82.9% of male and 81.3% of female younger OSY used khat regularly. For the older OSY, 88.6% of males and 84.2% of females reported regular use of khat. Amongst ISY, 78.9% of males and 60.9% of females used khat regularly.

Comparing between regions, regular khat use by OSY was common in Somali (99.3%) and Harari (92.4%) while it was less common in Amhara (59.3%). For ISY, regular khat use was highest in Harari (87.4%) and Dire Dawa (85.2%) and least in Addis Ababa (41.9%). Figures 3.1.5a and b summarize the regional variations in regular alcohol and khat use amongst ISY and OSY, respectively.

3.1.4 Sexual behavior

Understanding the sexual behavior of young people is very important since most new HIV infections occur in this group.

Premarital sex

Abstinence from sex before marriage and delay of sexual debut are important strategies that help to reduce the spread of HIV amongst youth.

The proportion of OSY and ISY who had ever had sex was 49 and 16%, respectively. Amongst the younger OSY, 35% of males and 29% of females had ever had sex; in the older OSY, 74% of males and 60% of females had ever had sex. In contrast, amongst the ISY only 19% of males and 13% of females had ever had sex.

Figure 3.1.6a Percentage of OSY (15-19 years old) who had ever had sex – by region and gender.

Figure 3.1.6b Percentage of OSY (20-24 years old) who had ever had sex – by region and gender.

By region, proportions of younger OSY reporting having had sex were highest in the Gambella region (53.8%) and lowest in the SNNPR (24%). Similarly amongst the older OSY, the proportion was highest in the Gambella (89.7%) and Beneshangul-Gumuz (87.7%) regions, and lowest in Harari (56.6%). Amongst ISY, proportions that reported having had sex were highest in the Oromia region (31.3%) and lowest in the Addis Ababa region (6.5%). Figures 3.1.6a, b and c show, by region and gender, the

proportions of younger and older OSY, and ISY who had ever had sex.

About 33% of the younger OSY and more than 25% of the ISY had had sex by the time they were 15 years old. The two most common reasons for starting sex were personal desire (68%) and peer pressure (22%). One of the UNAIDS indicators on adolescents is median age at sexual debut. The median age of first sex for older OSY was 18.9 years for males and 19.4 years for females. Data indicated that at 15.5 years old, only 6.6% of males and 10.3% of the females were sexually active; however, by 18.5 years old more males (38.8%) than females (34.7%) were sexually active (see Figure 3.1.7).

Most male ISY (49.3%) and OSY (37.6%) said that their first sexual partner had been close to their own age, on average 16 years old. In contrast, female youth reported that first sexual partners were often considerably older than they were. Accordingly, 44.2% of OSY and 35.9% of ISY reported that their first sexual partner had been 5-10 years older; moreover, 15% of all female youth reported that their first sexual partner had been more than 10 years older.

Figure 3.1.7 Cumulative percentage of youth who were sexually active at various ages – by gender.

Number of sexual partners

Amongst those who had ever had sex, respondents were asked about their non-commercial and commercial partners during the previous 12 months. Non-commercial partners were reported by 52.5% of the OSY (57.5% of males and 46.5% of females) and 52.9% of the ISY (44.9% of males and 64.8% of females). In comparison, far fewer respondents reported having had commercial partners in the past 12 months; commercial partners were reported by only 19.5% of OSY (16.8% of the younger and 20.8% of the older group) and 1.5% of ISY.

Amongst those who were sexually active, a smaller proportion of ISY (16.9%) than OSY (35.1% of the younger and 40.9% of the older) reported having more than one sexual partner in the previous 12 months. A greater proportion of male than female OSY had more than one sexual partner in the previous 12 months (49.7% of males and 22.4% of females; P<0.05). The percentage of ISY reporting more than one sexual partner in the previous 12 months (16.9%) was significantly lower (P<0.05) than the corresponding value for either age group of OSY (25.3% of younger OSY and 28.0% of older OSY).

Figure 3.1.8 shows the proportion of youth (ISY, and younger and older OSY) in each region that reported having more than one sexual partner during the previous 12 months. By region, the percentages of OSY reporting more than one sexual partner during the previous 12 months were highest in Tigray, Beneshangul-Gumuz and Gambella (61.1, 55.2 and 48.9%, respectively).

Condom use

Amongst those OSY who had non-commercial partners in the previous 12 months, 55.7% (62.6% of males and 45.4% of females) said that they had used a condom at their last sexual encounter and 39% (44.6% of males and 30.7% of females) had used condoms consistently. During their last sexual encounter with non-commercial partners, 52.4% of ISY (64.2% of males and 40.2% of females) had used a condom and 73.6% (79.2% of males and 64.4% of females) had used condoms consistently during the previous 12 months.

Figure 3.1.8 Sexually active youth who had more than one partner during the previous 12 months.

Although the proportion of youth who reported using a condom during their most recent sexual encounter tended to be higher amongst OSY than ISY, (56.6 vs. 52.4%, respectively) the difference was not significant. In contrast, consistent condom use was less common amongst OSY than ISY (39.1 vs. 73.6%, respectively; P<0.05). The commonest reasons for non-use of condoms amongst the youth were partner trust (54.4%) and partner objection (9.4%).

Figure 3.1.9 shows condom use at last sex with non-commercial partners by ISY and OSY (younger and older groups combined) by region. The numbers, as a percentage of sexually active youth, were highest for OSY in the Harari (79.5%) and Tigray (67.9%) regions and lowest amongst OSY in the Afar (38%) region. Figure 3.1.10 shows the percentages of sexually active ISY and OSY, by region, that used condoms consistently with non-commercial partners during the previous 12 months. Amongst OSY, the percentage using condoms consistently during the previous 12 months was highest in the Harari region (51.4%) and lowest in Dire Dawa AC (22.5%). For the ISY, consistent use of condoms with non-commercial partners was highest in the Somali (94.1%) and lowest in the Oromia (45.6%) region.

Figure 3.1.9 Condom use at last sex amongst sexually active youth.

Note: ISY were only surveyed in the Amhara, Oromia, Somali, Harari and Addis Ababa regions and the Dire Dawa AC.

More male than female youth reported using a condom with their last sexual partner (63.6% of males vs. 45.5% of females; P<0.05). Considering condom use at last sex by type of partner, male youth used condoms more often with commercial partners than with non-commercial sex partners (87.8% with commercial vs. 63.6% with non-commercial partner; P<0.05).

Figure 3.1.10 Consistent condom use with non-commercial partners in the last 12 months amongst sexually active youth.

3.1.5 STI and treatment seeking behavior

Amongst the sexually active respondents, few (4.7%) reported ever having had a STI. When the younger and older OSY were asked whether they had ever had genital discharge or genital ulcers/sores, around 4 and 5% reported the respective symptoms. Amongst ISY, less than 2% of sexually active respondents reported having had the symptoms in the previous 12 months (see Table 3.1.2).

Table 3.1.2 Percentage of sexually active respondents who reported having had STI symptoms in the previous 12 months – by target group.

Symptom

Percentage

ISY

Younger OSY

Older OSY

Males

(n = 274)

Females

(n = 257)

Males

(n = 783)

Females

(n = 574)

Males

(n = 1679)

Females

(n = 1026)

Genital discharge

1.8

0.8

5.7

6.1

5.2

5.6

Genital ulcers/sores

1.4

0.0

3.3

3.3

3.2

3.2

Respondents who said they had experienced symptoms of STIs in the past year were asked whether they sought medical treatment. Around half of the respondents sought medical treatment from health institutions, mainly at a health center or hospital. Notably, around 20% of the respondents reported that they stopped having sex when they had the STI symptoms. Only, 10% said that they told their sexual partners about the STI and less than 5% reported condom use when having sex during that period. Traditional medicine was sought by 15.5% of OSY but none of the ISY.

3.1.6 HIV testing

Amongst OSY, 26.9% of males and 29.5% of females said that they knew where they could get a confidential HIV test in their community. Amongst ISY, 31.5% of males and 29.1% of females knew that the service was available in their communities.

Key indicators used in this study included the proportion of respondents reporting that they had undergone voluntary HIV testing and the proportion that had obtained the result of their test. In general, very few youth (4.6%) reported ever having had an HIV test. Data indicated that only 3.3% of the younger OSY and 6.6% of the older OSY had ever had an HIV test. Comparable proportions of ISY (4%) said that they had been tested for HIV. Almost all of those tested said the testing was voluntary. All respondents who reported having undergone voluntary HIV testing obtained the results of their test. The majority (2.6%) of respondents who had taken an HIV test reported that their most recent VCT was undertaken within the past year; this was true for all age and gender groups.

3.1.7 Exposure to interventions

Use (at least once a week in the previous four weeks) of the different types of media was examined. A considerable proportion of OSY and ISY (59 and 77.9%, respectively) listened to the radio; similarly, 63 and 80.6% of OSY and ISY, respectively, watched television. In comparison, smaller proportions of OSY (23.1%) and ISY (32.7%) read printed media.

Respondents who had heard of HIV were asked whether they had heard or seen HIV/AIDS messages on radio or TV, or seen the messages in print during the previous 12 months. Amongst ISY, 93.1% reported that they had heard HIV/AIDS messages on the radio and of these the majority (87.5%) felt that the messages were clear. A large percentage (86.8%) of ISY had seen HIV/AIDS messages on television and of these 80.8% commented that the TV messages were clear. Some 63% of ISY read about HIV/AIDS in the printed media. The most commonly read types of printed media were brochures/leaflets (66.6%) and newspaper articles (47.7%). Exposure to HIV/AIDS messages in the media was lower amongst OSY than ISY. Amongst OSY, 76% had heard about HIV/AIDS on the radio and 71% had seen TV messages. The majority (90%) of OSY who had heard or seen HIV/AIDS messages on radio or television said the messages were clear. About 43% of OSY read about HIV/AIDS in the printed media. The most commonly read types of printed media were brochures/leaflets (62.5%) and newspaper articles (52%).

Amongst ISY and OSY, there was regional variation in the coverage of radio, television and printed media messages relating to HIV/AIDS. Nevertheless, over two-thirds of the ISY and OSY reported that they had been exposed to messages on HIV/AIDS in the mass media (see Figures 3.1.11a and 3.1.11b).

Figure 3.1.11a Exposure of ISY to HIV/AIDS messages through the mass media – by type of media and region.

Figure 3.1.11b Exposure of OSY to HIV/AIDS messages through the media – by type of media and region.

3.1.8 Relationship between knowledge, behavior, VCT and perception of risk

The relationship between knowledge and behavior was investigated. Figure 3.1.12 shows the gap between knowledge and behavior amongst the youth. More than 60% of the older OSY had had premarital sex despite knowing that abstinence could protect them from HIV/AIDS. Over 33% of the OSY who knew the message ‘Be faithful’ had had more than one partner in the previous 12 months. However, ISY who knew that consistent condom use could protect them from HIV/AIDS had almost always used condoms during non-commercial sexual encounters in the previous 12 months. Compared with OSY, the ISY who had correct knowledge about HIV/AIDS prevention methods seemed to exhibit safer sexual behaviors. This seemed to indicate that education played an important role in converting knowledge into practice (sexual behavior).

Figure 3.1.12 ABC vs. sexual behavior amongst ISY and younger and older OSY.

The gap between knowledge and behavior was shown clearly by data for older OSY; this group knew that abstinence and monogamy were protective against HIV infection but were still likely to have premarital sex and more than one partner in the last year.

The practice of risky sex was also examined amongst OSY and ISY. Amongst all youth, 17.4% reported having had risky sex, with a commercial or non-commercial partner, in the previous 12 months. More male youth was engaged in risky sex than female youth (19.4% of males vs. 16.1% of females; P<0.05). Figures 3.1.13a and 3.1.13b show regional variation in the percentages of OSY and ISY who reported having risky sex during the previous 12 months.

Figure 3.1.13a Percentage of sexually active OSY who had risky sex in the last year – by region.

The highest levels of risky sex were reported by OSY in the Gambella (35.6%), Beneshangul-Gumuz (26.3%) and Afar (25.6%) regions.

Amongst ISY, around 6% had been engaged in risky sex in the previous 12 months. The most common reason all youth gave for engaging in risky sex was that they trusted their partner. More than half of the ISY and OSY respondents didn’t use a condom the last time they had sex with a non-regular partner because they trusted their partner. Amongst those with more than one partner, 72% had engaged in risky sex during the previous 12 months. These findings were examined in relation to use of VCT services. Data showed that VCT services had been used by <4% of the youth reporting risky sex in the last year.

Figure 3.1.13b Percentage of sexually active ISY who had risky sex in the last year – by region.

The effect of regular alcohol and khat use on sexual behavior amongst the youth was also examined. Amongst those who reported having had risky sex in the previous 12 months, 44% used alcohol and khat regularly.

Figure 3.1.14 Perceived effects of exposure to mass media HIV/AIDS messages on incidence of risky sex in the last year amongst ISY, and younger and older OSY.

In general, levels of risky sex were lower amongst youth who had seen HIV/AIDS messages in the mass media during the last year. HIV/AIDS information seemed to have had more impact on the ISY and younger OSY than on older OSY (see Figure 3.1.14).

Most youth respondents (93.5%) felt that they were not at risk or were at low risk for HIV infection. This was even true for OSY who reported having had risky sex (22.3%) in the last year (see Figure 3.1.15).

Figure 3.1.15 Perception of risk for HIV infection amongst OSY who had risky sex in the previous 12 months.

Amongst OSY who reported having had risky sex in the previous 12 months, a higher proportion of OSY in Somali (94.5%), Dire Dawa (93.4%) and Harari (91.8%) said that they felt at no or low risk for HIV/AIDS compared with those in other regions. Of the ISY who had risky sex in the last year (6% of total), only 21% felt at moderate or high risk for HIV/AIDS.

3.2 Female sex workers

3.2.1 Socio-demographic characteristics

Interviews were conducted with a total of 2487 female sex workers (FSW) from seven urban centers in Ethiopia (namely, Bahir Dar, Nazareth, Liben-Borena, Awassa, Gambella, Addis Ababa and Dire Dawa). Amongst the FSW, 1266 (51.1%) were hotel/bar-based, 972 (39.2%) were home-based and the remaining 240 (9.7%) were street-based. Table 3.2.1 summarizes the socio-demographic characteristics of the FSWs.

Age

Respondents were between 15 and 49 years old (mean and median = 22.2 and 21.0 years old, respectively). The majority of respondents (44.6%) were between 20 and 24 years old. Notably, however, about 30% of the respondents were young women between 15 and 19 years old.

Education

About 74% of the respondents had attended school. Mean number of years of education was 7.1 years (median = 7 years), indicating that considerable numbers of the FSWs were literate. The proportion of illiterate FSWs (52.9%) was higher in Bahir Dar than in the other urban centers (see Table 3.2.1).

Marital status

Amongst the FSWs, 41.7% had ever been married. FSWs were between 7 and 29 years old at first marriage (median = 16 years old). Most respondents (88.6%) had married when they were <19 years old; notably, 43.7% of respondents had married at <15 years old.

Only 3.8% of the FSWs were married at the time of the interview. Most of the FSWs (77.4%) were not married and did not live with a sexual partner; nevertheless, some unmarried FSWs (18.1%) were living with a sexual partner. Very few FSWs reported that they were currently married and living with their spouse (0.4%). A further 0.6% were married but lived with a sexual partner other than their husband.

Residence, mobility and employment

The majority (63.5%) of FSWs had been born in urban areas while the rest (36.4%) had been born in the countryside. However, most urban born FSWs (72.9%) were not working in the towns/cities of their birth.

Results showed considerable mobility amongst the FSWs. Duration of residence in their current town/city ranged from less than a year to 49 years (median = 2 years of residence). Most FSWs (75.0%) had resided in their current location for <5 years. About 62% of the FSWs had moved to their current locations from other towns/cities where almost 32% of them had previously been sex workers.

Only 20.3% of the FSWs reported that they were involved in income-generating activities other than sex work. Commonly, this income-generation involved the sale of local alcoholic drinks (43.6%) or employment at a bar/hotel (38.9%).

Support

Around 28% of the FSWs reported that they were supporting other people. The number of adults supported ranged from 1 to 19. Around 29% of FSWs who had people to support were supporting ³2 adults; a small proportion (2.3%) supported >5 adults. The number of children supported ranged from 1 to 8, with about 37% of FSWs supporting ³2 children.

Religion

Amongst the FSWs, 91% were Christians while 7.1% were Muslims.

Circumcision

Many of the FSWs (77.2%) were circumcised; a few FSWs (6.0%) did not know whether they were circumcised or not. Around 33% of FSWs did not know which type of circumcision had been performed on them. Amongst those who knew the type of circumcision, non-infibulation was the most common type (reported by 62.9%).

Table 3.2.1 Socio-demographic characteristics of FSW by city.

Variables

Percentage of FSWs

Bahir-Dar

(n=344)

Nazareth

(n=338)

Liben-Borena

(n=350)

Awassa

(n=348)

Gambella

(n=301)

Addis Ababa

(n=460)

Dire Dawa

(n=346)

National

(n=2487)

Age group (years)

15–19

20–24

25–30

>30

32.5

34.6

18.3

14.5

37.6

41.1

14.5

6.8

24.4

41.1

17.5

17.0

24.9

51.6

18.7

4.7

33.6

47.2

15.3

4.0

31.5

43.3

17.7

7.4

29.5

53.8

14.5

2.3

30.5

44.6

16.7

8.2

Education

Illiterate

Read & write

1–4 years

5–8 years

9–10 years

11–12 years

12+ years

52.9

1.5

10.5

26.5

6.9

1.5

0.3

21.9

1.2

12.7

44.3

17.3

2.3

0.3

29.8

0.6

14.9

38.9

11.7

3.4

0.6

10.3

2.3

19.3

44.3

15.5

8.3

0.0

21.6

1.7

16.6

43.2

13.3

3.3

0.0

27.9

1.5

10.6

33.5

19.8

5.6

0.6

14.7

0.8

16.2

44.2

18.2

5.8

0.0

25.8

1.4

14.2

38.9

14.9

4.4

0.3

Currently married

Living with spouse

Living with other sexual partner

Not living with spouse or other sexual partner

Currently unmarried

Living with sexual partner

Not living with sexual partner

1.5

1.5

1.5

37.8

56.7

0.3

0.0

0.9

26.0

72.8

0.6

0.6

3.4

15.7

79.4

0.0

0.6

0.9

15.5

82.5

0.0

1.7

8.3

15.6

74.0

0.0

0.2

4.1

11.5

81.7

0.3

0.0

0.3

6.9

92.0

0.4

0.6

2.7

18.1

77.4

Lived in current place (years)

Less than 5

5–10

More than10

60.8

18.1

21.1

80.8

10.9

8.3

67.6

10.3

22.1

89.6

9.0

1.4

82.8

12.5

4.7

64.6

18.9

16.5

81.9

8.8

9.4

75.0

12.8

12.2

Circumcision (Yes)

Type of circumcision

Non-infibulation

Infibulation

Do not know type

63.3

25.8

0.5

69.1

74.9

53.8

0.4

45.1

82.6

75.1

0.7

23.9

85.6

99.3

0.0

0.3

89.4

55.8

0.4

43.5

72.8

35.3

1.2

46.8

74.3

90.3

1.2

8.6

77.2

62.9

0.6

32.8

3.2.2 STI/HIV/AIDS and related knowledge

Summaries of BSS indicators, and BSS knowledge indicators and components are presented in Annexes 3A and 3B.

Knowledge of STI symptoms

To assess general knowledge about STIs, all FSWs were asked whether they had heard of diseases that could be transmitted through sexual intercourse. Most FSWs (95.3%) had heard of STIs. Those who were aware of STIs were asked to describe the symptoms of STIs, for men and women separately (N.B. the symptoms were not read out). Table 3.2.2 summarizes the FSWs’ responses. For STI in women, the most commonly mentioned symptoms were genital discharge, followed by burning pain on urination and foul smelling discharge. For STI in men, genital discharge was also the most commonly mentioned symptom, followed by burning pain on urination and genital ulcers/sores.

Table 3.2.2 Knowledge of STI symptoms amongst FSW who were aware of the existence of STIs.

Variables

Percentage of total

(n = 2371)

Know female STI symptoms

- Genital discharge

- Burning pain on urination

- Foul smelling discharge

- Genital ulcers/sores

- Abdominal pain

- Swelling in groin area

- Itching

- Others

- No response

Know male STI symptoms

- Genital discharge

- Burning pain on urination

- Genital ulcers/sores

- Swelling in groin area

- Others

- No response

51.6

48.5

41.0

29.0

25.0

15.1

12.5

7.1

9.9

45.7

39.6

34.8

20.4

11.3

15.1

Knowledge and misconceptions about HIV/AIDS

The vast majority (98.2%) of FSWs had heard of HIV or AIDS. About 70% of FSWs said that they knew someone who was infected with HIV or had died of AIDS. Amongst this group of respondents, 7.0% said it was a close relative and 21.9% said it was a close friend; 65.4% said it was neither a close friend nor a relative.

Misconceptions about HIV transmission and knowledge of HIV prevention methods were used to indicate the FSWs’ knowledge about HIV/AIDS.

Amongst FSWs, 66.7% identified all three major methods for preventing HIV/AIDS. The majority (85.5%) of FSWs knew that correct and every time use of a condom when having sex was one of the three ways to prevent HIV/AIDS. Faithfulness with one uninfected partner and abstinence were mentioned as prevention methods against HIV/AIDS by 80.1 and 79.3% of FSWs, respectively. However, for FSWs, consistent condom use to reduce the risk of contracting HIV is the only appropriate primary prevention method.

Overall 89.7% of the FSWs had at least one misconception. Over half (53.4%) of the respondents believed that mosquito bites could spread HIV. Moreover, 23.2% of FSWs believed that sharing a meal with a person who is infected with HIV could transmit the virus. Another 23.1% of the FSWs did not think that a healthy looking person could be infected with HIV. With regard to local (country-specific) misconceptions, about 77 and 53% of respondents, respectively, thought that HIV could be acquired by eating raw eggs laid by a chicken that had swallowed a used condom or by eating raw meat prepared by a person infected with HIV. Another 20% of the FSWs believed that people could protect themselves from HIV by drinking local hard liquor or by eating hot pepper (berbere/mitmita).

Most respondents (94.3%) mentioned the shared use of needles as a mode of HIV transmission.

In terms of the UNAIDS indicator of ‘no incorrect belief’, which consists of only three of the misconceptions (see Annex 3B), about one third of the respondents correctly identified the misconceptions.

Comprehensive knowledge about HIV/AIDS was defined as knowledge of the three prevention methods and absence of misconceptions about HIV/AIDS transmission. By these criteria, only 23.7% of the FSWs had comprehensive knowledge.

Between the towns/cities, there were some variations in the knowledge and misconceptions of FSWs about HIV/AIDS (see Figure 3.2.1). For example, knowledge of the three preventive methods was least amongst FSWs in Gambella (45.2%) and highest among those in Dire Dawa (76.9%). Misconceptions about HIV/AIDS transmission (level of incorrect beliefs in terms of the three UNAIDS indicators) were widespread amongst FSWs in Bahir Dar (80.5%), Liben-Borena (78%) and Addis Ababa (75.9%). Notably, despite relatively high levels of HIV intervention activities, FSWs in Addis Ababa were amongst the least knowledgeable; this was true in terms of knowledge of preventive methods, levels of misconceptions and the total score for comprehensive knowledge about HIV/AIDS. FSWs in Dire Dawa had fewer misconceptions than FSWs in other towns/cities.

Figure 3.2.1 Knowledge and misconceptions of FSWs by city.

Knowledge about condoms

FSWs were asked about their awareness of and accessibility to condoms. Nearly all FSWs knew about male condoms. Even amongst those respondents who had never used condoms (n = 182), 83% said that they had heard of them.

The majority of FSWs (99.3%) said that they knew where they could obtain male condoms; the most commonly mentioned sources were shops (87.8%), bars/hotels (57.2%), pharmacies (45.2%), health centers/hospitals (31.7%) and family planning centers (20.4%).

According to 95.9% of FSWs, male condoms were available at locations close to (i.e. <30 min away from) their living or work places. At the time of the interview, the number of condoms in the possession of each FSW ranged from nil (23.8%) to 402 condoms (one person), with a median of three condoms.

Less than half of the FSWs (43.6%) had heard of female condoms. Overall, slightly higher proportions of street-based FSWs (59%), and FSWs in Dire Dawa (56.3%) and Addis Ababa (51.5%) had heard of female condoms.

Stigma and discrimination

Various questions relating to stigma and discrimination (see Annex 3B) were used to assess FSWs’ attitudes towards PLWHA.

Most respondents (87%) were willing to care for relatives who become ill with AIDS. Moreover, most FSWs (77.7%) felt that if a member of their family had AIDS it should not be kept a secret. Nevertheless, a considerable amount of discrimination towards PLWHA was observed. Overall, 88.1% of the respondents had at least one stigmatizing attitude towards PLWHA. Amongst FSWs, 44.3% were unwilling to share a meal with a person they knew who had HIV/AIDS. Furthermore, 62.7% said that they would not be willing to buy food from a shopkeeper or food seller who was known to have HIV. In addition, 68.5% thought that PLWHA should be quarantined in health care facilities.

Figure 3.2.2 indicates the proportion of FSWs in each city who had at least one stigmatizing attitude towards PLWHA. Data show variation amongst the attitudes of FSWs in the different cities; stigma and discrimination seemed to be least amongst FSWs in Awassa.

Figure 3.2.2 Percentage of FSWs with at least one stigmatizing attitude towards PLWHA – by city.

Mother-to-child transmission of HIV/AIDS

FSWs were asked various questions relating to mother-to-child transmission of HIV. The majority of respondents (83.6%) knew that a woman who was HIV positive could transmit the virus to her unborn child. Amongst this subgroup, the majority (85.1%) knew that a woman with HIV could transmit the virus to her newborn child through breast-feeding (see Annex 3B).

Respondents who were aware that HIV could be transmitted to an unborn child were asked what actions a pregnant woman could take to reduce mother-to-child transmission of HIV. Only 9.5% of FSWs who were asked this additional question said that the woman could take antiretroviral (ARV) medication. Other responses given by the FSWs were abortion (13.9%), nothing could be done (36.6%) and don’t know (21.0%). Results indicate that most respondents had no idea that it was possible to reduce mother-to-child transmission during pregnancy.

3.2.3 Alcohol and drug use

Overall, 79% of the FSWs had consumed drinks containing alcohol in the previous four weeks. This subgroup of respondents was asked about the frequency of their drinking; 72% of them reported regular alcohol use and about 33% reported that they drank alcohol everyday. More than half (56.1%) of the regular alcohol users were based in hotels or bars, 36% of them were home-based and the rest (7.9%) were street-based. Amongst the FSWs who drank any alcohol during the previous four weeks, the highest levels of regular alcohol use were found amongst FSWs in Awassa (89.7%) and Nazareth (88.5%); the smallest proportion of regular alcohol users (44.3%) was found amongst FSWs in Addis Ababa (see Figure 3.2.3).

Figure 3.2.3 Regular alcohol and khat use amongst ‘ever users’ – FSWs by city.

Overall, 52.2% of the respondents had ever used a drug. The most commonly mentioned drug was khat (51.7%), followed by shisha (8.8%) and hashish (1.2%). Table 3.2.3 shows the proportion of FSWs who had ever used each specific type of drug.

Table 3.2.3. ‘Ever use’ of specific types of drugs by FSW.

Category of FSW

Number (%)

Khat

Shisha

Benzene

Hashish

Mandrax

Cocaine

Crack

IDU*

Hotel/bar-based

703 (55.5)

114 (9.0)

7 (0.6)

12 (0.9)

0 (0.0)

0 (0.0)

0 (0.0)

8 (0.6)

Home-based

438 (45.1)

64 (6.6)

7 (0.7)

13 (1.3)

0 (0.0)

3 (0.3)

0 (0.0)

5 (0.5)

Street-based

141 (58.8)

40 (16.7)

5 (2.1)

5 (2.1)

0 (0.0)

0 (0.0)

0 (0.0)

2 (0.8)

*IDU = injecting drug user

About 80% of those who had ever used khat had used khat regularly during the previous four weeks. A very high proportion of FSWs in Dire Dawa (96.9%), Awassa (93.2%) and Nazareth (91.4%) had used khat regularly during the previous four weeks. The smallest percentage of regular khat users was observed amongst FSWs in Gambella (40%).

More than 66% of the FSWs were regular khat and alcohol users.

3.2.4 Sexual behavior

Amongst those FSWs who knew/remembered the age at which they first had sex, 90.8% reported that they were <19 years old. Worryingly, 49.9% reported that they were <15 years old.

Age when respondents first received money for sex ranged from 10 to 40 years old (mean and median = 19.2 and 19 years old, respectively). A small group of FSWs (8.2%) started to sell sex when they were <15 years old. On average, street-based FSWs started selling sex at younger ages than their hotel/bar- or home-based counterparts (18.2 vs. 19.2 and 19.5 years old, respectively, for street-based vs. hotel/bar- and home-based FSWs; P<0.001).

The most commonly mentioned reasons for becoming a sex worker were financial problems (36%), divorce/separation (18.4%) and disagreement with people they lived with (18.4%). A further 14% of the respondents said that they personally chose to become FSWs.

The amount of money received by FSWs in exchange for sex varied greatly, ranging from no charge to ETB 800 (US$ 1 = ETB 8.5 in May 2002). The FSWs received an average payment of ETB 41.7 the last time they had sex with a client. Accordingly, 52.1% of the FSWs reported that the last time they had sex with a client they had received between ETB 21 and 50. A lesser proportion (18.4%) of FSWs received between ETB 11 and 20. About 6% of the respondents reported receiving ETB 5 or less. On average, home-based FSWs had received smaller payments than their street- or hotel/bar-based counterparts the last time they had sex with a client. (ETB 20.2 for home-based vs. ETB 54.5 for street-based and ETB 55.1 for hotel/bar-based FSWs; P<0.001).

Number and type of sexual partners

FSWs were asked about their sexual partners in the previous seven days. They were asked how many of their partners were ‘paying clients’ and how many were ‘non-paying partners’.

FSWs reported having between nil and 84 paying clients in the previous seven days (median = 3 clients). A small proportion of FSWs (3.9%) reported that they had no clients in the previous seven days and 5.2% of FSWs did not know/remember how many clients they had had. A further 24.7% of FSWs reported having five or more clients over the previous seven days. Figure 3.2.4 shows the proportion of FSWs in the different cities who had 0, 1-4 and >5 clients during the previous seven days. FSWs in Addis Ababa and Nazareth had the highest numbers of clients; 45.1 and 44.8% of them, respectively, had had >5 clients.

About a third (34.5%) of FSWs reported having non-paying partners over the previous seven days, numbers ranged from 0 to 9 (median = one partner). Only 3.5% of FSWs had two or more non-paying partners. A further 8.3% of FSWs didn’t know/remember how many non-paying partners they had had over the previous seven days.

Figure 3.2.4 Numbers of clients reported by FSWs during the previous seven days – by city.

The median number of different sexual partners (paying and non-paying) during the previous seven days was three. Five or more different partners were reported by 30% of the FSWs. A few (5.4%) of the FSWs didn’t know/remember how many different sexual partners they had had over the previous seven days. On average, home-based FSWs had had a greater number of sexual partners during the previous seven days than their street- or hotel/bar-based counterparts (8.1 partners for home-based vs. 4.0 for street-based and 3.3 for hotel/bar-based FSWs; P<0.001).

Over 90% of the FSWs reported having at least one client on their most recent day of work.

Condom use

Results relating to condom use were encouraging; 91.6% of FSWs had used a condom the last time they had sex with a paying client. Findings were also positive with respect to the level of influence the FSWs had on condom use; 95.3% of those who used a condom were involved in the decision to use the condom (suggested by FSW in 52% of cases and as a joint decision by FSWs and clients in 43.3% of cases). Disaggregating condom use by FSW category showed that 93.9% of the home-based FSWs as compared with 98.6% of hotel/bar- and street-based FSWs had used a condom the last time they had sex with a paying client. Level of condom use by FSWs at the last sexual encounter with a paying client also showed some differences between the various cities; 100% of FSWs in Dire Dawa but only 80.2% of FSWs in Bahir Dar reported last-sex condom use.

Nevertheless, 27.1% of FSWs reported that they did not use a condom the last time they had sex with a non-paying partner; a further 17.5% of FSWs did not remember/respond to the question. The three most common reasons given for not using a condom at the last sexual encounter with a non-paying partner were: trusting the partner (42.2%), partner objection (22.4%) and use of other contraceptives (12.9%). Although only 55.4% of FSWs used a condom with their non-paying partner at the last sexual encounter, 92.3% of them were involved in the decision to use the condom.

Table 3.2.4 summarizes the four most common reasons given by the FSWs for non-use of condoms at their last-time sex; data are displayed by partner type (i.e. separately for paying clients and non-paying partners). It is particularly worrying to note that 28.9% of the FSWs who didn’t use a condom said that they had not used condoms with paying clients because they trusted them.

Reason given for non-use of condom

Percentage (%)

Paying clients

(n = 76)

Non-paying partners

(n = 161)

I trust my partner

28.9

42.2

Partner objected

22.4

22.4

Didn’t think it was necessary

11.8

7.5

I was drunk

9.2

–

Used other contraceptives

–

12.9

Table 3.2.4 Reasons commonly given by FSWs for non-use of condoms at last sexual encounters with paying clients and non-paying partners.

Consistent use of condoms was also high amongst FSWs. Most FSWs (90.8%) had used condoms with all paying clients during the previous 30 days; moreover, 70.5% of FSWs had consistently used condoms with their non-paying partners during the previous 12 months. Home-based FSWs had used condoms with paying clients less consistently than their hotel/bar- or street-based counterparts (87.8 vs. 94.8%, respectively). There was regional variation in the consistent use of condoms with paying clients; consistent use was highest among FSWs in Dire Dawa (98.6%) and least among those in Liben-Borena (78.0%).

Respondents who had not used condoms with their most recent partners (n = 137) were asked whether they had ever used male condoms; 36.5% said they had used condoms previously.

During the previous 12 months, 9.7% of FSWs reported that one or more of their sexual partners had forced them to have sex without their consent. Moreover, 13.5% of the respondents reported that they had been forced to have sex with an unknown person at sometime in their lives.

3.2.5 STIs and treatment seeking behavior

Respondents were asked whether they had experienced any genital discharge and/or genital ulcers during the previous 12 months. Overall, 4.9% of the FSWs reported having had STIs (genital discharge or ulcer/sore). The proportion of FSWs who had had symptoms of STIs during the previous 12 months is shown in Table 3.2.5.

Table 3.2.5 Percentage of FSWs who reported having had an STI in the past 12 months by category.

Symptoms

Percentage

Hotel/bar-based

(n =1266)

Home-based

(n = 972)

Street-based

(n = 240)

Genital discharge

2.1

7.4

2.5

Genital ulcers/sores

1.7

6.0

1.7

FSWs who had experienced an STI during the previous 12 months were asked what treatment they had received. A list of treatment behaviors was read out to the respondents and they could answer in one of four ways: yes, no, don’t know or no response. Multiple responses were possible. In general, 83.5% of the FSWs had sought medical care from health service institutions. The two most commonly mentioned health service institutions were government clinics/hospitals (50.0%) and private clinics/hospitals (29.2%). Other actions mentioned included: stopping sexual activities at the time when symptoms were present (20.8%); seeking advice from peers/friends about the symptoms (19.2%); and seeking advice/medicine from a private pharmacy (14.9%). About one in ten (9.2%) of the FSWs with a history of STI sought advice/medicine from a traditional healer or took traditional medicine they had at home.

When asked what they did first, 35.6% of FSWs mentioned that they sought advice/medicine from a government clinic/hospital. FSWs were also asked how long they waited after experiencing symptoms before they sought advice/medicine from a health worker in a clinic/hospital; 45.1% said they sought treatment within a week of experiencing symptoms of STIs. Most (79.6%) of the respondents said they had received a prescription for the medicine and the majority (>90%) had obtained and taken all the prescribed medicine.

FSWs reported that the cost of STI medication ranged from free treatment to ETB 200 (mean and median = ETB 35.5 and 28.0, respectively); 15.3% of FSWs received free treatment.

3.2.6 HIV testing

FSWs were asked various questions relating to HIV testing. These included questions assessing their knowledge of the existence of confidential testing facilities in the community, issues of disclosure of results, voluntary testing and the procedure for obtaining test results.

Overall, only 31.1% of respondents said that it was possible to get a confidential HIV test in their community; between towns/cities the percentages varied from 58% in Awassa to 5.8% in Dire Dawa. As few as 7.7% of the sex workers said that they had ever had an HIV test; of these, 73.8% said that testing was voluntary. Most (91.4%) of those who had taken an HIV test reported that they had obtained the results of their test. Not all HIV testing was carried out in conjunction with counseling; for example, only 81.8 and 77.5% of the tested respondents had received pre- and post-test counseling, respectively. Around 60% of the FSWs who had been tested, had taken their most recent test within the previous year. Many FSWs (81.9%) said that they would be willing to undergo VCT if the services were made available to them.

3.2.7 Exposure to interventions

Respondents were asked about their general exposure to the mass media during the previous four weeks and specific exposure to HIV/AIDS messages in the previous 12 months. Results showed that radio, television and the printed media had been used, at least once a week over the previous four weeks, by 74.4, 38 and 14.9% of the respondents, respectively. Notably, 28.7, 46.6 and 67.9% of the respondents did not use radio, TV and printed media, respectively.

Amongst the respondents, 78.1, 61.6 and 26.6%, respectively, had listened to, watched and read messages about HIV/AIDS during the previous 12 months. Most (83%) of the FSWs had been exposed to messages about HIV/AIDS through radio, TV or printed materials. The vast majority of respondents thought that radio and TV messages about HIV/AIDS were clearly stated (93.2 and 94.5%, respectively). Amongst the printed media, the most commonly seen or read articles about HIV/AIDS were those printed on brochures/leaflets (64.6%) followed by those in newspapers (44.7%).

Figure 3.2.5 shows the geographic variation in exposure of FSWs to mass media messages on HIV/AIDS issues. Radio messages had reached a considerable proportion of FSWs in all cities, except Gambella. Television messages had reached a considerable proportion of FSWs in Dire Dawa, Nazareth and Liben-Borena cities. In all cities, printed materials were the least penetrative media, although they reached a substantial proportion (42.4%) of FSWs in Awassa. Amongst printed materials, those read most often by FSWs in Awassa were brochures/leaflets (68.7%) and magazine/newspaper articles (51%).

Figure 3.2.5 Percentage of FSWs who had been exposed to mass media messages about HIV/AIDS in the previous 12 months – by type of media.

Only 4.1% of the respondents knew of a FSW support group in their community; amongst this group, 52.4% had attended a FSW support group during the previous 12 months. Almost half of the FSWs (48%) had discussed HIV/AIDS with partners, family members or someone from the community. Nevertheless, interaction of the FSWs with targeted community interventions was very poor. Only 15.2% participated in anti-AIDS activities and only 14.5% had been in contact with outreach workers, mostly government health service providers who gave them counseling on HIV/AIDS, in the previous six months. Furthermore, in the previous 12 months, peer educators at social venues (such as youth clubs and religious places) had approached only 15.6% of the respondents. In addition, only 12.4% of FSWs had attended any community events in which issues on HIV/AIDS were discussed or presented. Overall, 60.5% of the FSWs had participated in or had been exposed to at least one of the above community interventions during the previous 12 months.

3.2.8 Relationships of knowledge, behavior and perception of risk

Analysis of knowledge and misconceptions with respect to socio-demographic factors showed that literate FSWs were about 3-times less likely to have misconceptions than their illiterate counterparts (P<0.001). Level of education had no effect on the FSWs’ knowledge about preventive methods for HIV/AIDS. Exposure to mass media messages about HIV/AIDS was significantly and positively associated with knowledge of the three preventive methods and lack of misconceptions (P<0.001).

The relationship between FSWs’ knowledge and sexual behavior was examined. Knowledge that correct and consistent condom use could protect from HIV infection was positively associated with condom use at last sexual encounter with a paying client. Accordingly, 93.8% of FSWs who knew about correct and consistent condom use compared with only 78.3% of FSWs without this knowledge had used a condom at their last sexual encounter with a paying client (P<0.001). Moreover, 92.1% of FSWs who knew about correct and consistent condom use compared with only 81.6% of FSWs (P<0.001) without this knowledge used condoms consistently with paying clients during the previous 30 days.

Other factors significantly associated with the use of condoms included education, alcohol and drug use, exposure to media and personal risk perceptions. For example, considerably more literate than illiterate FSWs (97.3 vs. 86.6%; P<0.001) had used condoms consistently during sexual encounters over the previous 30 days.

The role of the media in shaping the HIV/AIDS knowledge and practice of FSWs was examined. Most (89%) of the FSWs who had been exposed to HIV/AIDS messages in the previous 12 months, through at least one of the media channels (i.e. radio, TV or printed media), knew that correct and consistent use of condoms during sex could prevent HIV infection; in contrast, only 78% of FSWs who had not been exposed to media messages had similar knowledge (P<0.001). Furthermore, exposure to media messages had a positive effect on the level of misconceptions relating to HIV/AIDS amongst FSWs; there were no misconceptions about HIV/AIDS amongst 34.7% of FSWs exposed to media messages but only 24.4% of those who were not exposed to media messages were without misconceptions (P<0.001).

FSWs who were exposed to HIV/AIDS messages, through at least one of the mass media channels, were twice as likely to have used condoms during their most recent commercial sex encounter than FSWs who were not exposed to mass media HIV/AIDS messages (odds ratio (OR) = 2.23; 95% confidence interval (CI) 1.57, 3.18).

FSWs were asked to rank their chances of becoming infected with HIV (as no chance, low, moderate or high chance) based on their past sexual and other risk behaviors. Many FSWs (38.3%) could not rank their chance of contracting the HIV infection. However, 16.7 and 15.6% of the FSWs perceived their chances of contracting HIV to be high and moderate, respectively; a further 16.4% said there was a low chance and the remaining 9.7% thought there was no chance that they would become infected.

Respondents were asked to give reasons for their personal perceived risk of HIV infection. The majority (86.5%) of FSWs who perceived their risk as nil or low, said that they always used condoms and 35% said sterile needles had been used whenever they had received injections. Amongst the FSWs who perceived their risk of HIV infection as moderate or high, the most common reason given was that they had multiple sexual partners. Other reasons given for personal perceived risk of HIV infection included condom breakage (46.9% of respondents) and sex without a condom (23.1% of respondents).

Data indicated that 65.1% of FSWs who practiced unprotected sex at their last commercial sex encounter and 73.7% of FSWs who didn’t use condoms consistently with paying clients during the previous 30 days perceived themselves at medium or high risk of HIV infection. Personal risk perception amongst FSWs was found to be associated significantly with attitudes towards PLWHA. Respondents who perceived their chance of acquiring HIV as moderate or high were three-times more likely to have accepting attitudes to PLWHA than were respondents who perceived their risks as nil or low.

Figure 3.2.6 summarizes, by town/city, the FSWs’ personal perceptions of risk for HIV infection. More than 60% of FSWs in the towns/cities of Gambella, Liben-Borena, Nazareth and Bahir Dar perceived their risk of HIV infection as moderate or high.

Figure 3.2.6 Personal perception of risk for HIV infection amongst FSWs – by city.


Target group	Number (%)
	Khat			Shisha	Benzene	Hashish	Mandrax	Cocaine	Crack	IDU*
	Males	Females	Total
ISY	507 (16.4)	92 (2.9)	599 (9.69)	55 (0.9)	11 (0.2)	1 (0.0)	0 (0.0)	0 (0.0)	8 (0.1)	36 (0.6)
Younger OSY	1131 (31.5)	393 (11.0)	1524 (21.2)	280 (3.9)	23 (0.3)	23 (0.3)	4 (0.1)	4 (0.1)	5 (0.1)	59 (0.8)
Older OSY	1837 (52.6)	637 (18.7)	2474 (35.9)	483 (7.0)	10 (0.1)	28 0.4)	2 (0.0)	1 (0.0)	1 (0.0)	49 (0.7)


Symptom	Percentage
	ISY		Younger OSY		Older OSY
	Males (n = 274)	Females (n = 257)	Males (n = 783)	Females (n = 574)	Males (n = 1679)	Females (n = 1026)
Genital discharge	1.8	0.8	5.7	6.1	5.2	5.6
Genital ulcers/sores	1.4	0.0	3.3	3.3	3.2	3.2


Category of FSW	Number (%)
	Khat	Shisha	Benzene	Hashish	Mandrax	Cocaine	Crack	IDU*
Hotel/bar-based	703 (55.5)	114 (9.0)	7 (0.6)	12 (0.9)	0 (0.0)	0 (0.0)	0 (0.0)	8 (0.6)
Home-based	438 (45.1)	64 (6.6)	7 (0.7)	13 (1.3)	0 (0.0)	3 (0.3)	0 (0.0)	5 (0.5)
Street-based	141 (58.8)	40 (16.7)	5 (2.1)	5 (2.1)	0 (0.0)	0 (0.0)	0 (0.0)	2 (0.8)


Reason given for non-use of condom	Percentage (%)
	Paying clients (n = 76)	Non-paying partners (n = 161)
I trust my partner	28.9	42.2
Partner objected	22.4	22.4
Didn’t think it was necessary	11.8	7.5
I was drunk	9.2	–
Used other contraceptives	–	12.9


Symptoms	Percentage
	Hotel/bar-based (n =1266)	Home-based (n = 972)	Street-based (n = 240)
Genital discharge	2.1	7.4	2.5
Genital ulcers/sores	1.7	6.0	1.7