6. Conclusions and recommendations
6.2.1 Policy and advocacy level
6.2.2 Information, education and communication/behavioral change communication (IEC/BCC)
6.1 Conclusions
Knowledge of the three major preventive methods was reasonably good. However, almost half the respondents were unable to name all three preventive methods. Moreover, there was a knowledge gap amongst the rural population groups. Condoms were accessible and not too expensive but major misconceptions existed about condoms.
Misconceptions about HIV/AIDS existed amongst all the population groups. However, levels of misconceptions were higher amongst the underprivileged groups, such as the farmers and pastoralists. Because of misconceptions about HIV/AIDS, comprehensive knowledge was very low in all groups. Therefore, in addressing knowledge, misconceptions should be considered.
There was a high level of stigma and discrimination; this existed in various forms. Stigma and discrimination were worst amongst the rural population groups, particularly amongst the females. Stigma and discrimination remain a challenge to HIV/AIDS control and prevention efforts in Ethiopia.
In the previous 12 months, very few youth or farmers had reportedly had commercial sex; in contrast, commercial sex was common amongst the uniformed services.
There were high levels of premarital sex amongst the youth. Number of sexual partners was higher amongst the out-of-school youth (OSY) than the in-school youth (ISY), and amongst males than females. A considerable proportion of the adult population groups had had more than one sexual partner in the previous 12 months. About one in three married respondents reported that they had had extramarital sex in the previous 12 months. All these sexual behaviors provided opportunities for the spread of HIV/AIDS.
Most of the sexually active youth had unprotected sex with non-commercial partners, particularly the OSY. A substantial proportion of FSWs had unprotected sex the last time they had sex with their non-paying partners.
With the exception of FSWs, condom use and consistent condom use were lower in females than in males.
The coverage of VCT services was found to be limited and the proportion of respondents who reported that they had ever had an HIV test was very low. High cost, lack of access and unknown reliability appeared to be barriers to VCT for respondents. Nevertheless, many respondents commented that they were willing to undergo VCT in the future.
Considerable proportions of youth and FSWs used drugs (mostly khat and shisha) and alcohol.
Risk perception for HIV infection was low. Even FSWs did not perceive themselves to be at risk for HIV infection.
With the exception of the ISY, exposure to community interventions, other than mass media messages, was low amongst all population groups.
6.2 Recommendations
6.2.1 Policy and advocacy level
i) Sustained political commitment and involvement of leaders is needed at all levels to support behavioral change and decrease stigmatization and discrimination.
ii) Governmental, non-governmental and other bilateral organizations need to promote the establishment and running of recreational facilities and libraries, and focus on the provision of employment opportunities for the youth.
iii) The media has to continue its efforts: to address both ISY and OSY; to reach the rural population (especially through radio programs); to help the general population to develop positive attitudes towards PLWHA; and to build comprehensive knowledge on HIV/AIDS (including minimization of misconceptions).
iv) Cognizant of regional variation, decision makers at higher government levels should pay special attention to some of the regions that had low scores for comprehensive knowledge and lacked intervention activities, such as the Afar, Gambella and Somali regions.
v) Parents, religious organizations, governmental and non-governmental organizations need to be mobilized to influence public opinion on HIV/AIDS and related high-risk behaviors.
vi) Comprehensive HIV/AIDS prevention and control interventions and job creation should be targeted at youth (15-24 years old), particularly the females.
6.2.2 Information, education and communication/behavioral change communication (IEC/BCC)
i) Misconceptions were widespread in all target groups. Mass media and IEC activities should address misconceptions to enhance behavioral change.
ii) Current IEC needs to be evaluated with a view to adapting the country strategy for BCC in order to enhance behavioral change.
iii) Anti-AIDS clubs, which were found to be of great value in terms of improving knowledge, attitudes and practice, have to be strengthened amongst the ISY and need to be expanded to OSY.
iv) Parents should be involved in HIV/AIDS-related intervention activities. They should be enabled and encouraged to participate. Encouragement of open communication between parents and their children will help to reinforce behavior.
6.2.3 Program level
i) Increased awareness and expansion of VCT services are required to promote and sustain behavioral change. The VCT services should be more accessible to the community, the uniformed services and the mobile population groups.
ii) Awareness of pregnant mother-to-child transmission (PMTCT) of HIV needs to be increased; moreover, services reducing the risk for PMTCT need to be initiated and made widely available.
iii) HIV/AIDS intervention programs should extend to the rural communities (i.e. to pastoralists and farmers) and special strategies should be designed to increase access of these communities to the mass media; moreover, alternative methods that are appropriate to rural areas, such as out-reach services, should be used.
iv) Increased involvement of FSWs is needed to address their needs in intervention activities; this may be accomplished through expansion of FSW forums and provision of vocational training.
v) Emphasis should be given to discouraging drug and alcohol use amongst the youth. Some of the intervention activities could be conducted in schools by integration with the activities of school clubs. If appropriate measures are not taken at this stage, drug and alcohol use may lead to serious problems.
vi) Promotion of abstinence and decreasing the magnitude of premarital sex amongst the youth should be given priority. In addition, promotion of other preventive methods should be targeted and individualized. Promotion of condoms should continue for all sexually active individuals.
vii) Negotiation skills should always be a priority in training. In particular, females should be encouraged to demand condom use and should be protected against violence.
viii) Establishment of programs promoting the use of condoms, particularly programs targeting FSWs, should be a high priority. Governmental and non-governmental institutions operating in the region could organize these programs; moreover, health workers, volunteers and peer groups could facilitate implementation of the programs.
ix) Programs designed to control HIV/AIDS transmission should aim to bring about behavioral change and focus on the promotion of safer sex. Intensive IEC programs, which take into account the heterogeneous characteristics of the population, should be developed. These programs should aim to delay sexual debut and should include age appropriate information on HIV transmission and prevention, and the support services available.
x) Control programs for sexually transmitted infections (STIs) that are provided by health institutions need to be strengthened to include youth friendly services, early diagnosis and treatment.
xi) Peer education relating to sex education has an important role in reaching ISY and OSY, as well as other target groups. Accordingly, locally developed, culturally appropriate educational materials should support IEC activities.
xii) Target specific strategies and interventions should be designed for the groups that are mobile such as drivers (taxi drivers, intercity bus drivers and truckers) and the uniformed services.
xiii) In the uniformed service personnel and their families, promotion of VCT through increased access and education, continued promotion of condoms and an emphasis on consistent condom use are recommended. In addition, extension of IEC services to the community around uniformed services camps and specifically to FSWs and female youth should be useful.
xiv) An enabling environment or environmental intervention (e.g. control of illegal video showing houses and nightclubs) is required.
