The current report is the 5th in the “AIDS in Ethiopia" series. The 1st edition appeared in 1996, while the 4th was published in 2002. The present edition reports the 2003 sentinel surveillance findings and estimates the HIV/AIDS status in the country. Besides the National Sentinel Surveillance (NSS) in antenatal care attendees" which has been going on for a number of years, HIV prevalence in Voluntary Counseling and Testing (VCT} clients, voluntary blood donors, foreign migration visa applicants as well as hospital based reports of suspected AIDS and STD patients, are collected systematically and analyzed.
All the tests and analysis on the results were done on anonymous and unlinked specimens. With respect NSS, the blood samples were tested using ELISA Immunoassay (EIA) at the regional testing centers and quality control was performed at the Ethiopian Health and Nutrition Institute (EHNRI). Crude prevalence rates were calculated using site data, while national HIV/AIDS prevalence and related estimates were made using EPP and Spectrum computer software. The current (2003) NSS is based on a much larger database—from 29 rural and 37 urban sites—compared to the 5 rural and 28 urban sites in 2001. Estimates of the number of people requiring antiretroviral treatment, HIV positive mothers and births were also done for the first time.
Out of the 23,861 NSS samples obtained in 2003, 8.2% (4.1% rural and 12% urban) were found to be HIV positive. The estimated national adult HIV prevalence in 2003 is 4.4%, of which 12.6% are urban and 2.6% rural. Trend analysis of prevalence from 1982-2003 showed an urban epidemic that rose sharply to a peak, and that has plateaued over the last 7 years; a steady rise of rural prevalence with consistent decrease in the rate of progression; and a continuing gradual rise in national prevalence but with beginning signs of leveling at relatively low level. The rate of new infections (incidence), which is usually the most reliable in indicating the progression of an epidemic, showed an urban incidence that rose sharply until 1990/91, declined over the following 7 years and plateaued thereafter albeit at a high level; rural incidence rose slowly until 2000 and leveled off at a much lower rate than the urban; and although national incidence parallels both the urban and rural trends, it is closer to the rural incidence.
The cumulative number of people living with HIV/AIDS is about 1.5 million (3.8% male and 5% female; 12.6% urban & 2.6% rural) out of which about 96,000 are children under 15 years. The estimated number of new AIDS cases in the adult population in 2003 was 98,000 (46% male & 54% female) while that in children was 25,000. Some 245,000 people living with HIV/AIDS (PLWHA) were in need of antiretroviral treatment (ART) in 2003 and some 90,000 adults and 25,000 children had died of AIDS also in 2003. There were an estimated 539,000 AIDS orphans in 2003.
Of the 15,580 blood donors from different parts of Ethiopia in 2003, 4.7% (3.8% female & 5.0% male) were positive for HIV. So were 3.6% of the 68,273 visa applicants; 16.7% (14.6% male & 19.5% female) of the 26,355 VCT clients; and, 46.7% (46% female & 54% male) of the 15,264 (male 58% and females 42%) suspected AIDS cases reported. Despite the specific limitations these findings pose to extrapolate the result to the general population and due to their inbuilt biases, they indicate a much lower prevalence rate than would be expected.
The analysis and estimates of the different derived variable on the NSS show that the 2003 national HIV prevalence was well as the absolute numbers are lower than those of 2001. This is partially due to the expanded database particularly in the rural sites, and also due to the use of more robust analytical software (EPP). There is currently a general consensus globally that country level prevalence rate from previous years were overestimated due to the use of relatively less refined methodologies.
However, there seems to be genuine and significant decline in the rate of new infection between years 1991-97 in urban areas and the rate of progression of the epidemic in the urban and rural areas in the last 5-7 and 3-5 years, respectively. This is also corroborated by the consistency of some of the service based prevalence and their trend analysis over the years. Moreover, the indirect evidences of behavioral modifications such as the increase in distribution of condoms from less than 1 million in 1996 to about 66 million in 2003, and the substantive increase in voluntary and premarital HIV testing support the observation/ conclusion. Hence it would be rational to suggest that there is some degree of behavioral change in the community resulting in the observed findings. However, the aggregate numbers are still staggering and with a lot of socio-economic and resource implications.
Although the behavioral surveys to date indicate some encouraging signs, the limited impact surveys and socio-economic impact analysis on blood sample results such as life expectancy, orphaned children, trained workforce and the social services, indicate a grave situation requiring an immediate scaled up and focused intervention.
In conclusion, the national HIV incidence rate in Ethiopia leveling off and the rate at which it is progressing is declining over the last few years and the epidemic appears to be stabilizing, particularly in urban areas, indicating some behavioral change in the population. This is also supported by the level of awareness about the disease, the tremendous increase in condom distribution and the increasing utilization of VCT services by different social groups. We need to capitalize on these achievements and do more. However, given the magnitude of the impact, the disturbing picture of the after effects and the poverty level of the country, the positive trends are not satisfactory enough to give respite. The cumulative numbers of PLWHA and orphaned children needing care and support will be taxing, to say the least. So will the demand on the limited social services, particularly the health care delivery system. The other socio-economic impacts are also expected to be daunting and required special attention if we were to continue and succeed on the present mode of economic development and poverty alleviation efforts.