According to the National Guidelines for the Management of STIs jointly prepared by the Federal Ministry of Health and Federal HAPCO, sexually transmitted infections are caused by more than 30 pathogens that can be transmitted through unprotected sex. STIs may be broadly classified into ulcerative and non-ulcerative (discharge) or curable and non-curable (MoH, 2006). While it’s easy to prevent the transmission of non-ulcerative or discharge STIs through the correct and consistent use of condoms, it’s rather difficult to prevent the transmission of ulcerative STIs, as open sores and infected parts may be found in areas where condoms cannot cover. Thus, in such cases the best prevention method is abstinence. STIs are especially more severe on women as the consequence of some STIs may result in cervical cancer, death during child birth and child infection during pregnancy or childbirth.
Although the Ethiopian government has come up with a National guideline to treat and care for STIs by using syndromic approach – an approach that uses a set of symptoms to treat possible cases of STIs by giving medications believed to be the appropriate treatment, STIs that do not show sufficient symptoms with potentially fatal consequences may be left undetected. Such an approach, albeit best in a resource limited country as Ethiopia, where availability of fully equipped laboratories are very limited and skilled health care practitioners are hard to come by, it may not treat or address a lot of people’s problems with asymptomatic STIs.
Furthermore, because the presence of STIs, especially ulcerative STIs, exacerbates the risk of acquiring HIV, as the open sores and cuts provide easy access for the HIV virus to pass into the blood stream in cases of unprotected sexual intercourse, early diagnosis is important to prevent HIV acquisition.
According to a WHO factsheet published in August 2011, “the presence of untreated STIs (both those which cause ulcers [and] those which do not) increase the risk of both acquisition and transmission of HIV by a factor of up to 10. Thus, prompt treatment of STIs is important to reduce the risk of HIV infection” (WHO, 2011).
Therefore, in sero-discordant relationships, where one partner is HIV positive and has other STIs, the chances of transmitting HIV to their uninfected partner increases, if the STI is not treated promptly. The same is true, for the HIV negative partner who has an untreated sexually transmitted infection.
To see how much testing for STIs embarrasses people, we spoke to one college student in Addis Ababa. *Zeinab is a twenty year old college student who has been going out with her boyfriend for a couple of years, whom she plans to marry. Although, Zeinab is still a virgin, she has had several intimate moments with her boyfriend without having actual sexual intercourse. Because of this, Zeinab used to feel that she would be safe from all STIs and, thus, did not see the need to seek medical help. It wasn’t until Zeinab decides to volunteer in an organization that works in the area of HIV/AIDS that she finds out she may be at risk of acquiring STIs. Because she has no symptoms and most STI tests use the syndromic approach, she does not know how to get tested or what to tell the doctors. Embarrassed and worried, she’s waiting for the time when she gets married and has the freedom to ask for all possible tests.
Although, Zeinab has already decided to marry her boyfriend and is HIV negative at the time being, she nonetheless feels that talking about STIs and getting tested is difficult in such a traditional society as ours. She also feels that although much is being done about HIV on various media, there is hardly anything on STIs and on how to prevent them.
Adolescents who start sexual intercourse at an early age are at higher risk of acquiring STIs because they are not in a good position to negotiate for safer sex and due to the increased number of sexual partners they will have in their lifetime.
With this in mind, more awareness raising work needs to be done in schools, colleges and youth clubs to inform the more susceptible population on the dangers of STIs, how STIs are transmitted and on how to prevent them.
*Names in this article have been changed to protect identity.
Sero-discordance is a term used to describe the sero status of couples where one partner is HIV positive and the other is HIV negative. Sero-discordant couples could be married, pre-marital or cohabiting.
A case study conducted in selected health centers in Dessie found that, couples’ sero-discordance was mostly due to frequent history of travel, short or long term departure from partner and partners’ history of STI and alcohol abuse, even though there may be other reasons at country level.
According to the 2005 Ethiopian Demographic and Health Survey (EDHS), from 2,674 couples tested for HIV, 98% of the cohabiting couples were concordant negative, while 1.8% of the 2.1% were discordant. This shows that, 1.8% of negative partners in sero-discordant relationships are at high risk of contracting the HIV virus unless the necessary measures are taken to avert infection. Worldwide, it is estimated that only half of the 33 million people living with HIV/AIDS know their HIV status, which demonstrates the great need to scale up couples’ HIV counseling and testing.
On the one hand, although individual testing can inform the sero-status of an individual, high risk of HIV infection or sero-conversion is still a looming threat for individuals in sexual partnerships, unless both parties are tested together. While it’s relatively easy to find pre-marital couples going to HIV counseling and testing (HCT), especially before nuptials, it’s not very common for married or cohabiting couples going to HCT centers together unless one falls ill or has been exposed to risky behavior.
Because many couples do not come together for HIV counseling and testing, HCT counselors find it difficult to give comprehensive care, treatment and support to both partners and whole family units. This is especially true in urban areas where HIV Counseling and Testing refusal is higher than in rural areas, as found out by EDHS, 2005.
An informal discussion with a VCT counselor at Zewditu Hospital showed that, reasons individuals in partnerships who get tested for HIV do not want to disclose their status to their partner or bring partner to HCT centers are because: they don’t want to seem unfaithful, are afraid of separation or divorce and say they trust partner and do not need to have partner tested, among others.
One may ask why couples need to get HIV counseling and testing. Can it be helped if one is HIV positive and the other is not? Or is there any way to prevent infection among discordant couples?
According to a scientific study conducted by the United States National Institute of Health, an HIV positive person’s effective adherence to antiretrovirals (ARV) can reduce the transmission of HIV to their uninfected partner by 96% (WHO/UNAIDS joint press release, 2011). This means that as soon as sero-discordant couples know of their status, they can start ARV treatment to significantly reduce the concentration of HIV in the bloodstream and genital secretions thereby reducing HIV transmission. According to World Health Organization, “Proof of concept that antiretroviral drugs decrease HIV transmission comes from the prevention of mother to child transmission of HIV.”
Nevertheless, because, antiretroviral treatment (ART) for HIV prevention is not 100%, it’s recommended that it be used along with a package of prevention and treatment interventions, such as the proper and consistent use of condoms and voluntary male circumcision among discordant couples to effectively and substantially reduce transmission.
Having said this, however, the debate whether or not to start ART when CD4 count is greater than 350 is still ongoing. In the Ethiopian context, WHO guidelines for the initiation of ARV treatment is set at CD4 count of ≤350 or at clinical stage 3. Thus, sero-negative persons with sero-positive partners who start ART in line with WHO’s guidelines can significantly reduce HIV transmission to their partners given that they also use condoms consistently and correctly along with other prevention packages.
Such findings, as stipulated by a WHO/UNAIDS joint press release “will not only empower people to get tested for HIV, but also to disclose their HIV status, discuss HIV prevention options with their partners and access essential HIV services. It will also significantly contribute to reducing the stigma and discrimination surrounding HIV.”
Thus, while it is encouraging that, in the 2008/2009 Ethiopian fiscal year, 31,831 Health Extension Workers were deployed to villages across the country to improve access and equity in the delivery of essential health services (Progress Report 2010, FHAPCO) including, the prevention, care and treatment of HIV/AIDS, which translates to a substantial number of couples living in villages getting HIV counseling and testing services in their homes, there’s still a great need to scale-up couples’ HIV counseling and testing in urban areas to achieve the global vision of zero new HIV infection, zero AIDS related deaths and zero discrimination.
In Ethiopia, different alcoholic drinks are consumed, from the traditionally prepared beer and honey mead wine to industrially produced beer, wine, distilled spirits etc. Drinking alcohol is very much part of the Ethiopian culture. Apart from it being a way to unwind and socialize with friends, it is usually a big part of wedding celebrations, social gatherings, holidays and other festivities.
When alcoholic drinks are abused, apart from having both short and long term direct negative health effects, it can also affect behavior negatively and expose drinkers to unwanted sexual risk taking.
In the urban and metropolitan cities of Ethiopia, a wide range of both modern and traditional bars are available selling from low-priced drinks with unknown alcoholic content to high end wine and distilled alcoholic beverages. In the absence of effective implementation of alcohol prohibitory laws for minors in the country, both under age youths and adults can go into any bar of their choice and drink as much as they desire, as long as they can pay for it. This puts underage adolescents in a vulnerable position exposing them to risky sexual encounters and other undesirable consequences.
In Ethiopia, youths, after their 12th grade matriculation which is usually around the age of 18, join different universities and stay at campus dormitories or in nearby rented houses for the duration of their studies. During this time, because there is minimal or no parental oversight, there is a chance for them to be engaged in drinking bouts and binges from time to time.
Eskinder and Nahom, who are currently in their first year of postgraduate education, started to binge drink while they were in their sophomore year. Eskinder, a social studies postgraduate student who came from Awassa to join Addis Ababa University five years ago, recalls that when he first joined, he didn’t have friends and was new to many things. He was, thus, very much focused on his studies and spent much of his freshman year studying.
However, in sophomore year, everything changed, Eskinder said. “We started hanging out with senior students around the basketball court. And they would tell us about their nights, and how fun they were. They would then invite us to hang out with them in the evening. Although we did not like it the first time, we slowly got used to the lifestyle and got sucked in.”
College youths at this age are eager to experience all kinds of things with a great desire to belong and conform to popular campus culture. Unless strengthened to resist peer pressure, there is a real danger for them to be exposed to risky sexual behavior from alcohol intoxication. This, not only, can derail them from their goals, but it can also expose them to unwanted pregnancies, HIV infection and other STIs.
Eskinder said “sometimes I would be asleep in my dorm and would get a phone call from friends at around 10:00 pm, asking me to join them for drinks; I would get up from bed to join them.” They sometimes would be partying until over midnight, by which time campus gates would close, forcing them to jump in through the fence. Nahom said he once had an accident trying to jump in through the fence.
He said, as university students, they almost never drank moderately, they drank to get intoxicated. “Think about it, why would you drink something so bitter if you’re not going to get drunk” was what Nahom said.
When talking about how often they drank, Nahom said “it’s like a wave coming to take you away, a group of friends find you, may be walking on the road, and just take you to go out and have drinks with them, without any prior plans.”
They would go out for drinks whenever they had the money. Nahom said “we always went out with girls to drink”. One of the things they regret about drinking was that drinking caused them to lose their inhibitions when it comes to sexual encounters, sometimes making them lose control, even if it’s with their girlfriends. Nahom said although he always uses condoms, he has had sex without protection on few occasions, because his girl friend didn’t want to use condoms and because it was harder to negotiate for safer sex while intoxicated. “It’s difficult to negotiate for safer sex and use condoms in the heat of the moment while intoxicated” said Nahom.
Although there is evidence that alcohol has physiological suppressive effects on sexual arousal for both men and women, there is also co-occurring evidence that acute alcohol consumption depresses one’s ability to make quick and proper judgments and causes loss of inhibition. According to a study “when men consciously intend to suppress arousal in the face of erotic stimulation, alcohol reduces their effectiveness in doing so” (George W, 2000). Especially when faced with a counter prompt not to engage in risky sexual behavior or use condoms, persons under the influence find it difficult to inhibit risky sexual behavior and make proper judgments. This is because alcohol makes drinkers lose the proper sense of evaluating risk and negative consequences causing them to concentrate more on immediate events than distant ones. Such an effect is called alcohol myopia. This makes acute alcohol drinkers shortsighted during intoxication and likely to engage in unsafe or unwise sexual practices due to loss of ability to appraise distant effects.
Both, Eskinder and Nahom, regret having had to drink so much to the extent of losing their focus in their studies and being exposed to risky sexual encounters.
Since excessive drinking exposes the youth to serious health risks and undesired consequences, it’s crucial to increase youths’ self-efficacy to control their drinking from early on. Furthermore, it could be useful for responsible bodies to come up with effective ways of enforcing alcohol prohibiting laws for minors, while employing other means to curtail excessive drinking by the youth.
A study conducted by the CDC states that “Latex condoms, when used consistently and correctly, are highly effective in preventing the transmission of HIV.” For centuries male condoms have been in use to prevent pregnancy and sexually transmitted diseases (STDs). Although, there are different types of condoms, such as those made from latex, polyurethane and lamb intestine, the most widely used in Ethiopia is the male latex condom.
Estifanos Teshome, a healthy-looking vivacious character living with HIV, told us that when he first started to have sexual intercourse at the age of 11, not much was known about condoms or HIV/AIDS. He said someone who wanted to buy condoms, found in pharmacies at the time, was considered as a promiscuous person. Not only that “At that time, if a woman asked a man to use a condom, the man will think that it’s because she has an STI or HIV. No one would trust her or would want to have any relations with her. In those days, the general opinion was that condoms were for promiscuous persons and those who had STIs.”
He argues that even today, this perception has not changed much. “I work in a health center in the area of HIV/AIDS, I see people look at those who come to take condoms suspiciously as though they were doing something wrong, as if they were promiscuous. It’s still frowned upon.”
The 2005 DHS shows that the level of knowledge for prevention methods of HIV/AIDS such as abstinence and faithfulness is relatively high as compared to knowledge of condoms and its role in the prevention of HIV transmission. It states that only “around four in ten women and six in ten men are aware that using a condom during sexual encounters can reduce HIV/AIDS transmission” (DHS,2005).
Estifanos told us that although he knew about the benefits of condoms, he did not like to use it because he thought putting it on was too troublesome and did not like its smell and oiliness. “Even today, if I were to dress well and had money to spend, I can convince ladies to go out with me. I can easily persuade them to have sex without a condom, you see, nowadays women’s focus is not so much on negotiating for safer sex, they just want to be with someone with money,” said Estifanos.
Interestingly, however, based on the 2008 Health Impact Evaluation, although one may think that young women in the lowest wealth quintile would engage in risky sexual behavior, young women with secondary and above education and those in the highest wealth quintile engage in risky sexual behavior more than those in the lowest. This is despite the fact that the level of comprehensive knowledge about HIV increases with education and wealth status (2008 Health Impact Evaluation).
On the other hand, Kelemu Belete, a 20 year-old boy who debuted sexual intercourse at the age of 15, told us that although he has never had sex without a condom, he has a female friend who has had sex without a condom with a partner who told her that because he looks healthy, she should trust him to have unprotected sex.
“Even though she had the awareness about condoms and HIV, she was forced to have unprotected sex maybe because she felt too embarrassed to persuade him to use one,” Kelemu said.
The 2008 Health Impact Evaluation shows that only 53.2% of women know that it is possible for a healthy-looking person to have the HIV virus.
In a patriarchal society as ours, where the level of women’s empowerment in making decisions about their own health is very low and where only 15 percent of currently married women make sole decisions regarding their own health care (DHS, 2005), the responsibility for the prevention of HIV through the use of condoms largely lies on men.
On the other hand, though, as the trend shows, if the women who are educated, those in the higher wealth quintile and those in better position to negotiate for safer sex engage in risky sexual behavior, then it’s necessary that a strong and definite behavior change that would make sexual intercourse without using condoms consistently and correctly unacceptable be brought about.
*Names of individuals in this article have been changed.
This true story is about an HIV positive pregnant mother who told us her fascinating story while she was waiting to get antenatal care.
This mother, who was engaged in housework in Dubai about twenty years ago, was told by her employers to give blood for HIV testing. During that time, since the notion of having housemaids tested for HIV was not new, it did not come to her as a surprise. So, she goes with her employers and gives her blood as requested.
However, what transpired when her test results came was nothing like she had expected. Men wearing masks and dressed in protective clothing come with the police and knock on her door. When she looks through the peephole, she sees the men standing with her employers. Not thinking much of it, she opens the door for them. Once inside, the men notify her that they had come to take her away and recommend she has something to eat first. Perplexed, she thinks someone from her family may have passed and they had come to tell her the merdo – bad news. After she has finished eating, they take her into a closed van and check her into a facility where people like her were held awaiting their deportation. She could not understand what was happening. When she looks at her employers, she sees the wife crying. However, she does not tell her the reason.
After she arrives at the facility, she sees a big poster in the room that reads HIV+ with a red ribbon on it. That is when she realized she was HIV positive and was being deported as a result. No one gave her counseling before or after her test. Devastated by the news and by the way she found out, she resolves never to tell anyone believing she would be stigmatized and ostracized. Her thought was to go to her country and die there.
When she arrives in Ethiopia, there was a popular song that went something like ….”I am finished”… a fitting song, she thought, because in her mind she was finished as well.
As time went by, however, when she sees she was doing well she resolves to work and make a living. Having heard that an HIV positive person should eat well for better health, she decides the best place to do that would be if she worked as a housemaid. Once employed in housework, she tells her employers she can’t prepare raw foods, with the pretext that she was allergic, in fear of transmitting the virus to them. In this way, she worked and lived with the virus for 16 years without having the need to take antiretroviral treatment.
This woman is now married and about to have her second child. She told us that her firstborn was HIV free because she had taken all the necessary precautions. She met her husband when he was very sick after having lost his girlfriend to AIDS. When they met, he had lost all hope of living; he was distraught and not working. Afterwards though, his life has taken a complete turn. She told us, he now works and leads a good and positive life.
Although this woman had not gotten any counseling or support, she was able to lead a positive life. After having known her status, she did not give up. She went on to have her diploma and Bachelor of Arts degree in Management. She now says “being HIV positive doesn’t mean it’s the end of your life, you can definitely live”.
This happy pregnant woman is now getting all the medical help she needs to have an HIV free child for the second time. She told us she lives better than any healthy person. She said “I eat and drink well. I’m healthy and I can live a good life. “Enquliliche!” - A term used to make others envious.What an impressive and inspiring woman. It was very refreshing to find someone so positive and optimistic about life. Being HIV positive, as the lady said is not the end of the world. If your outlook is right, you can accomplish a great deal and lead a happy and fulfilling life.
A Rally for Parents Testing: A key for safeguarding the future of Ethiopia’s Children
September 10, 2011 (Addis Ababa, Ethiopia): The 7th National HIV Counseling and Testing Day event was kicked off today with a rally on the streets of Addis on a theme of Parents testing to Prevent the transmission of HIV from the mother to child.
Parents, pregnant women, youth, officials and representatives from partner organizations marched carrying messages and testimonials that encourage parents to know their HIV status in order to prevent transmission from mother-to-child along with the Ethiopian ground force’s March band. The rally ended at Gandhi Hospital with the inauguration of a billboard promoting the theme.
On his welcoming speech Dr. Dereje Alemayehu, Medical Director of Gandhi Hospital, said as Gandhi being one of the main maternity hospitals, around 25-30 pregnant mothers visit the hospital daily. In the fiscal year 2003 E.C, from the projected number of 2,660 mothers coming for testing a total of 3,296 mothers actually got counseling and testing, meeting the hospital’s goal by more than 100%. There, however, needs to be a collaborative effort to make the coming generation HIV free.
A report from the Federal HIV/AIDS Prevention and Control indicates currently more than 90,000 pregnant women are living with HIV and every year 14,000 babies are born from HIV positive mothers among which only 10% are using PMTCT service.
CDC Ethiopia’s Program Officer, Dr. Tekeste Kebede, also remarked the benefits of knowing ones HIV status earlier to be able to start the treatment on time and to also give birth to HIV free babies. He also spoke how CDC and other partners have been striving to make HIV Counseling and Testing accessible to pregnant mothers and their partners.
Women should take the lead to have HIV counseling and testing to bring HIV free babies into the world and to raise the awareness of women everywhere to have antenatal, delivery and postnatal care for healthy motherhood, said W/ro Meseret Abdi, Addis Ababa Women’s Association, Deputy Director.
The event stresses on the importance of testing together for the prevention of mother-to-child HIV transmission as opposed to mothers only to ensure that both parents are protecting their child. AAHAPCO organized the event in collaboration with its partners.
In support of this campaign a variety of communication materials were produced and will be distributed nationally encouraging parents to know their status were produced by the AIDS Resource Center. Television and Radio spots were also transmitted and promotional messages were posted on local newspapers to reach different parts of the society.
A panel discussion based on the current theme was also conducted with different prominent organizations working in the field through Fana Broadcasting Corporate. Participants discussed reasons why service providers have to initiate HCT to expecting mothers and the need for increasing male involvement in the service.
Community and religious leaders will also carry the messages to their communities and followers stressing on parents knowing their HIV status to secure the wellbeing of their communities. So far there have been around 9.4 million people who have got HIV Counselling Services in Ethiopia.
In similar development recently Zewditu Memorial and Minilik II hospitals have launched an HIV counselling and testing service for the hearing impaired in response to the shortage of access to HCT services to the disabled.
HCT programs encourage parents to know their HIV status when they are expecting a baby and for parents who are HIV positive to access treatment for preventing the transmission of HIV to their child. It also increases knowledge about availability and accessibility of treatment.
Frehiwot Yilma, AIDS Resource Center
Tel: +251 11 550 3584 Extension 1129
Fax: +251 11 550 3749
Addis Ababa, 09 September 2011 - An HIV positive 16 year old Girum Abdosh, who hopes to become a professional dancer, told his story with tears advocating for HIV counseling and testing in order to prevent the transmission of HIV from mother to child.
On a half-day panel discussion organized by Addis Ababa HAPCO in collaboration with NASTAD, Ethiopia and Addis Ababa Women’s Association, Girum gave a testimony of how he got HIV from his mother. He told the audience how much suffering he had passed through as a child before starting the treatment.
Saying no child should pass through what he passed through, Girum pointed out the need for parents to be tested and get the necessary care for the sake of their children. When asked, Girum said he wished to have better health and better living.
This half-day conference which was mainly organized to raise awareness on the prevention of HIV transmission from mother-to-child and healthy pregnant mothers as a whole by promoting antenatal, delivery and postnatal care commenced with a welcoming address. Ato Taddesse Atlabachew, Head of Addis Ababa HAPCO, gave a speech about how the efforts to combat the spread of HIV/AIDS in the past were not as effective since endeavors were not inclusive of the community’s participation.
In light of this, he said, it was necessary to formulate policies that included the participation of the community and that of institutions at various levels. Accordingly, several activities have been carried out in Addis Ababa to prevent and control HIV/AIDS. Such as the establishment of VCT centers in various places, community based activities against HIV/AIDS, giving support and care to people living with HIV/AIDS and orphans, giving accessible health services to people living with HIV/AIDS, distribution of condoms etc.
Then Wro Bizualem Gebeyehu, director of Addis Ababa Women’s Association, told the audience how the Association has been trying to raise the awareness of various executive bodies and stakeholders to work towards reducing the number of mothers dying due to delivery and to eliminate the number of babies born with HIV. Wro Bizualem, in her speech, pointed out the importance of couples’ testing vis-à-vis mothers’ testing and the need to promote couples’ testing in the upcoming VCT day celebrations.
Following this, two HIV positive mothers went out on stage with their daughters to testify how they were able to give birth to HIV free girls. Then, Dr. Tadesse, Addis Ababa Health Bureau’s representative, gave a comprehensive presentation about the need for HTC and PMTCT with detailed information on the Ethiopian context.
The conference was concluded, after Wro. Yemwodish’s, president of Ethiopian Poets Association, poem recital entitled “mother” and a dance show by AAWA’s band.
01 September 2011 - A free voluntary counseling and testing service for the hearing impaired was launched today, September 1, 2011, at the Zewditu Memorial Hospital, Addis Ababa. This disability-friendly VCT center will start its work with two community counselors who can effectively communicate and give free counseling services to the hearing impaired. This event was attended by Ato Tadesse Atlabachew, Head of Addis Ababa HAPCO, Dr. Carmela Abate, Coordinator, PEPFAR Ethiopia and Ato Habtamu Kebebe, Director, Ethiopian National Association for the Deaf and other stakeholders. After a series of speeches a small poem was read followed by a short drama sketching the special needs of the hearing impaired.
The event started with Dr. Samrawit Reisom, Zewditu’s VCT Coordinator, giving a welcoming address. Then, Ato Tadesse Atlabachew followed, by outlining Addis Ababa HAPCO’s efforts to incorporate the special needs of the disabled in anti-HIV/AIDS activities. He listed what the Office has been doing in the past two years in relation to HIV and disability. Among which were the training of health care practitioners in sign language and those who know sign language in voluntary counseling and testing. He said that AAHAPCO’s efforts to give anti-HIV/AIDS services to the physically disabled should be seen as an endeavor which goes hand-in-hand with the government’s five year plan for growth and transformation. He further stated that the Office’s main purpose for carrying out disability friendly anti-HIV/AIDS activities is not only because they are entitled to these services but also because anti-HIV/AIDS activities that do not incorporate their special needs cannot be complete ones.
The ceremony was then followed by Ato Habtamu Kebebe giving a speech about the needs of the hearing impaired in relation to HIV counseling and testing. He pointed out how the hearing impaired had difficulty getting counseling and testing because translators were not allowed to translate so as not to violate clients’ confidentiality. Now that community counselors from the hearing impaired have been trained this community will be served in their own language. He concluded by making a call to other health centers to duplicate what has been initiated at Zewditu that more population may be served.
Dr. Carmela Abate also made a short remark on how WHO and the National Guidelines on HIV Counseling and Testing alike recognize the special needs of the physically disabled. This need, however, which encompasses 17% of the population, had not been addressed before. She expressed her pleasure that PEPFAR had been involved in supporting Handicap International to raise the awareness of service providers to address the special needs of the physically disabled. After Dr. Carmela said that 7 million people should not be written off because their special needs had not been considered she congratulated all for their concerted efforts and closed her remark.Zewditu’s VCT center, based on Sr. Almaz Nedi’s presentation, is a health integrated center that provides free same day counseling and testing throughout the week except on Sundays. Since it started its operation in 2002, the center has given services to a total of 25,113 couples and 80,623 individual clients. The VCT center seeks not only to bring behavioral change, give care to people with HIV/AIDS and promote VCT in the community; it also seeks to replicate its best practices to other health centers.
Promoting HIV Counseling and Testing
There are still many who give birth at home increasing the risk of HIV transmission from mother to child. Studies show that mother-to-child transmission of HIV can occur during pregnancy, at delivery or during breastfeeding in the absence of preventive measures. In developing countries, statistics show that, in the absence of intervention, around 5% of HIV exposed children are infected during pregnancy, 15% at delivery and around 10% during breastfeeding (ARC, PMTCT resources). Moreover, 2010’s national health statistics estimated total adult HIV prevalence at 2.4%, while total HIV positive births were 14,276 from a total of 90,311 HIV positive pregnancies (FHAPCO, 2007). Although HIV infections among infants are relatively small when compared to adult infections, 90% of pediatric infections are due to vertical transmission of HIV from mother-to-child which can largely be prevented (Guidelines for PMTCT in Ethiopia, 2007).
To find out how provider initiated HIV counseling and testing was being implemented; we went to Gandhi Memorial, the oldest maternity hospital in Addis Ababa. When we got there, we were met with mentor mothers engaged in informing and mentoring pregnant women about PMTCT and the benefits of being tested complementary to what is offered as routine tests by health care providers. These HIV positive mentor mothers make rounds for certain hours of the day to raise the awareness of pregnant women about PMTCT and give psychosocial support to those who need it. They do this by organizing coffee ceremonies to introduce them with mothers who had passed through the same process and by sharing their own experiences.
We also spoke to Sr. Etalemahu, the nurse in charge of the PMTCT unit at the hospital, and asked her what major challenges they face as health care providers when it comes to implementing PMTCT program. She told us the major challenges were related to lack of awareness such as pregnant mothers coming for the first time during labor without having had any antenatal care, husbands not taking part in counseling and testing with their pregnant wives and unwillingness of economically dependent HIV positive mothers to tell their husbands their serostatus in fear of being left by them.
Gandhi memorial hospital, from a total of HIV free babies delivered to HIV positive mothers, has delivered 500 HIV positive births since it started giving PMTCT services in 2000 E.C. According to nurse Etalemahu, these were mainly due to improper taking of the prophylaxes, late initiation of medication and mix feeding of breast milk with formula, among other things.According to the National Guidelines for PMTCT, Ethiopia has set a goal to attain zero HIV positive births by 2020. For this to be accomplished, pregnant mothers need to be encouraged to have antenatal, postnatal and delivery care in a health care setting or to have skilled delivery where they can get ART and ARV prophylaxis both for themselves and their child. In addition, mothers need to get sufficient counseling and education as to how to feed their infants and when to visit health centers at the first sign of illness. On the other hand, couples should also be encouraged to be tested before becoming pregnant and to make regular visits to health care centers during the course of their pregnancy. For these, both PIHCTs and VCTs play an important role and should be highly promoted.
As many of you are familiar, ART is an antiretroviral treatment initiated to HIV patients based on their clinical stage. According to World Health Organization’s guidelines in resource-limited settings, ARV is initiated according to the organization’s definition of AIDS stages based on laboratory and clinical assessments. Once ART is initiated, if taken adherently, it reduces immune suppression, slows disease progression, prolongs survival and improves the quality of life. If, however, the treatment is not adhered to due to other reasons such as stigma, feeling better, depression, being fed- up of drugs etc, then it will lead to viral replication and the development of drug resistant viral strains. In such cases, the resumption of first-line regimen may not mitigate replication of drug resistant strains calling for the initiation of second or third-line treatments. This has its own consequences as second and third-line treatments are more costly and the shift to higher-lines also limits the choice of medications available to patients.
The other problem with non-adherence to ART is that the drug resistant strains can be transmitted to others whereby new HIV infected individuals become resistant to treatment without having taken the medication before. This is a major public health concern because there’s already limited availability of drugs’ choice in the country (Adherence to ART in adults, population Council, 2004). Moreover, the availability of ART in Ethiopia is limited to first and second-line regimens, which means once a patient switches to second-line regimen, there’s no other line remaining to be administered as a last resort if the patient has to switch again.
With this in view, I wanted to see what the adherence level was at the Black Lion Hospital and went to the ART clinic there to speak to Sr. Aregash. Much to my surprise and joy I was able to find that there were not many lost to non-adherence due to follow-ups done by what they call ‘expert patients’. These ‘expert patients’ pull out the addresses of ART users and follow-up on those who have not come to take their medications on time. There is, however, a small number that were lost to moves without a forwarding address and others due to take-up of holy water (tsebel). After persistent follow-up by the ‘expert patients’, these too were returned to resume treatment based on their CD4 count or viral load. There was one patient, however, who was admitted due to non-adherence because he thought he had gotten better, which made me wonder whether he had been advised adequately or not. Although I was not able to speak to him, I was glad to hear that he was receiving the necessary treatment.
In conclusion, although it was good news that Black Lion’s ART users have high adherence levels, I hope the same experience holds true both in other health centers and outside Addis. As I mentioned previously non-adherence to ART has dire individual and public health consequences. In light of this, to hear of non-adherence due to the take-up of tsebel and other forms of religious ‘remedies’ is a bit worrisome in such a religious country as ours. Equally worrisome was ART users’ non-adherence on account of better health. Thus, I thought I would close by making a call to all religious leaders to promote treatment adherence among their followers and also for ART providers to give adequate information for the sake of the patients’ health and that of the nation’s as a whole.