4. Qualitative Results

A total of 24 focus group discussions (FGD) and 23 individual in-depth interviews (IDI) were conducted with the in-school and out-of-school youth (ISY and OSY), factory workers, truckers, intercity bus and minibus drivers, pastoralists, farmers and female sex workers (FSWs) (see Annexes 5A-D for numbers and characteristics of the FGD and IDI participants).

In this section, the results are presented separately for each target group. FGD and IDI participants are referred to as discussants and interviewees, respectively. When referring to a combination of discussants and interviewees, the term ‘participants’ is used.

4.1 In- and out–of-school youth in three regional cities (Dire Dawa, Bahir Dar and Jijiga)

4.1.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS

Modes of transmission

Almost all of the ISY and OSY participants knew that unprotected sexual intercourse or the sharing of sharp objects (blood contaminated) with an infected person could transmit HIV; this was mentioned during all FGDs and IDIs in the three cities. Moreover, a few participants mentioned mother-to-child transmission during pregnancy and breastfeeding, transmission by blood transfusion, transmission from contaminated medical equipment and transmission during traditional malpractices that involve cutting (e.g. uvulectomy). Misconceptions relating to HIV transmission included transmission by sharing clothes or kissing.

Methods of prevention

In all three cities, almost all the female and the majority of male participants were able to name the three major preventive methods (i.e. abstinence, faithfulness and condom use). However, in Jijiga a few male participants were unable to name the three major methods correctly. Females were more aware of preventive methods than males.

4.1.2 Relationship between HIV infection and other STIs

All female participants, irrespective of the target region, mentioned syphilis and gonorrhea as examples of STIs. All participants (male and female) said that both STIs and HIV were transmitted by sexual contact. In Dire Dawa and Bahir Dar, male and female participants said that infection with STIs facilitated the transmission of HIV infection. The reason given was that wounds resulting from STIs facilitated transmission of HIV. In Jijiga, males were not able to point out the relationship between HIV infection and other STIs beyond describing both STIs and HIV as sexually transmitted diseases. Male participants, at all locations, mentioned that AIDS does not have a cure while other STIs do have cures. The males also commented that condom use could prevent STIs but that solely using condoms could not prevent HIV infection.

4.1.3 Misconceptions about HIV/AIDS, its transmission, and condoms and their effects

Various misconceptions existed amongst the youth. Both female ISY and OSY focus groups in Jijiga and Dire Dawa mentioned similar misconceptions. The first misconception, described by females, related to the use of stimulants (drugs) such as khat and alcohol by male youth. According to the females in Dire Dawa, male youths were saying, ‘There is no HIV/AIDS after 2.00 pm [1400 hours].’ This was the time (1400 hours) when the male youths started to chew khat. Use of khat stimulated and encouraged the male youths to forget their fear of HIV/AIDS. Similarly, according to female youths in Jijiga the male youths were saying, ‘There is no HIV/AIDS after 10.00 pm [2200 hours].’

The second misconception related to sexual pleasure when using a condom. The male youths in Jijiga were saying, ‘Having sex using condoms is like eating chocolate together with its cover.’

The third misconception seemed to be deeply rooted. According to the females in Dire Dawa the males were saying, ‘The lubricant in the condom itself has the virus’ and ‘It [HIV] is designed to destroy us, the Africans.’ In Jijiga, the female OSY discussants strengthened this idea by suggesting reasons for their belief. They asked one related question, ‘Why is a condom so cheap in Ethiopia when it is expensive in developed countries?’ This was a point of discussion and argument for some of the youth when trying to justify why the youth was not interested in using condoms. The above concern was also shared by female ISY and OSY discussants in Bahir Dar, where they associated low cost with ‘poor quality of condoms’. In Dire Dawa, the youths were saying, ‘There are people who believe that HIV/AIDS became widely spread in our country after people started to use condoms.’

Male groups of ISY and OSY in Dire Dawa both mentioned the belief that ‘condoms cause HIV infection’. In Bahir Dar, participants agreed that this type of thinking was common. In addition, males in Bahir Dar mentioned a further misconception that, ‘Raw eggs and raw meat also transmit the HIV infection.’

The male ISY interviewee in Dire Dawa said, ‘I do not trust condoms.’ He believed that condoms were a cause of the spread of the disease. He also discouraged care to HIV/AIDS patients because it sustained the spread of the disease. In contrast, in Dire Dawa, the male OSY interviewee felt that there were no misconceptions, especially in recent times.

In Jijiga, according to the youth, there were additional misconceptions amongst Somali people >40 years old. The older Somalis believed that, ‘HIV/AIDS is a disease of the Christians and the Amhara [non-Somalis]’; this was assumed because they thought that Muslims were not involved in premarital sex and extramarital affairs.

Implications of the misconceptions

Both discussants and interviewees stated clearly that the youth was suspicious of condoms and refrained from using condoms for fear of getting the virus from the lubricant. Therefore, although condoms were readily available, the actual use of condoms was low unless partners were commercial sex workers. Most of the youth gave great emphasis to protecting themselves from sharp objects rather than protecting themselves during sexual contact. Misconceptions relating to condoms were masking the main mode of transmission i.e. heterosexual transmission.

4.1.4 Stigma and attitudes towards PLWHA

During FGDs it was noted that some of the youth, especially those belonging to anti-AIDS clubs, had better attitudes than other members of the general population towards PLWHA. These youths prepared food and washed clothes for, and were friends to PLWHA. However, amongst the general population there were problems; for example, because of stigma and discrimination PLWHA were not able to rent houses or have somebody to care for them. Moreover, some people were scared that simply touching PLWHA could transmit the virus.

One female discussant from Dire Dawa talked about a woman who was believed to be HIV positive. The discussant said, ‘When we, the anti-AIDS club members, went to talk to her, she told us not to come to her house again but to meet her at the kebele.’ She was afraid that the people around her would make her an outcast if they knew that she had the virus. A similar example was mentioned by the OSY discussants from Jijiga. The female OSY interviewee from Dire Dawa mentioned that she faced opposition from her family and other people because she was caring for an AIDS patient.

Interviewees from all cities said, ‘The youths have positive attitudes towards PLWHA.’ They all said that they were willing to provide their support and care for PLWHA. One of them, from Dire Dawa, had already started to provide care to a neighbor who was suffering from AIDS.

Male participants in Dire Dawa and Bahir Dar revealed that PLWHA were rejected and stigmatized by most community members. However, the male OSY interviewee felt that stigmatization was decreasing. In Jijiga, with the exception of the male OSY interviewee, all agreed that there was some kind of rejection and stigmatization of PLWHA. They pointed out that HIV positive people did not want to expose themselves for fear of rejection by the community. However, they believed attitudes amongst the youth were changing and that the youth had started to be involved in HIV/AIDS care and support activities.

4.1.5 Voluntary counseling and testing (VCT)

Female interviewees in Dire Dawa said that they were not aware whether VCT services were available in their area. The male ISY interviewee in Dire Dawa (15 years old) said he had never heard of VCT in his area but that he knew there was ‘a testing machine’ in Addis Ababa. Some ISY and OSY discussants in Dire Dawa mentioned that they had heard of VCT services but felt that they were too expensive (50 Ethiopian birr (ETB); US$ 1 = ETB 8.5 in August 2002). The female discussants in Dire Dawa stated that, ‘If the service puts emphasis on being voluntary, it has to be free of charge.’ Many youths, especially members of anti-AIDS clubs, wanted to have VCT; however, they had not undergone VCT because it was not free-of-charge. Nevertheless, they said, ‘Knowing our HIV status is very advantageous in that we will take care of ourselves much better than before.’

In Jijiga, male interviewees, and female discussants and interviewees said that the VCT service was not available in their area. Female discussants said, ‘Most of the youth may not be willing to be tested because of stigmatization.’ However, female ISY and OSY expressed their willingness to be tested.

Unlike the participants in the other towns, in Bahir Dar, both the focus group discussants and the individual interviewees were aware that VCT services were provided at the zonal hospital in Bahir Dar.

4.1.6 Influence of knowledge, education and religion on behavior

Knowledge

Female participants said that although they expected informed individuals to behave better, in general, those with knowledge of HIV preventive methods did not adapt their behavior accordingly. No behavioral changes were observed in the youth although almost all had knowledge of the preventive methods. This lack of behavioral change was related to widespread misconceptions, drug abuse and unemployment.

The male discussants from Dire Dawa and Jijiga commented on this problem from two angles. The OSY discussants mentioned that practice of safe behavior was influenced positively by knowledge of preventive methods. When considering practices of the youth, the discussants felt that the ISY at lower grades were at higher risk because they did not have knowledge of how to protect themselves. Conversely, when the youths completed 12^th Grade, most were unemployed; observation of these OSYs showed that they were exposed to high-risk behaviors despite their knowledge of preventive methods.

Education

Female discussants in Jijiga and ISY and OSY interviewees in Dire Dawa and Bahir Dar said, ‘The educated ones are the most exposed to the disease. They have risky behaviors.’ The female discussants in Dire Dawa commented that education did not seem to have any effect. They felt that rather than educational level, the most important thing determining the practice of preventive methods was an individual’s personal strength and nerve.

In Dire Dawa, the female discussants used a nickname, ‘sugar daddy’, for relatively wealthy older men who had relationships with young girls. These men were usually educated but insisted on having sex with the girls without using condoms. Most girls who were commercial sex workers, refused to have sex without a condom; however, there were occasions when men had forced them to have sex without a condom where they shouted for help and were saved by the police. Girls who were not commercial sex workers, usually agreed to have sex without a condom in order to receive money from the ‘sugar daddies’. According to the female discussants, in spite of their level of education, behavior of the ‘sugar daddies’ was dangerous to the community. The female OSY interviewee from Dire Dawa said, ‘Educational level does not matter in the case of HIV/AIDS.’ She said that what matters is ‘the individual’s thinking’.

In Bahir Dar, with the exception of the ISY discussants, all participants commented that educational level did not alter behaviors related to HIV/AIDS. It was pointed out that educated individuals were observed to be involved in risky sexual behaviors.

The male ISY and OSY discussants from Dire Dawa and Jijiga, believed that education contributed to self-protection and that as education level increased, risky sexual behavior decreased. However, those who were educated (12^th Grade complete) and yet unemployed were involved in risky behavior, attributing this behavior to unemployment and hopelessness. The male OSY interviewee said, ‘Educational status has no contribution because we are observing that those who are educated are equally practicing unsafe sex and dying of HIV/AIDS.’ He also said, ‘When one does not have a stable life and is getting no money, the individual will be involved in high-risk behaviors due to hopelessness.’

Religion

In Dire Dawa, female participants said, ‘Religions advise people to be faithful’ and ‘In the churches, the preachers teach us about HIV/AIDS’ and ‘The Bible itself restricts us not to have sex before marriage.’ These points indicate that religions contribute significantly to safer and appropriate behaviors. Each religion had its own contribution, as long as the religion was followed strictly. One of the group members felt that the issue of teaching about condoms should be reconsidered amongst religious people, so that religious leaders could teach people; however, most other group members disagreed with her. These females objected to preaching about condoms in churches and mosques because they felt that it encouraged promiscuity. They felt that teaching from religious leaders should only emphasize faithfulness and abstinence.

According to one of the female discussants, the Moslem faith allows men to have more than one wife. Nevertheless, as long as the Koran’s teachings are followed properly, the man will not go to women other than his wives and the wives will not go to other men. Therefore, their behavior will not spread HIV/AIDS.

Males from Dire Dawa and Jijiga raised the same issues as the females. They believed that all religions had something to contribute to HIV/AIDS prevention. They said, ‘Religions teach us to avoid premarital sex and to avoid extramarital affairs.’ However, the male ISY discussants added that some of the religious leaders did not have adequate knowledge of HIV/AIDS and consequently, it was difficult for them to teach about HIV/AIDS.

4.1.7 Contribution of information sources to increased knowledge and behavioral change

Sources of information about HIV/AIDS

Amongst the mass media, radio, television and printed materials (magazines, newspapers, posters and brochures) were mentioned as sources of information about HIV/AIDS. Moreover, other sources such as health bureaus, NGOs, HIV/AIDS secretariat offices and associations of PLWHA, anti-AIDS clubs and parents were mentioned.

In Bahir Dar, teachers and health professionals were also included as sources of information. Additional sources of information in Jijiga included friends, teachers, religious institutions and school mini-media. The male ISY interviewee felt that there was underutilization of family as a source of information on HIV/AIDS. However, the male OSY interviewee mentioned that families participated in teaching their daughters. The discussants in Jijiga pointed out the absence of TV programs in the Somali language; in consequence, because of language barriers, they felt that the Somali people did not benefit from watching TV programs on HIV/AIDS.

Usefulness of the information

Almost all discussants considered that TV programs were the most useful source of information. In particular, TV programs were considered useful because the information was sometimes accompanied by experiences of PLWHA. Nevertheless, in Jijiga some ISY discussants preferred newspapers because they could be read several times.

Participants agreed that all types of information from PLWHA were useful. According to the female OSY discussants from Jijiga, brochures were not useful as sources of information because most people did not like to read and the messages were often unclear.

Weaknesses of the information sources

In Dire Dawa, the female OSY said, ‘The information transmitted on TV screens is not adequate for those who are knowledgeable about the disease.’ Some participants considered frightening messages bad. Long messages were considered ineffective and boring. Moreover, it was considered inappropriate to teach children <15 years old about condoms; it was felt that the messages might encourage them to be sexually active.

The female interviewees from Jijiga felt that educational maxims, such as ‘value your life’, did not convey clear messages on HIV/AIDS; instead, the interviewees recommended better explanations about the virus and the disease. The interviewees expanded this concept with the explanation that people value their lives when they see hope in their lives; they felt that young people who were struggling for existence would not take the messages seriously.

In Dire Dawa, the ISY said that there was little contribution by family (parents) in the prevention of HIV/AIDS. Some participants mentioned that people became suspicious when an infected person who was still physically fit was teaching them and thought that the individual was pretending to be infected for the purpose of the teaching.

4.1.8 Perception and behavior/practice

Abstinence

Female participants in all three regions said, ‘Abstinence is not commonly practiced in the community as a whole.’ They added that, ‘There might be a few young people who abstain.’ The female OSY interviewee from Dire Dawa said abstinence was not common but that she practiced abstinence. In contrast, the female ISY interviewee from Dire Dawa said that many people were abstaining and that she preferred abstinence for herself.

The female discussants and the OSY interviewee from Jijiga said, ‘Abstinence is not commonly practiced among the youth in particular and in the community in general.’ However, both mentioned that they used abstinence to protect themselves from HIV infection. In Jijiga, female discussants commented that Somali girls practiced abstinence more frequently than girls from other ethnic groups.

Male participants, in all three regions, said, ‘Abstinence is not practical in the youth.’ The reasons mentioned included the statement that, ‘The youth is in a fire age and want to try and taste sexual pleasure.’ Moreover, they suggested that those who were considering marriage wanted to have sexual intercourse before deciding.

In Jijiga, in contrast to views of the females, the male youth said, ‘Abstinence is impractical even in Somali girls.’ One of the reasons given was that a female would suspect her boyfriend of being unfaithful if he failed to have a sexual relationship with her. Moreover, the boys thought that if they did not have sexual intercourse with their girlfriends, that the girls would leave them. Male ISY discussants from Bahir Dar pointed out the existence of a few purposeful and intelligent young people who abstained from sexual intercourse.

One–to-one relationships (faithfulness)

One-to-one relationships were not practiced commonly by the youth. Females and males tended to stay with a partner for a maximum of 2-6 months and then, for various reasons, to start alternative relationships. Multiple partners were common for both males and females. However, one of the female interviewees from Dire Dawa felt that there were behavioral changes in this regard. In Jijiga, all the female participants said that faithfulness was uncommon. In Jijiga, the female OSY discussants said, ‘The usual practice is to have two friends at the same time, one is for love and the other is for financial advantages [money etc.].’

In contrast to the statements above, in Bahir Dar, many female participants said that faithfulness was becoming common practice; however, a few ISY discussants opposed this idea. Furthermore, the female OSY interviewee said, ‘This preventive method faithfulness works only for religious people.’

Young males in Dire Dawa and Bahir Dar said that faithfulness was not common and that when it happened it only lasted for a few months; subsequently, additional partners were found. One reason for this behavior was that the young males felt that having multiple partners was a sign of ‘pride and superiority’. Nevertheless, the male interviewees said, ‘The youth is now changing its behavior and is becoming faithful.’

Condom use

In the three regions, participants said that condoms were available from bars, small shops, the Family Guidance Association of Ethiopia (FGAE) clinics, anti-AIDS clubs and pharmacies. The price was very cheap (ETB 0.25 for three condoms); in some places condoms were provided free-of-charge. In Dire Dawa, most of the youth did not commonly use condoms because they ‘trusted each other’. Although they were not completely sure, they thought that FSWs always used condoms. This belief was mentioned persistently by the youth from the three regions.

In the community, condom use varied with type of sexual relationship. In all three regions, it was usual for males visiting FSWs to use condoms; however, there was a tendency for FSWs to allow sex without a condom if higher prices were paid. Males who had one girlfriend did not usually use condoms and said, ‘We trust each other.’ The female OSY discussants from Dire Dawa said, ‘We have less power to decide on condom use, because of their [the males’] status.’ The OSY discussants from Jijiga added that the Somali and Moslem communities considered that condoms were haram (forbidden).

All male participants said that condoms were available and that the price was reasonably low. In Jijiga, however, condoms were not sold in Somali owned shops. The male discussants said, ‘The majority of the youth, especially school students do not use condoms.’ They felt that condoms were more useful to FSWs. The male OSY interviewee from Dire Dawa felt that condom use was increasing. The male ISY interviewee from Jijiga pointed out that most Moslems did not use condoms. The male ISY discussants from Jijiga said, ‘The Somalis think that condoms are part of the cultures of other ethnic groups such as the Amhara [i.e. non-Somalis].’

4.1.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex

Risk groups

All female participants said that the youth (male and female) and FSWs were at high risk for HIV. The male participants also included other groups, such as farmers, drivers and their assistants, businessmen, street children and the uniformed services.

Circumstances/factors contributing to unprotected sex

The female youth mentioned drug use (including khat and local alcohol) and watching ‘dirty movies’ (pornographic films) as factors that provoked the youth to practice unprotected sex. Commonly, the youth was involved in unstable sexual relationships. At the beginning of a sexual relationship (days 1 to 15), they might use condoms; however, later on they would have unprotected sex because the sexual partners started to trust each other. Nevertheless, in general, these relationships lasted for a maximum of six months and broke up easily. Subsequently, both partners would have alternative sexual friends and the pattern would begin again. Unemployment and lack of recreational facilities were given, amongst others, as reasons for this kind of behavior.

The male youth mentioned drug use (including khat, alcohol and hashish) and watching pornographic films as factors contributing to the practice of risky sex. Commonly, after taking drugs or watching pornographic films, a male youth would visit a FSW or other casual partner. On rare occasions, a male youth would visit his girlfriend, if she were available. The ISY male discussants from Jijiga also mentioned a tendency for young males to establish sexual affairs with female newcomers. In relation to risky sex, group sex (i.e. practicing sexual intercourse in a group on a single girl through violence) was also mentioned by the group discussants from Jijiga.

Types of drugs commonly used by youth in the study areas

Khat, alcohol (including local drinks) and shisha were mentioned by the female discussants from Dire Dawa as the types of drugs used commonly by the youth. It was reported that after taking drugs the male youths were often too ‘out of their minds’ to remember to use condoms. Although use of drugs was common practice amongst the boys, very few girls used them.

Male discussants from the three cities mentioned the same types of drugs as the females. Drug use was said to prompt the males to visit FSWs and predisposed them to having sex without a condom. Some young males explained that different species of khat had different effects on the individual (e.g. some increased sexual desire).

Commercial sex work

Female participants in all three cities said that commercial sex work was very common. There were many bars, nightclubs and local houses selling drinks; all of which favored the practice. The female discussants in Jijiga commented that commercial sex work was never practiced amongst the Somalis.

According to the males, drivers, soldiers, daily laborers, and married and older men visited FSWs. It was also pointed out that FSWs had boyfriends (lovers) with whom they did not use condoms. Usually, these boyfriends were young people. Although FSWs were said to use condoms more often than other people, street-based sex workers engaged in unprotected sex when they were offered higher prices. In Bahir Dar, it was mentioned that girls from rural areas were considered to be free of HIV/AIDS and consequently, were often exposed to unprotected sex; participants said that these girls were often forced to have sex without a condom. Male youths were said to visit FSWs only on rare occasions, after they had taken drugs.

4.1.10 Perceived risk behaviors and behavioral change

According to female participants, young females had a particular fear of contracting HIV. In general, the FGDs indicated that the male youth often seemed to behave unthinkingly and forgot about HIV, especially after taking drugs including khat. In the past, most of the male youth did not even want to accept the existence of HIV; however, in recent times, a few of the youth had started to change their behavior (e.g. they were using condoms and being faithful). The two female interviewees from Jijiga said, ‘We will continue to practice abstinence until we get married.’ Both of them claimed to be virgins. In Bahir Dar, the female discussants said that youths perceived that they were at risk; however, behavioral change was not observed. The female OSY interviewee said, ‘There is good risk perception as well as some behavioral change amongst the youth.’

Several male participants said that all the youth seemed to fear HIV/AIDS but still chose to participate in unprotected sex. In contrast, the male ISY interviewee from Jijiga said, ‘The youth [including himself] does not fear HIV/AIDS and there is no change in behavior.’ His ideas were supported by all the male discussants. Nevertheless, the youth reported that FSWs were showing significant changes in their behavior by using condoms.

4.1.11 Participation in anti-AIDS clubs

According to the female participants, in recent times, the youth had started to participate in anti-AIDS clubs. Female discussants from Dire Dawa and Jijiga commented that participants in anti-AIDS clubs seemed to have better behavior than the uninvolved youth. For example, anti-AIDS club participants were providing care for PLWHA. In Bahir Dar, participants mentioned that anti-AIDS clubs were important sources of information on HIV/AIDS. Nevertheless, it was pointed out that the messages transmitted by the clubs were of limited value. In Dire Dawa, the female discussants pointed out that there were still youths who made fun of anti-AIDS club programs.

Almost all the males said, ‘There are encouraging activities by the anti-AIDS clubs.’ Anti-AIDS clubs were operating in all kebeles in the three cities; they were providing care and support for PLWHA, and peer and community education.

4.1.12 Suggestions to avert the spread of HIV/AIDS

Expansion of the activities of anti-AIDS clubs and better employment opportunities were suggested as ways of averting the spread of HIV/AIDS. Additionally, all participants mentioned expansion of recreational facilities. In Dire Dawa, OSY discussants suggested a ban on the screening of pornographic films by video houses and the closure of bars and nightclubs.

In Jijiga, suggestions included expansion of libraries and involvement of religious leaders. The female OSY interviewee in Jijiga suggested evaluation of the effects of anti-AIDS clubs. In Bahir Dar, male participants strongly advocated the involvement of parents and the need for open communication. Continuous efforts to teach the community, expansion of VCT services and establishment of youth centers were also suggested. Furthermore, the male ISY in Jijiga also suggested that society’s ‘role models’ should show positive behavior.

4.2 Akaki Textile Factory workers

4.2.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS

Modes of transmission

Male and female discussants and interviewees from the Akaki factory mentioned unprotected sex and contaminated sharp materials as means for the transmission of HIV infection.

Methods of prevention

The discussants listed the three major preventive methods (abstinence, faithfulness and condom use). The male individual interviewee did not mention abstinence but was able to list faithfulness, condom use and avoidance of behaviors, such as drug use, that increase the risk for unprotected sex. The female individual interviewee could only mention faithfulness amongst the preventive methods.

4.2.2 Relationship between HIV infection and other STIs

The factory workers were able to mention most of the common STIs such as gonorrhea, syphilis and chancroid. They said that affected individuals sought treatments from clinics. They commented that HIV infection was incurable while STIs had drugs to treat them.

4.2.3 Misconceptions about HIV/AIDS, HIV transmission and condom use

The factory workers raised the misconception that condoms carry the HIV virus. The observed difference in quality of condoms available on the market was mentioned amongst the reasons for their suspicion. Cheap condoms, which were available widely, were said to have the virus (for example, they mentioned Hiwot Trust condoms). In contrast, condoms such as Durex were said to be expensive and of high quality. Observations by the youth and the elderly indicated that they were overwhelmed by this kind of misconception. The elderly thought that HIV was the curse of God and did not think that it could be prevented. The male interviewee also mentioned this misconception. He thought that this misconception had contributed to the spread of HIV. The male interviewee also pointed out that Hiwot condoms had a bad odor while Durex condoms had a good odor; he ranked Hiwot condoms as third class. A further misconception was mentioned by a female discussant; she said that eating eggs from a chicken that had swallowed a used condom was believed to transmit HIV infection.

4.2.4 Stigma and attitudes towards PLWHA

In contrast with previous years, when there was marked discrimination against PLWHA, the factory workers said that there was now a positive attitude towards PLWHA; moreover, they appreciated the care and social support provided in the factory for PLWHA. This concept was also revealed by the in-depth interviews.

One of the female discussants expressed her concerns regarding stigma. She said that three years previously she herself had been discriminated against and stigmatized. She had been suffering from tuberculosis and had developed ‘almaz balechira’ (herpes zoster). She remembered that her workmates would not shake hands with her. For this reason, she decided to take an HIV test; the result was negative. At the time of the study, her social relationships had normalized. The woman also mentioned a case of a man whose wife had died previously due to HIV/AIDS. When the man died, he had skin lesions and because of this many people refused to give routine care to his dead body; eventually, the man’s brother provided care for the body.

4.2.5 Voluntary testing and counseling

All participants from the factory were aware of the existence of VCT services; however, although they were interested in being tested, they said that the cost was too high. There was no VCT service in the factory.

4.2.6 Influence of knowledge, educational status and religion on behavior

Knowledge and educational status

Both discussants and interviewees felt that, in the majority of cases, educated people who had knowledge about HIV/AIDS had better opportunity to protect themselves because they knew the preventive methods. However, the male interviewee added that most of the factory workers were uneducated and hence careless about using preventive methods. Nevertheless, male discussants said that risky behavioral practices were observed amongst individuals who had completed 12^th Grade but were then unemployed. In contrast, the female discussants and interviewee explained that higher educational status did not guarantee the practice of safe behavior. In fact, the females pointed out that educated men were not practicing safe sex; these individuals were able to engage in this risky behavior because they had higher incomes and could afford to pay higher prices for sex.

Religion

All discussants and interviewees highlighted the contribution of religion to the prevention of HIV/AIDS. Religions (i.e. Orthodox Christianity, Islam and the Protestant faith) were said to participate in teaching the community about faithfulness (one-to-one) and abstinence. All of these religions were said to condemn sexual intercourse before marriage and extramarital sex.

4.2.7 Contribution of information sources to increased knowledge and behavioral change

Sources of information

Participants listed the following sources of information about HIV/AIDS: radio, television, leaflets, newspapers and drama. Radio messages were preferred for their wide coverage of the population and power in influencing people’s behavior. In addition, television programs that presented PLWHA were found to be effective in influencing behavior.

Participants felt that, in recent times, families had started to discuss HIV/AIDS more openly. The male interviewee also mentioned that HIV was discussed in schools and amongst friends.

Both the discussants and the interviewees revealed that there was no active anti-AIDS club in their work place; however, they spoke about some of the activities that happened in Akaki town.

4.2.8 Perception and behavior/practice

Abstinence

The male interviewee believed that none of the youth but about half of unmarried people practiced abstinence. Similarly, the female discussants and interviewee believed that abstinence was not a common practice amongst factory workers or the wider community. One of the discussants was advising her daughter and her daughter’s boyfriend to take HIV tests and to make sure that the results were negative before they started to have sexual intercourse.

One-to-one (faithfulness)

The male discussants thought that only 25-50% of unmarried people were practicing abstinence. Moreover, they estimated that about 25% of married people were unfaithful to their partners. One reason given for not complying with the ‘one-to-one’ preventive method was that having multiple sexual partners was considered to be a sign of pride and superiority, especially by males. The male interviewee also revealed that faithfulness did not seem to be practiced amongst the factory workers. According to the female discussants and interviewee, feelings towards faithfulness were mixed; it was felt that more females than males practiced faithfulness. The female interviewee said, ‘I am married and faithful to my husband.’ However, she said, ‘This [faithfulness] is not commonly practiced among the factory workers.’

Condoms

Male and female discussants and interviewees revealed that condoms were available, in the factory and in the shops. The condoms were very cheap. Condoms were supplied to the factory by the FGAE. Reportedly, the factory workers did not use condoms with their regular partners; however, they used condoms with other partners. Some participants felt that condoms were more useful to FSWs and the youth than to factory workers. When condoms were not used it was said to be the result of a lack of awareness or the use of drugs, such as alcohol. According to the male interviewee, condoms were used by the educated and unmarried but married people did not use them. One of the reasons for not using condoms was that people did not like to be seen buying or possessing condoms. In particular, they were concerned that other people would think they had condoms because they were unfaithful to their partners.

4.2.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex

Risk groups

The factory workers mentioned that the following groups were at high risk for HIV: drivers, the youth (both males and females) and sometimes farmers who were visiting urban areas to buy goods and sell farm produce. Discussants and interviewees noted that there were only a few FSWs around the factory area (contrasting with the situation in Addis Ababa). According to the male participants, only a few young factory workers visited these FSWs.

Circumstances contributing to unprotected sex

Unemployment, alcoholic beverages, khat and films that aroused sexual desire were mentioned as factors predisposing individuals to unprotected sex. Participants commented that khat and alcohol were accessible in the area. At the end of each month, the workers received their salaries; at this time, consumption of alcohol increased and subsequently workers visited FSWs.

4.2.10 Perceived risk behaviors and behavioral change

It was mentioned that people had started to be afraid of HIV/AIDS. This was ascribed to the mass media coverage. It was believed that there was behavioral change amongst the factory workers. However, all participants felt that the number of individuals dying from HIV/AIDS had increased. When the slow changes of behavior were considered alongside the rapid spread of the disease, participants felt that a great deal of behavioral change was still needed.

4.2.11 Suggestions to avert the spread of HIV/AIDS

Participants suggested various ways to reduce the spread of HIV/AIDS, including: education of the community (especially the youth) about the preventive methods; expansion of VCT services, including the provision of services in the factory; and instigation of legal action against illegal video houses. Legal action against infected persons who had deliberately infected their partners by not disclosing their HIV status was also mentioned.

4.3 Truckers

4.3.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS

Modes of transmission

The discussants and the interviewee mentioned only unprotected sex and contaminated sharp materials as means for the transmission of HIV infection. One of the discussants said that sharing blankets used by an infected person could transmit HIV.

Methods of prevention

The discussants and the interviewee listed the three prevention methods. However, among the FGD participants the older ones opposed the use of condoms as a method of prevention, especially for truck drivers, because condom use encouraged people to have sexual affairs outside their marriages. Nevertheless, teaching the youth about condoms was felt to be very important.

4.3.2 Relationship between HIV and other STIs

The truck drivers were able to mention most of the common STIs, such as gonorrhea, syphilis and chancroid. They also explained the relationships of HIV infection with STIs. They said that both HIV and STIs were transmitted through unprotected sexual intercourse. Moreover, they said that STIs were treatable but HIV/AIDS was not. The discussants said that for treatment of STIs, the truckers visited Kazanchis Health Center (previously called Borchele) in Addis Ababa or other health centers, hospitals or private clinics. The truckers commented that, in the past, health professionals talked extensively about STIs. However, they felt that, ‘In recent years, nobody talks about STIs except HIV/AIDS.’

4.3.3 Misconceptions about HIV/AIDS, HIV transmission and condom use

Amongst other misconceptions, the truckers mentioned that sharing blankets could transmit HIV and that condoms were produced specifically for people practicing oral and anal sex. Additionally, the misconception that condoms spread HIV, rather than preventing the infection, was said to exist amongst some of the truckers. Some of these misconceptions were said to be common amongst the older truck drivers.

4.3.4 Stigma and attitudes towards PLWHA

The truckers commented that there was no way to know whether a driver was infected or not. However, they said that there were several infected drivers. When someone was seriously sick or had died, families including the sick person hid the real cause, particularly when the cause was HIV/AIDS. Instead, they explained that the cause was a lung disease or ‘a disease from wind’. Because of this behavior it was always difficult to know the extent of the HIV/AIDS problem in the truckers’ community. They also said that the existing problem was so huge that they did not have adequate capacity to help all the chronically sick HIV infected drivers. It was said that, nowadays, when a driver dies of AIDS, nobody remembers to help his family. Most drivers’ families lived in rented houses; when the wage earner died, his family suffered.

According to the discussants, stigmatization of PLWHA had decreased; however, the interviewee mentioned that the truckers were not willing to drink or sleep together with PLWHA.

4.3.5 Voluntary counseling and testing

All participants were aware of the existence of VCT services. However, although they wanted to be tested, the cost of tests was said to be too high (ranging from ETB 50-200/test). In addition, they felt that they did not have time to be tested because they were very busy. They also explained that they had no information, e.g. official government recommendations, as to the reliability of HIV testing at VCT centers. These points were considered to be barriers to taking HIV tests.

4.3.6 Influence of knowledge, educational status and religion on behavior

Knowledge and education

Knowledge about HIV/AIDS was said to be helpful in preventing the spread of HIV/AIDS. However, participants commented that educational status did not necessarily protect people from acquiring HIV/AIDS. The interviewee mentioned that he had seen educated people who were infected with HIV.

Religion

All participants accepted the contribution of religion to the prevention of the spread of HIV/AIDS. However, the interviewee was skeptical about the current practices and doubted their impact. He believed that religious leaders should be trained and provided with adequate knowledge on HIV/AIDS, so that they could provide effective teaching on HIV/AIDS to their followers and the community.

4.3.7 Contribution of information sources to increased knowledge and behavioral change

The truckers mentioned radio, television, leaflets and newspapers as sources of information on HIV/AIDS. They believed that TV messages were effective ways to influence behavior. However, they commented that the time allocated to HIV/AIDS messages on TV was very short and full of advertisements. When discussing convenience, TV and radio programs were considered less useful because not all trucks had radios and truckers did not commonly watch TV programs. It was also said that truckers did not often read newspapers because driving was tiring and people were not accustomed to reading newspapers. The interviewee suggested that peer group education was the most appropriate source of information for truckers (i.e. trucker to trucker education).

4.3.8 Perception and behavior/practice

Abstinence

Participants mentioned that very few (if any) truckers practiced abstinence. One of the truckers said, ‘We are too old too abstain.’

One-to-one (faithfulness)

The participants agreed that ‘one-to-one’ relationships were relatively impossible in the case of truckers, particularly because truckers were away from their families for long periods of time.

Condom use

Condoms were available widely. According to the discussants, most of the truckers used condoms. However, one of the discussants said that condom use was low after drinking alcohol. Moreover, the interviewee said that condom use was low amongst the truckers. The interviewee attributed this to a lack of knowledge and low levels of demand for condoms by FSWs working in peripheral parts of Ethiopia. Compared with FSWs based in peripheral areas, he believed that FSWs working in the central part of Ethiopia were better at asking males to use condoms.

4.3.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex

Risk groups

The truck drivers mentioned that the following groups were at high risk for HIV: drivers, teachers, soldiers, the youth and health workers. All participants said that commercial sex workers were abundant along the Ethio-Djibouti route and were found in all of the small towns. They said that the lives of the FSWs depended on the presence of truckers. Because many of the FSWs were young and beautiful they always had clients. It was also mentioned that FSWs followed the movement of soldiers and camps.

Circumstances and types of drugs

Alcoholic drinks and khat were said to be the most commonly used drugs amongst the drivers. Khat use followed by alcohol consumption was said to be associated with unprotected sexual intercourse.

4.3.10 Perceived risk behaviors and behavioral change

Most truckers feared HIV/AIDS and yet not all of them protected themselves. The truckers referred to HIV/AIDS as ‘the land mine’ or ‘the explosive’.

There was mixed feeling as to whether behavioral change had occurred amongst truckers. The discussants felt that there were some behavioral changes amongst the truck drivers although the number of HIV/AIDS cases had increased. In contrast, the interviewee said that there was no behavioral change and that most drivers visited FSWs.

4.3.11 Participation in anti-AIDS clubs

The discussants and interviewee revealed that there were no active anti-AIDS clubs for the truckers. However, they explained that a proposal for strengthening intervention programs amongst the truckers had been submitted to the National HIV/AIDS Prevention Secretariat.

4.3.12 Suggestions to avert the spread of HIV/AIDS

Participants suggested various ways to reduce the spread of HIV/AIDS, including: reduction of the number of FSWs; expansion of VCT services; provision of care for PLWHA; and elimination of nightclubs and red-light houses. When the discussants and the interviewee were asked to comment on trends in the numbers of AIDS cases, they said that the number of cases was increasing.

4.4 Intercity bus drivers and minibus drivers

4.4.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS

Modes of transmission

Almost all of the participants knew about HIV/AIDS and the major routes of transmission. The intercity bus driver interviewee included mother-to-child transmission, which was not identified by the discussants.

Methods of prevention

Among the preventive methods, ‘one-to-one’ relationships and condom use were mentioned. However, none of the drivers included abstinence among the preventive methods.

4.4.2 Misconceptions about HIV/AIDS, HIV transmission and condom use

The misconception that the lubricant in condoms carries the HIV virus was mentioned. Some assumed HIV to be a kind of biological warfare. Others said, ‘HIV infection has increased since people started to use condoms.’ In addition, it was mentioned that there were some people who believed that, ‘There is no AIDS.’ Moreover, others considered the epidemic to be ‘a punishment from God’. These misconceptions had contributed to the spread of HIV/AIDS.

4.4.3 Stigma and attitudes towards PLWHA

The participants expressed a positive attitude towards PLWHA; all of them were willing to take care of PLWHA.

4.4.4 Voluntary counseling and testing

Although they had not attempted to take HIV tests, the participants were aware of VCT services.

4.4.5 Influence of knowledge, educational status and religion on behavior

Knowledge and educational status

Although knowledge about HIV/AIDS and educational status were contributing to behavioral change amongst the drivers, not all educated people had changed their behavior.

Religion

The discussants and interviewee highlighted the role of religion in behavioral change. The minibus driver said attending church ceremonies helped much more than condom promotion advertisements because he thought that promotion of condoms encouraged people to engage in multiple partnerships.

4.4.6 Contribution of information sources to increased knowledge and behavioral change

Mass media

Participants mentioned various sources of HIV/AIDS information, including: radio, television, mini-media and printed materials. Pamphlets, newsletters and mini-media available at the bus station were mentioned and discussed. Television and radio interviews with PLWHA were considered to be the most effective ways of influencing people’s behavior. Radio was considered to be the most appropriate and important source of information on HIV/AIDS, especially for drivers. However, television was said to be more helpful than radio in influencing people’s behavior; in particular, television dramas were mentioned as being powerful influences.

Interpersonal communication

Participants mentioned interpersonal communication with health professionals, teachers, parents and friends as sources of HIV/AIDS information. However, from the perspective of the discussants and interviewees, interpersonal communication was not considered to be the most important source of information.

4.4.7 Perception and behavior/practice

Abstinence

Concerning the current practice of the three preventive methods by the intercity bus and minibus drivers, abstinence was said to be almost impossible. One of the discussants said that abstinence was a possible practice for only a few individuals.

Faithfulness (one-to-one)

Intercity bus drivers mentioned that ‘one-to-one’ relationships had become common practice. Moreover, incidence of marriage had increased. Nevertheless, both types of drivers mentioned that it was difficult to maintain faithfulness by couples. It was pointed out that most drivers had multiple sexual partners.

Condom use

Participants said that condoms were available everywhere. They believed that the use of condoms had increased, especially when partners were not married.

4.4.8 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex

Risk groups

Participants mentioned that the following groups were at high risk for HIV: drivers, the youth (including students), government employees, females and soldiers. Participation in commercial sex work was said to be common amongst young females.

Factors and circumstances for unprotected sex

Alcohol and drug (khat and hashish) use were mentioned amongst the factors contributing to unprotected sex.

When drug use was coupled with alcohol consumption, unprotected sexual intercourse was likely to follow. The drivers explained that drinking alcohol after chewing khat increased sexual desire and promoted the occurrence of unprotected sex. The minibus driver interviewee associated HIV/AIDS with poverty and said, ‘It is the poor who are affected.’

4.4.9 Perceived risk behaviors and behavioral change

People’s awareness of HIV/AIDS had increased and almost all people feared HIV/AIDS. However, according to the minibus drivers, degree of behavioral change was not impressive. In fact, the minibus drivers said that there was no change in people’s behavior even though they knew that AIDS killed. Many of the drivers associated the lack of behavioral change with the nature of their work, which introduced them to many young girls and women. However, a different view was mentioned by one of the discussants. He said that there was behavioral change amongst drivers and that this resulted from observations that a number of drivers had suffered from and died of AIDS. Condom use had increased. Moreover, condoms were being used with regular partners and when having sexual intercourse with FSWs.

4.4.10 Participation in anti-AIDS clubs

The intercity bus and minibus drivers were not participating in any type of anti-AIDS activity and were not members of anti-AIDS clubs.

4.4.11 Suggestions to avert the spread of HIV/AIDS

Participants suggested various approaches to reducing the spread of HIV/AIDS, including: the provision of job opportunities; expansion of health education and VCT services; and the control of illegal video houses. In addition, participants suggested that girls should be taught to dress decently (i.e. to wear clothes that covered provocative parts of their bodies). They felt that the way some girls dressed was too attractive and tempting for males. Participants also suggested using drivers’ associations to approach and teach drivers about HIV/AIDS.