4. Qualitative Results (cont.)

Almost 50% of participants (discussants and interviewees) had basic knowledge of HIV transmission. The most frequently mentioned modes of transmission were: sexual intercourse and the use of contaminated sharps. Female pastoralists were observed to have inadequate knowledge about modes of HIV transmission.

Methods of prevention

Nearly all the males and a few female discussants were able to list the three major preventive methods. However, most female discussants did not mention abstinence or condom use and the female interviewee did not mention abstinence.

When asked how often the preventive methods were practiced, it was said that abstinence had become a common practice; in the past, abstinence was considered almost impossible. However, the female discussants agreed that abstinence was very difficult in practice. All discussants and interviewees (males and females) pointed out that faithfulness was practiced more commonly than in previous years; this change in behavior was due to increased awareness and fear of HIV/AIDS.

4.5.2 Relationship between HIV and other STIs

Participants were able to name the most common STIs. The female interviewee explained that people visited traditional healers when suffering from STIs. In contrast, when people were infected with HIV, they visited modern health institutions.

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

The misconception that condoms carry the virus and transmit HIV infection was common amongst the pastoralists. In addition, because the pastoralists did not know how to use condoms, they had various fears relating to condom use; these included a fear that the condom would break during sexual intercourse. Female pastoralists also feared that condoms would slip off into the vagina and would be retained in the reproductive tract, causing serious reproductive problems. One female discussant said that she believed that condoms could break during sexual intercourse and be retained in the uterus where babies were conceived. As pointed out by the participants, these kinds of misconceptions had implications for the spread of HIV infection.

4.5.4 Influence of knowledge, educational status and religion on behavior

Knowledge and educational status

The role of education and knowledge about HIV/AIDS in reducing the risk for HIV infection was discussed. With the exception of the male discussants, all participants mentioned that knowledge and educational status had positive implications for behavioral change. According to the male discussants, educational status did not seem to affect people’s sexual behavior. The male discussants supported their idea by pointing out that they had seen educated people with AIDS.

Religion

All discussants and interviewees clearly stated the advantages of involving religious leaders in the prevention of HIV/AIDS, in particular, because the religious leaders had high levels of credibility and acceptance amongst the community.

4.5.5 Contribution of information to increased knowledge and behavioral change

Mass media

Almost all discussants and interviewees said that they had little access to the mass media; several reasons were given. Televisions were available only in the towns. Therefore, unless the pastoralists were visiting urban areas, there was no chance for them to watch TV programs. They also pointed out that radios were not available in many of the households. Furthermore, even when radios were available, people were not keen to listen to the programs because of language barriers; radios were not utilized properly. Because most pastoralists were illiterate, printed media was not utilized.

Interpersonal communication

Participants mentioned that interpersonal communication was the main source of HIV/AIDS information for the pastoralist communities; for example, friends, health workers, family members, teachers, community health committees and NGO workers (e.g. workers for Save the Children–USA) were used as sources of information.

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

Risk groups

Participants believed that there were no high-risk groups for HIV in their rural areas because there were no bars or FSWs. However, the male discussants mentioned the youth as a risk group. In urban areas, participants identified FSWs, drivers, merchants and soldiers as high-risk groups.

Factors and circumstances

Amongst factors contributing to the practice of unprotected sex, use of drugs (such as khat and alcohol) was mentioned. In the rural areas, according to the male discussants, the community (Aba Geda) had closed local bars selling alcohol.

4.5.7 Voluntary counseling and testing

The male discussants and interviewee had heard about VCT; however, they said that the services were not available in their areas.

4.5.8 Perception and behavior/practice

Participants revealed that multiple sexual partnerships were very common in the area. According to the Geda system, a man could have three or four sexual partners and similarly, his wife could have a sexual partner with the knowledge of her husband. However, in recent times, fear of HIV/AIDS had encouraged people to start protecting themselves, particularly by limiting numbers of sexual partners.

Many of the female participants had never seen a condom or if they had seen a condom, it was during health education. Almost all said that they had never seen PLWHA. However, they suspected HIV/AIDS when they saw individuals with the signs and symptoms. Participants believed that there was behavioral change amongst the pastoralists.

4.6 Farmers

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

Mode of transmission

Knowledge about the transmission of HIV varied; modes of transmission mentioned ranged from sexual intercourse to the sharing of needles, safety pins and blades. Kissing, breathing and close contact were also mentioned. The male discussants gave further explanations as to how close contact and kissing could transmit the virus. They explained that through kissing and shaking hands it was possible transmit the virus if there were lesions, wounds or cuts on the body parts that were in contact.

Methods of prevention

Concerning knowledge of the preventive methods, all participants emphasized the sharps (needles, blades etc.) that were shared with family members and neighbors. When the females were asked about the preventive methods, none of them could name all three preventive methods; however, some female discussants and the female interviewee mentioned faithfulness and VCT before marriage.

4.6.2 Relationship between HIV and other STIs

Female farmers could not easily name the different types of STIs; the female discussants mentioned only syphilis and gonorrhea. However, the male discussants and male interviewee were able to mention the commonest STIs, such as gonorrhea, syphilis and chancroid. They explained that people visited traditional healers for treatment of STIs. Traditional healers were the first choice for STI treatment because people wanted to keep their infections a secret. When they were asked about the relationship between STIs and HIV infection, they said that both were transmitted through sexual intercourse. Moreover, they highlighted the fact that STIs were treatable while HIV/AIDS was not.

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

Various misconceptions were discussed. Amongst these the major misconceptions were the transmission of HIV infection through eating raw meat, raw eggs, bananas, oranges, tomatoes and sugar cane. Raw meat was said to cause the disease because people who were infected might have handled it and there might have been contact with blood. Similarly, sugar cane could be contaminated during cutting because it could come into contact with blood from cuts on the hands of the workers.

It was thought that chickens bought from urban areas were infected with the virus because they swallowed condoms; consumption of raw eggs from these chickens was thought to transmit the virus. Raw eggs from chickens that had fed on the wastes of an HIV/AIDS patient were also thought to carry the infection. In addition, both males and females mentioned transmission of HIV through breathing, sleeping together and by close contact such as shaking hands. The male interviewee mentioned the misconception that condoms transmit the virus. He also believed that HIV/AIDS was an expression of ‘God’s anger’ because of people’s misbehavior in sexual acts.

4.6.4 Stigma and attitudes towards PLWHA

The participants, especially the females, stated that they were not willing to take care of PLWHA. This was because they did not understand how HIV was transmitted. However, the males believed that they should help PLWHA. It was explained that there was discrimination and stigma attached to PLWHA. The majority of people did not want to mix themselves and their families with PLWHA. Stigma was not limited to the person who was affected by HIV/AIDS but also to his/her family and people who were providing care. Some participants gave examples of these attitudes and stigma that were derived from their own observations.

4.6.5 Voluntary counseling and testing

The participants knew that young people whose marriages were arranged by their parents could get tested for HIV. They explained that parents had started to demand HIV test results before they arranged marriages. This practice had expanded in some families over the last two years. In addition, testing for HIV after reunion and after separation for long periods of time was mentioned. However, people were not aware of VCT services, which were provided to any person who wanted to be tested.

4.6.6 Influence of knowledge, educational status and religion on behavior

Knowledge and education

Both male and female participants explained that education and knowledge about HIV/AIDS were useful in changing an individual’s behavior. The females commented that educated people and those with knowledge were in a better position to protect themselves from acquisition of HIV/AIDS. Conversely, the males explained that HIV/AIDS was killing both the educated and the uneducated. They believed that the disease was not specifically a disease of the uneducated. They also mentioned that although HIV/AIDS was a disease of the urban areas, nowadays the disease had started to affect rural people. Participants believed that although HIV affected both educated and uneducated groups, it affected more of the uneducated group and those without knowledge.

Religion

Discussants and interviewees mentioned that religious leaders (in mosques and churches) had started to teach people about HIV/AIDS. The leaders preached about faithfulness and avoidance of premarital sex. Participants believed that all religions were very useful in the prevention of HIV/AIDS, as long as the followers adhered to the doctrines and the word of God.

4.6.7 Contribution of information to increased knowledge and behavioral change

Mass media

Amongst the sources of information on HIV/AIDS, the majority of discussants mentioned radio. Some said that the radio messages were clear and that they preferred radios to other sources of information. Other participants said that people were not serious enough and did not listen to radio messages, adding that people would rather listen to music. In addition, the majority of households did not have radios.

Interpersonal communication

The major sources of information in the villages were students who were attending schools. The students taught their families and the community about HIV/AIDS (how it was transmitted and how it could be prevented). Some students presented their messages in the form of dramas, shown to the community once a month, especially during vacations (when the schools were closed). Discussants and interviewees commented that people were interested when they attended this kind of presentation. Some parents rewarded the students with money so that the students would continue their efforts. The female interviewee clearly remembered the story of a drama that she had attended. For a few of the farmers who could read and write, leaflets and posters were the other sources of information; however, distribution of leaflets was limited to the offices of peasant associations. The male discussants and interviewee mentioned that people who had died as a result of HIV/AIDS were points of discussion in the community; they felt that this somehow helped the community to become aware of HIV/AIDS and encouraged them to take care of themselves.

When the participants were asked if there were any organized anti-AIDS activities, they said that there were none in the villages.

4.6.8 Perception and behavior/practice

Abstinence

Abstinence was said to be common amongst rural youngsters. However, the discussants and interviewees did not know whether abstinence could prevent the acquisition of HIV infection.

Faithfulness

Discussants said that faithfulness was the most important preventive method. However, they also mentioned that polygamy was common and an accepted practice in the community. The female discussants said that males were responsible for not accepting and breaking up ‘one-to-one’ relationships.

Condom use

According to the discussants and interviewees, farmers did not use condoms. Amongst the reasons given, it was said that there was a very low level of knowledge about condoms.

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

Risk groups

The discussants and interviewees mentioned that youngsters (15-25 years old), especially the males, were at risk of acquiring HIV infection. The high-risk groups listed by the males included merchants, the uniformed services, students, teachers, drivers and FSWs. They explained that most of these groups moved from place to place and were exposed to HIV/AIDS. Amongst the groups, participants considered that merchants were at the highest risk because they were highly mobile and frequently visited towns.

There were no FSWs in the area. However, because men were free to move from place to place they could go to towns and visit FSWs. The female participants mentioned that after drinking alcohol, the men might have unprotected sex with FSWs and then transmit HIV to their wives.

4.6.10 Factors and circumstances contributing to unprotected sex

According to the participants there were no drugs in the area. Although khat was widely used by both males and females, it was not considered to be a drug. Its potential role in the spread of HIV/AIDS was not recognized. Khat was used to stimulate people to work. They said that, in the rural areas, it was not common practice to drink alcohol after chewing khat. In fact, the male discussants and interviewee mentioned that sexual desire was very low after chewing khat.

4.6.11 Perceived risk behavior and behavioral change

The risk perception of the rural people concentrated on materials, such as sharps, that were considered dangerous in relation to HIV transmission; they also included those described in Section 4.6.3. People tried to avoid these materials. They said, ‘Borrowing materials such as sharps from neighbors is being abandoned.’ They added, ‘When we can not have a new blade, we boil or burn and use it [the old blade].’ The male interviewee said that people perceived their risks in relation to their previous risky behaviors, as they did not know whether they were infected or not. They also perceived their risks from educational information they received.

Rather than trying to use condoms, farmers preferred to remain in ‘one-to-one’ relationships. This was related to misconceptions regarding condom use.

Participants felt that there were changes in behavior amongst the farmers. For example, previously when a man died his brother had to marry his sister-in-law; in recent times this practice had decreased. Polygamy was also decreasing. Participants also said that people had become accustomed to HIV testing before marriage. Although condoms were available in the shops and community health posts, many people did not like to use condoms. According to the male discussants, students, merchants and drivers used condoms. Discussants had seen individuals returning from the towns after acquiring HIV/AIDS and becoming sick; these individuals had died in their respective villages. People in the villages had learnt that these individuals had died of AIDS and they had started to take HIV/AIDS seriously. On various occasions, these situations were points of discussion and debate.

4.6.12 Suggestions to avert the spread of HIV/AIDS

Participants suggested various ways to reduce the spread of HIV/AIDS, including the use of students, volunteers, health workers, teachers and religious leaders to increase awareness and knowledge of HIV/AIDS in the community. They also suggested that each individual and family, and the government should take action against HIV/AIDS and should teach the rural community about HIV/AIDS.

4.7 Female sex workers (bar-based, home-based and street-based)

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

Modes of transmission

The home-based interviewee was aware of the presence of HIV/AIDS. However, she was not able to mention the three major modes of transmission. Instead, she associated HIV transmission with deep kissing and with the breakage of condoms. Similarly, the bar-based interviewee mentioned that transmission was by blood and wounds. In contrast, home-, bar- and street-based discussants mentioned unprotected sexual intercourse and sharp materials that were contaminated with blood.

Methods of prevention

All participants mentioned that condoms were the most important preventive method for FSWs. They did not mention abstinence or faithfulness, which obviously would not work in their situations. All of them focused on and explained: their skills in negotiating with clients for condom use; their decisions when clients refused to use condoms; and other precautions related to condom use.

4.7.2 Relationship between HIV and other STIs

With the exception of the home- and bar-based interviewees (both of whom were illiterate), all the participants were able to mention the commonest STIs (gonorrhea, syphilis and chancroid). The majority explained that HIV infection exposed the body to STIs by weakening the body defense mechanism. Some participants (especially the home- and street-based discussants) clarified this idea by mentioning the white blood cells of the body, which were the targets of the virus. They also said that there was a tendency for ‘transformation of STIs to HIV/AIDS’; all discussants and groups mentioned this belief. Participants said that FSWs visited traditional healers and used mineral water for treatment of HIV/AIDS; in contrast, they used health institutions in the case of STIs. One of the reasons given for this behavior was that STIs were treatable and curable while HIV/AIDS was not.

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

The misconception that the ‘condom has the virus’ was mentioned, particularly by the discussants. However, although this thinking existed in the community, especially amongst males, it was explained that the FSWs relied on condoms. Therefore, unlike the other target groups, they were not worried about the misconception. They believed that condoms were protective. They said that if condoms were not protective, ‘All female sex workers would have died or become sick.’

Some discussants said, ‘HIV/AIDS is present only in radio and televisions.’ When asked what this meant, they said that nowadays FSWs were at less risk than other groups because they regularly used condoms.

4.7.4 Stigma and attitudes towards PLWHA

The majority of participants said that they had positive attitudes towards PLWHA. The street- and bar-based discussants mentioned that some of them were already helping their friends. However, one street-based discussant said that since discovering her friend’s HIV status, she was not happy to eat or share clothes with her. Some participants expressed concerns that they had been identified as high risk for HIV/AIDS and were stigmatized as if they were ‘AIDS themselves’.

4.7.5 Voluntary counseling and testing

None of the participants had been tested for HIV. Nevertheless, all of them were aware of the existence of VCT services. The majority of FSWs were afraid of ‘what will happen after they hear the results’. The street-based discussants said that the cost of the test was now very low; for example, it cost ETB 10 at the Kazanchis Health Center (previously called Borchele). However, they did not dare to get tested.

4.7.6 Influence of knowledge, educational status and religion on behavior

Knowledge and educational status

Almost all FSWs believed that knowledge and education contributed significantly in influencing a person’s behavior. They appreciated that knowledge of condom use had helped them to protect themselves. The majority of the street-based girls said that education about AIDS was included in formal classroom teaching (at 4^th Grade and above). However, the street-based girls also explained that even women without any formal education could have knowledge about HIV/AIDS and could take appropriate precautions; knowledge was available if a woman listened to the radio or took advice from a person who was knowledgeable about HIV/AIDS. However, the bar-based discussants said that education had no major impact, especially on FSWs because of their behavior and work related risks.

Religion

The majority of FSWs did not explain the role of religion in protecting people from risky behaviors; this was because of their lifestyles. Some of them believed that God would continue to protect them until they had alternatives to sex work.

4.7.7 Contribution of information to increased knowledge and behavioral change

Mass media

Radio and television were the major media sources of HIV related information for the FSWs, especially for the bar-based FSWs. Some literate participants also read leaflets and other printed materials.

Interpersonal communication

The street-based FSWs did not mention any of the mass media but mentioned the advice that they received from health workers, NGO workers and other individuals. They also mentioned discussions with other FSWs. The bar-based interviewee said that she was no longer interested in listening to the mass media. When she was asked why, she said that the messages from radio and television frustrated her greatly, so she had decided to stop listening to/watching the programs.

4.7.8 Perception and behavior/practice

The majority of FSWs perceived that they were in a job that continuously exposed them to HIV infection. All said that they were using condoms with their clients. They explained that condoms were available everywhere and were cheap. The majority bought and kept condoms; some were provided with free-of-charge condoms. The FSWs preferred the condoms that they bought themselves to those provided by clients because they believed that some men pierced the tips of the condoms. One FSW said that the quality of condoms supplied by clients was poor because the clients carried the condoms in their back pockets. Participants also mentioned that most clients were willing to use condoms but that some men did not like them. In all of these situations the FSWs said, ‘We do not accept sex without condoms.’ In contrast, FSWs said that sexual intercourse with lovers was performed without condoms. Nevertheless, it seemed that only a few FSWs actually had unprotected sex with their lovers or ‘boyfriends’.

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

Risk groups

FSWs mentioned the youth, especially students, as a high-risk group for HIV. They said this group was at high risk because it did not protect itself. Most discussants and interviewees also mentioned married people as a risk group. Moreover, street-based FSWs also mentioned schoolteachers because they had multiple sexual partners amongst their female students. None of the FSWs mentioned that FSWs were one of the risk groups.

Factors and circumstances

FSWs mentioned that commonly used drugs included khat, alcohol, hashish and shisha. Most FSWs chewed khat and drank alcohol. Some also used hashish, especially the street-based girls. A few of them mentioned that excessive drinking exposed them to unprotected sex. Therefore, they tended to control the amount they drank when a client offered them alcoholic drinks. The street-based girls preferred to use small hotels rather than big government hotels when they went out with their clients. In small hotels, when clients tried to force them to have sexual intercourse without a condom, the owners of the hotels helped them. However, in big hotels, it was very difficult to get assistance even if they cried for help.

4.7.10 Perceived risk behaviors and behavioral change

FSWs had a strong fear of HIV/AIDS. They felt that they had changed their behavior. The majority believed that they were protecting themselves by using condoms. However, they expressed their concerns that a few FSWs were not changing their behavior and continued to practice unprotected sex when offered better pay. They also pointed out that some males did not protect themselves and asked to have sex without condoms. A few FSWs did not use condoms with their lovers or ‘boyfriends’.

4.7.11 Participation in anti-AIDS clubs

Almost none of the FSWs were participating in anti-AIDS clubs. Participation only seemed to occur in situations where there were NGO activities.

4.7.12 Suggestions to avert the spread of HIV/AIDS

FSWs suggested various ways of reducing the spread of HIV/AIDS, including: continuity of anti-AIDS activities; involvement of religious leaders in the provision of health education; creation of job opportunities to provide alternative employment for FSW; and the provision of training and financial loans to FSW so that they could engage in small-scale income generating activities.