Previous PageTable Of ContentsNext Page

CHAPTER 4: NATIONAL LEVEL HIV/AIDS INDICATORS

Download the full document (pdf format )

4.1 Impact

4.2 HIV/AIDS Prevention

4.3 HIV/AIDS Care, Support and Treatment

One characteristic of a good M&E System is that it must be simple and not costly to implement. The National M&E Framework has been designed with due consideration of these factors and existing capacity and opportunities to implement. The Framework consisted of indicators to assess progresses made on HIV/AIDS at national level. Half of the indicators will be collected through surveys, some using already existing surveys such as DHS, BSS and Sentinel Surveillance. Others will be gathered from routine project/program reports at different levels.

The indicators are primarily identified based on the goals and objectives outlined in the NSF in response to HIV/AIDS; and they are grouped into the priority intervention areas currently identified. In Chapter 6, the details of all indicators, frequency of data collection, measurement tools and responsible body for implementing or organizing data collection are stated.

4.1 Impact

Effective HIV/AIDS prevention and care programs will ultimately lead to reduction in the spread of HIV, which is the main objective of the NSF in response to the epidemic in Ethiopia. The Declaration of Commitment on HIV/AIDS adopted by the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in June 2001 also urges member states to aim for reducing HIV prevalence.

In Ethiopia, based on Sentinel Surveillance data, HIV prevalence among pregnant women aged 15 to 24 years was 12.1 percent in 2001 (MoH 2002). Ethiopia being one of the member states that signed the Declaration of Commitment, it is expected to work towards reduction of the reported 12.1 percent HIV prevalence to 9 percent by 2005.

Key objective

  • To reduce the spread of HIV in Ethiopia

    Indicator

    Imp1

    Percentage of pregnant women aged 15-49 years attending ANC clinics who are HIV infected (disaggregated by age, region and urban/rural)

    4.2 HIV/AIDS Prevention

    4.2.1 Behaviour Change Communication (BCC)

    Knowledge is an important prerequisite for prevention of HIV transmission as well as to care for and support PLWHA. DHS Ethiopia 2000 showed that 85 percent of women and 96 percent of men have heard of AIDS. However, when asked about methods to prevent HIV transmission, only 17 percent of women and 36 percent of men mentioned use of condoms; 11 percent of women and 17 percent of men identified abstain from sex; and 53 percent of women and 70 percent of men believed having sex with only one partner. Related to sexual behaviour/practice, only 13 percent of women and 30 percent of men reported they used condoms during last sexual encounter with a non-cohabitating partner; and one in two men with an STI or associated symptoms did not seek medical advice or treatment. These findings reveal: (i) although a large proportion of the people have heard about HIV/AIDS, their knowledge on prevention methods of the HIV virus is not high, and (ii) there is big gap between people’s knowledge about HIV/AIDS and their sexual behaviour. Evidences also show that misconceptions about HIV/AIDS is high and care and support for PLWHA is low. For example, BSS-Ethiopia shows that more than three-quarters of youth had at least one misconception about HIV/AIDS (BSS 2002).

    These evidences suggest the need to deliver appropriate messages consistently to all population groups with emphasis to those at risk of HIV infection. On the other hand, intervention programs should go beyond merely offering information and should foster “life skills” — decision making, problem solving, negotiating capability — which enable individuals to translate knowledge, attitudes and values into actual abilities that are important for behavioral change. Behaviour Change Communication (BCC) is a basic strategy to attain positive behavioural change among individuals and the society. BCC is an interactive process aimed at changing social and individual behaviour, using targeted, specific messages and different communication approaches, which is linked to services for effective outcomes (NACS & PACT-Ethiopia 2002).

    Main strategies:

  • Provide regular and consistent messages on prevention of HIV transmission by developing messages separately for specific target groups such as youth, women, commercial sex workers, uniformed people, mobile labour forces, refugees, IDPs, farmers, pastoralists and workers

  • Adapt and coordinate the implementation of the National HIV/AIDS Communication Framework based on local realities in regions, Woredas and institutions

  • Involve public figures, religious and community leaders so that they can serve as actors of change

  • Fully engage primary, secondary, higher learning and vocational educational institutions in BCC with appropriate packages such as Life-Skills Education

    Key objective

  • Reduce high-risk behavior by promoting delayed onset of sexual activity, abstinence, faithfulness, use of condoms, early and effective treatment of STIs and reduce stigma and discrimination

    Indicators

    Prv1

    Percentage of people aged 15-49 years who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (disaggregated by age, sex, target population, region and urban/rural)

    Prv2

    Median age at first sex (disaggregated by age, sex, region and urban/rural)

    Prv3

    Number of teachers trained in life-skills-based HIV/AIDS education and graduated in the last 12 months

    Prv4

    Percentage of people aged 15-49 years reporting the use of a condom during last sexual intercourse with a non-regular sexual partner (disaggregated by age, sex, target population, region and urban/rural)

    Prv5

    Percentage of people aged 15-49 years expressing accepting attitudes towards people with HIV/AIDS (disaggregated by age, sex, target population, region and urban/rural)

    4.2.2 Condom promotion and distribution

    Sex abstinence and mutual faithful partnership are among the first lines of defense against HIV infection. However, for those who cannot limit themselves to any of these methods, use of condoms is the only effective way to prevent against the virus. Regarding adolescents, there is a trade-off between informing them to only abstain sex and providing them with additional information about use of condoms as an alternate HIV prevention mechanism when they cannot abstain. However, different studies have shown that an effective strategy to promote sex abstinence is through comprehensive sexual education that offers a wide range of information including use of condoms. However, comprehensive sexual education should encourage adolescents to delay sexual behaviors until they are physically, cognitively, and emotionally ready for mature sexual relationships and their consequences.

    Main strategies:

  • Provide information on the use of condoms through appropriate channels and targeting population groups at higher risk

  • Distribute condoms through public outlets such as health institutions, pharmacies, shops, kiosks, recreation centers, hotels, etc.

  • Encourage condom provision as part of workplace intervention

  • Assure quality of condoms supplied to the public

  • Make quality female condoms available and accessible

    Key objective

  • To provide an alternative protective mechanism for those who cannot limit themselves to abstinence or faithful sexual partnership through improved availability and accessibility of condoms.

    Indicators

    Prv4

    Percentage of people aged 15-49 years reporting the use of a condom during last sexual intercourse with a non-regular sexual partner (disaggregated by age, sex, target population, region and urban/rural) [Also used for BCC]

    Prv6

    Percent of condoms imported that meet the national quality standard

    Prv7

    Total number of condoms available for distribution nationwide during the preceding 12 months, divided by the total population aged 15-49 (disaggregated by male/female condoms)

    Prv8

    The proportion of randomly selected retail outlets and service delivery points that have condoms in stock at the time of a survey (disaggregated by region and urban/rural)

    4.2.3 Blood safety

    The risk of HIV transmission through transfusion of contaminated blood is the highest, from 900 to 1000 in 1000 cases (Whiteside & Sunter 2000). In the case of Ethiopia, the national prevalence of HIV infection among low-risk segment of voluntary blood donors is 6.1 percent, indicating that necessary precautions should be made in providing blood transfusion (MoH). HIV transmission through transfusion of unsafe blood can be avoided by making blood donations as safe as possible by seeking donors from low-risk populations, screening potential donors with questions designed to identify high-risk donors, testing the collected blood for HIV, and increasing voluntary non-enumerated blood donors in the country. The Ethiopian Red Cross Society (ERCS), which is the only source of blood supply in Ethiopia, has put in place a system to screening donated blood in all of its outlets and hospitals engaged in the provision of blood transfusion services. The service is progressively expanding too and ERCS currently has 10 blood bank centers in the country that are equipped with testing facilities.

    Main strategies:

  • Providing blood banks and health facilities with uninterrupted supply of necessary equipment and reagents

  • Expanding new blood banks in the Regions

  • Motivating a pool of non-remunerated low risk blood donors

  • Training of health professionals in HIV screening, basics of blood transfusion and blood safety and efficient use of blood products

    Key objective

  • To ensure availability of HIV-free blood in health facilities and ERCS blood banks in the country by increasing the number of voluntary, non-remunerated blood donors in the country

    Indicators

    Prv9

    Percentage of voluntary, non-remunerated blood donors donating blood in the last 12 months (disaggregated by age, sex and urban/rural)

    Prv10

    Number of blood units collected in the last 12 months (disaggregated by region and urban/rural)

    Prv11

    Number of blood banks in the country (disaggregated by region and urban/rural)

    4.2.4 Management of sexually transmitted infections (STIs)

    STIs are among the major causes of morbidity in Ethiopia, they are in the top ten causes for outpatient visits and high prevalence rates have been reported from various population groups (NAC 2001). Having other sexually transmitted infections can increase the odds of contracting HIV during sex with an infected person. This calls for programs aimed to reverse HIV infection trends to focus on prevention and early treatment of STIs.

    Main strategies:

  • Undertake primary prevention of STIs through BCC and condom promotion

  • Timely update the national drug-list according to the anti-microbial sensitivity and ensure availability of adequate drugs and supplies and effective treatment of STIs in all health care facilities

  • Incorporate comprehensive STI syndromic management approach in the health workers training curriculum

    Key objectives

  • Improve people’s awareness on prevention of STIs, their symptoms and the need for early treatment

  • Improve access to quality STI treatment services

  • Scale-up syndromic management of STIs

    Indicators

    Prv12

    Percentage of people aged 15-49 years who know two or more symptoms of STIs
    (disaggregated by age, sex, target population, region and urban/rural)

    Prv13

    Percentage of patients with STIs at health-care facilities who are appropriately diagnosed, treated and counseled (disaggregated by age, sex, region and urban/rural)

    Prv14

    Percent of health facilities providing STI care that have a current supply of essential STI drugs and report no stock out lasting longer than one week in the preceding 12 months (disaggregated by region)

    Prv15

    Number of health workers trained onsyndromic management of STIs according to national guideline in the last 12 months (disaggregated by region)

    4.2.5 HIV counseling and testing

    Voluntary Counseling and Testing (VCT) services are very helpful for both prevention and treatment services in that (i) people who test HIV positive can seek information, support and treatment; (ii) as studies show, people who undergo VCT change their sexual behaviour to protect themselves and their partners (WHO 2002). Despite these benefits, VCT coverage among people who need the service is 6 percent in less developed countries of Africa (WHO 2002). In Ethiopia, the number of VCT sites is increasing, numerous training sessions have been conducted for professionals, and test kits have been distributed in all Regions. There are 144 VCT sites in Ethiopia (HAPCO 2003). However, considering their critical advantage, VCT sites should be made widely available in all geographic areas and their accessibility improved. On the other hand, HIV counseling and testing services are necessary not only to those who are voluntarily coming for the service to VCT centers but also to all HIV-suspected in- and out-patients at the health facilities.

    Main strategies:

  • Establishing VCT centers where they are needed

  • Improving quality of counseling and testing services

  • Training of staff for counseling and testing

  • Establishing a referral system for care and support

    Key objective

  • To make HIV counseling and testing services available for people so that it serves as an entry point for HIV prevention and care

    Indicators

    Prv16

    Number of individuals receiving HIV counseling and testing in the last 12 months:

      (a) Number of individuals who received pre-test counselling,

      (b) Percent of those counselled who received HIV testing,

      (c) Percent of those tested who were positive,

      (d) Percent of those tested who received their results through post-test counselling services, and

      (e) Percent of those tested HIV-positive who were referred to care and support services
      (disaggregated by type of service (voluntary/diagnostic), age, sex, region and urban/rural)

    4.2.6 Prevention of mother-to-child transmission (PMTCT)

    HIV can be transmitted from mother to child during pregnancy, labour, delivery or breastfeeding. If no proper measures are taken, the risk of an infant acquiring the virus from an infected mother is 25 percent to 35 percent. A study has indicated that the rate of MTCT in Ethiopia is estimated to range from 29 percent to 47 percent (NAC 2001). The combination of high total fertility rate in Ethiopia, 5.9 children per woman (DHS 2000), and rate of MTCT, is clear evidence that the number of infants born HIV-positive is alarming.

    The UNGASS goal in preventing mother-to-child transmission of HIV is to reduce the proportion of infants infected with HIV by 20 percent and 50 percent by 2005 and 2010, respectively. Prevention of mother-to-child transmission refers to services that counsel women about HIV, offer an HIV test, and provide ART and supplemental feeding. In Ethiopia, there are currently five PMTCT sites and a rapid expansion throughout the country is planned. The government of Ethiopia in its Policy on Anti Retroviral Drugs Supply and Use has made provision of PMTCT drugs for free to pregnant women who tested positive. The country is also gradually introducing PMTCT+. PMTCT+ is an HIV care and treatment program that establishes HIV primary care services for women identified as HIV infected through perinatal prevention programs and their infants, children, and family/household members. The fundamentals of PMTCT+ are: HIV primary care that includes provision of antiretroviral therapy; family-centered care; comprehensive care via multidisciplinary team with attention to clinical, psychosocial and environmental issues; and focus on adherence and retention in care.

    Main strategies:

  • BCC intervention to protect women of childbearing age from becoming infected with HIV

  • Provide VCT services integrated with ANC and post-natal care

  • Assure availability of and facilitate access to ARDs and other appropriate supplies for PMTCT and PMTCT+

  • Support for alternative feeding to breast milk

  • Link PMTCT with care and support initiatives organized for orphans and HIV-infected women

    Key objective

  • To minimize the vertical transmission of HIV by increasing coverage of and access to PMTCT and PMTCT+ services

    Indicators

    Prv17

    Percentage of HIV-infected pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of MTCT in accordance with nationally approved treatment protocol in the last 12 months (disaggregated by region)

    Prv18

    Percentage of HIV-infected infants born to HIV-infected mothers (disaggregated by region)

    Prv19

    Percentage of all possible public, private, missionary and workplace health facilities (family planning and primary health care clinics, ANC/MCH, and maternity hospitals) providing the minimum package of services to prevent HIV infection in women and infants in the past 12 months (disaggregated by region)

    Prv20

    Percentage of pregnant women that:

      a. Attend at least one ANC visit

      b. Attend at least one ANC visit that is a PMTCT site

      c. Receive pre-test counseling on HIV

      d. Receive testing for HIV

      e. Receive post-test counseling on HIV

      f. Receive HIV results

    Prv21

    Number of health facilities providing PMTCT services in the past 12 months (disaggregated by region)

    4.2.7 Universal precautions (UP) and post-exposure prophylaxis (PEP)

    Universal precaution is the prevention of transmission of blood born pathogens - like HIV - through strict respect by health care providers of rules concerning care and nursing (NAC 2001). The 2003 Joint Mid-Term Review of the national response to HIV/AIDS observed shortage of protective materials for many of the Regions in the Country. Only few of the Regions are reported to have prepared policies and strategies and conducted training for health professionals on universal precautions. Considering the high prevalence of HIV/AIDS in Ethiopia and shortage of protective materials in health facilities, health care providers are at high risk of HIV infection. Universal precaution requires sustained provision of protective materials, proper training of health care providers and adherence to sterilization and disinfection protocols.

    Post-Exposure Prophylaxis (PEP) is short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure, either occupationally or through sexual intercourse. Within the health sector, PEP should be provided as part of a comprehensive universal precautions package that reduces staff exposure to infectious hazards at work.

    The risk of exposure from needle sticks and other means exists in many settings where protective supplies are limited and the rates of HIV infection in the patient population are high. The availability of PEP may reduce the occurrence of occupationally acquired HIV infection in health care workers. It is believed that the availability of PEP for health workers will serve to increase staff motivation to work with people infected with HIV, and may help to retain staff concerned about the risk of exposure to HIV in the workplace. There is significant debate on the need to use PEP after sexual exposure. The UN offers PEP to its staff in cases of rape when the likelihood of HIV exposure is considered high. PEP with antiretroviral treatment may reduce the risk of becoming infected.

    The Policy on Anti Retroviral Drugs Supply and Use emphasizes the need to strengthening universal precautions and establishing a system of Accidental Blood Exposure (ABE) surveillance in institutions.

    Main strategies:

  • Formulate policies and guidelines on universal precautions and post-exposure prophylaxis

  • Train health care providers in universal precautions and PEP

  • Ensure consistent availability of protective materials and equipment such as syringes, gloves, antiseptics and sterilization facilities

    Key objective

  • To prevent HIV transmission in health care settings

    Indicator

    Prv22

    Percentage of health facilities that have guidelines to prevent nosocomial transmission of HIV, adequate sterilization procedures, and protective materials and equipment such as syringes, gloves and antiseptics in stock at the time of the survey (disaggregated by region)

    4.2.8 Service availability

    Availability of services such as VCT, ART and PMTCT is vital for preventing transmission of the HIV virus as well as to extend and improve the quality of life of PLWHA. The services are considered available when they are geographically and economically accessible to the users.

    Main strategy:

  • Advocacy and resource mobilization for budget allocation/utilization so as to make services such as VCT, ART and PMTCT equitably available

    Key objective

  • Basic services such as VCT, ART, and PMTCT are widely available

    Indicators

    Prv23

    Percentage of Woredas with at least one VCT center in the last 12 months (disaggregated by region)

    Prv24

    Percentage of Woredas with at least one health facility providing PMTCT (disaggregated by region)

    Prv25

    Percentage of Woredas with at leas one health facility providing ART (disaggregated by region)

    Prv26

    Number of Regions/Woredas who have established HIV/AIDS resource center

    4.3 HIV/AIDS Care, Support and Treatment

    4.3.1 Psychosocial and Economic Support

    In general, HIV/AIDS has severe social, psychological and economic influences on both the individuals and societies. The disease causes painful stress, disability and death to the individual patient. On the other hand, the familial, social and economic problems associated with the disease are overwhelming that include divorce, family disintegration and orphaned children. As the disease largely affects the adult population, large number of families and children are left without the principal income provider. Through sickness and discrimination, HIV-infected adults become less productive and unable to support themselves, let alone their families. The epidemic is also associated with poverty; the poor are likely to have less good health and diet, and live more risky lives. In general, poorer countries have higher rates of infection, and poorer people within poor countries have higher rates of infection than do the better off. Ethiopia is one of the poorest countries in the world and where the number of PLWHA is the second largest in Africa, next to South Africa. Therefore, the need for psychosocial and economic support to PLWHA and affected families is high.

    Main strategies:

  • Increase awareness of the family and community and strengthen their support for HIV/AIDS patients and affected families

  • Support NGOs and CBOs involved in psychosocial and economic support to PLWHA and affected families

  • Support and organize self-help groups of PLWHA

  • Provide counseling and psychosocial support to PLWHA, at health facilities and at home

  • Promote workplace care and support interventions

    Key objective

  • Mitigate the adverse socioeconomic impact of HIV/AIDS by providing appropriate support

    Indicators

    CST1

    Percentage of people aged 15-59 who has been ill for 3 or more months in the last 12 months and whose household received free basic external support in caring for the chronically ill person (disaggregated by age, sex, region and source, type and level of free support)

    CST2

    Number of people aged 15-59 who has received help from home-based program in the last 12 months (disaggregated age, sex, region and type and level of support)

    4.3.2 Clinical care including ARV therapy and TB treatment

    Although HIV/AIDS is not curable, it has become treatable through advances made in the management of opportunistic infections and development of more effective ARV therapies. Provision of essential drugs, drugs for opportunistic infection including TB, and ARV therapy are necessary to extend life and enhance the quality of life for many people living with HIV/AIDS. VCT services and PMTCT will also be more successful if they are linked with such clinical care and support.

    Main strategies:

  • Provide appropriate clinical treatment and nursing support for opportunistic infections in AIDS patients

  • Educate family members on basic nursing skills and promote hygiene and nutrition for PLWHA at health facilities and at home

  • Evaluate anti-retroviral treatment options in terms of access and affordability and establish ARV treatment initiative programs

  • Train health workers on the diagnosis and treatment of HIV/AIDS and opportunistic infections, including on non-judgmental attitudes towards AIDS patients and their families and on universal precautions

  • Make ARV drugs available at affordable prices

    Key objective

  • Extend life and enhance the quality of life of people living with HIV/AIDS

    Indicators

    CST3

    Percentage of people with advanced HIV infection receiving ARV combination therapy (disaggregated by age, sex, region, and urban/rural)

    CST4

    Percentage of health facilities that either provide comprehensive care and support services onsite for people living with HIV/AIDS or through an effective referral system (disaggregated by region)

    CST5

    Percentage of health facilities that have the capacity and conditions to provide basic level HIV testing and HIV/AIDS clinical management (disaggregated by region)

    CST6

    Percentage of health facilities that have the capacity and conditions to provide advanced level HIV care and support services, including provision and monitoring of ART (disaggregated by region)

    CST7

    Percentage of designated laboratories with the capacity to monitor ART according to national guidelines

    4.3.3 Orphans and vulnerable children (OVC)

    One of the worst consequences of AIDS is the fact that it creates a number of AIDS orphans, children whose parents die from AIDS. The loss of a parent has profound significance for a child. The death of a mother, in particular, has dramatic psychosocial consequences. Loss of a father often means the loss of income and results in economic depreciation. Various definitions of AIDS orphans are used: maternal orphan – children who lost their mother to AIDS; paternal orphan - children who lost their father to AIDS; and double orphan - children who lost both parents to AIDS. Vulnerable children are those with a chronically ill parent (mother or father) very sick for 3 or more months.

    MoH report estimated the number of maternal orphans in Ethiopia – children under the age of 15 who lost their mother to AIDS – to be 1.2 million in 2001 and projected to increase to 1.8 million by 2007 and to 2.5 million in 2014 unless effective measures are taken to curb the trend of the epidemic (MoH 2002).

    Main strategies:

  • Support NGOs and CBOs involved in supporting OVCs

  • Strengthen and provide technical assistance to the community in order to effectively utilize the traditional coping mechanisms of handling OVCs

  • Increase awareness of the community and educate youth in school and design ways of retaining HIV/AIDS affected orphans in school

    Key objective

  • Mitigate the adverse socioeconomic impact of HIV/AIDS by providing appropriate support to AIDS orphans and vulnerable children

    Indicators

    CST8

    Percentage of households caring for orphans and vulnerable children who received free external support in the last 12 months (disaggregated by age and sex of OVC, region and source, type and level of free support)

    CST9

    Number of orphans and vulnerable children who received free external support in the last 12 months (disaggregated by age and sex of OVC, region and type and level of free support)

    CST10

    Ratio of current school attendance among orphans to that among non-orphans aged 10-14 (disaggregated by age, sex, region and urban/rural)

    4.3.4 Legal and human rights

    An environment in which rights of PLWHA are respected ensures that vulnerability to HIV/AIDS is reduced, those infected with and affected by the epidemic live a life of dignity without discrimination and the personal and societal impact of HIV infection is alleviated (OHCHR & UNAIDS 1998). This requires widespread review or reforms of laws and legal support services, with a focus on anti-discrimination and protection of PLWHA and those most vulnerable to the epidemic. Areas that need legislative and health policy and standard revision in relation to HIV/AIDS include measures such as informed consent, partner notification, universal precautions, orphans inheritance, criminal laws, obligations of HIV positive people, anti-discrimination laws, privacy and confidentiality, employment regulations and HIV/AIDS goods and services.

    Main strategies:

  • Legislative review/reform with regard to the rights of people infected and affected by HIV/AIDS to non-discrimination, health, information, education, employment, social welfare and public participation

  • Review and revise existing policies and develop new ones where needed to support the enforcement of the laws and legislations

  • Develop public and private sector standards regarding codes of conduct, human right principles, professional responsibilities and practices

  • Create supportive and enabling environment for women and other vulnerable groups through community dialogue

  • Support free legal services through the government and professional associations

    Key objective

  • To ensure that the legal rights of PLWHA, their families and the vulnerable groups are respected, protected and their special needs progressively realized and public security maintained, by enacting legislations and availing legal services

    Indicators

    CST11
    National policy index on human rights

      - Country has laws and regulations that protect against discrimination of people living with HIV/AIDS

      - Country has laws and regulations that protect against discrimination of groups of people identified as being especially vulnerable to HIV/AIDS

      - Country has a policy to ensure equal access for men and women to prevention and care, with emphasis on vulnerable groups

      - Country has a policy to ensure that HIV/AIDS research protocols involving human subjects are reviewed and approved by an ethics committee (at the Science and Technology Commission of Ethiopia)

    CST12

    Percentage of PLWHA who correctly know their rights and obligations (disaggregated by age, sex and region)

    CST13

    Percentage of HIV/AIDS related court cases in the last 12 months that were settled in the same period



    Previous PageTop Of PageNext Page