HIV/AIDS in Ethiopia - UCSF - AIDS Research Institute - University of ...

HIV/AIDS in Ethiopia
Lisa Garbus, MPP
AIDS Policy Research Center, University of California San Francisco
Published April 2003
Updated April 2003
© 2003 Regents of the University of California

HIV/AIDS in Ethiopia 2
Table of Contents
(click on page number to go directly to that section)
PREFACE ....................................................................................................................................................................4
EPIDEMIOLOGY.....................................................................................................................................................12
AT A GLANCE ..........................................................................................................................................................12
HIV SENTINEL SURVEILLANCE ...............................................................................................................................14
TRANSMISSION PATTERNS.......................................................................................................................................21
UNAIDS ESTIMATES ..............................................................................................................................................22
AIDS CASES............................................................................................................................................................22
AGE AND GENDER ...................................................................................................................................................22
AIDS MORTALITY...................................................................................................................................................23
PREVALENCE PROJECTIONS .....................................................................................................................................23
PROGRESSION OF THE HIV EPIDEMIC......................................................................................................................24
DATA QUALITY ISSUES............................................................................................................................................25
POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT .................................................................28
AT A GLANCE ..........................................................................................................................................................28
COUNTRY OVERVIEW..............................................................................................................................................34
GOVERNANCE..........................................................................................................................................................35
POPULATION MOBILITY...........................................................................................................................................35
ECONOMY................................................................................................................................................................37
PUBLIC EXPENDITURE TRENDS................................................................................................................................39
DEBT .......................................................................................................................................................................39
FOOD SECURITY ......................................................................................................................................................41
HUMAN DEVELOPMENT...........................................................................................................................................42
HEALTH...................................................................................................................................................................43
SEXUAL & REPRODUCTIVE HEALTH........................................................................................................................45
SEXUALLY TRANSMITTED INFECTIONS....................................................................................................................46
EDUCATION .............................................................................................................................................................47
GENDER...................................................................................................................................................................47
KNOWLEDGE OF HIV/AIDS ....................................................................................................................................50
STIGMA....................................................................................................................................................................52
SEXUAL BEHAVIOR..................................................................................................................................................54
CONDOMS................................................................................................................................................................57
SEX WORK...............................................................................................................................................................58
ALCOHOL AND DRUG USE .......................................................................................................................................58
MALE CIRCUMCISION ..............................................................................................................................................59
IMPACT.....................................................................................................................................................................60
AT A GLANCE ..........................................................................................................................................................60
DEMOGRAPHIC ........................................................................................................................................................61
AIDS MORTALITY...................................................................................................................................................63
MACROECONOMIC...................................................................................................................................................64
HOUSEHOLD ............................................................................................................................................................65
ORPHANS AND OTHER VULNERABLE CHILDREN .....................................................................................................67
RESPONSE ................................................................................................................................................................69
AT A GLANCE ..........................................................................................................................................................69
GOVERNMENT RESPONSE ........................................................................................................................................74
HUMAN RIGHTS.......................................................................................................................................................80

HIV/AIDS in Ethiopia 3
BUDGETS .................................................................................................................................................................81
DONORS...................................................................................................................................................................81
NGOS......................................................................................................................................................................84
ORPHANS.................................................................................................................................................................85
BLOOD.....................................................................................................................................................................85
UNIVERSAL PRECAUTIONS.......................................................................................................................................86
POST EXPOSURE PROPHYLAXIS ...............................................................................................................................86
PMTCT...................................................................................................................................................................86
VCT ........................................................................................................................................................................86
CARE AND SUPPORT ................................................................................................................................................87
ART ........................................................................................................................................................................87
MILITARY................................................................................................................................................................88
OTHER MOBILE POPULATIONS ................................................................................................................................88
PRIVATE SECTOR.....................................................................................................................................................89
LINKS.........................................................................................................................................................................90
GOVERNMENT .........................................................................................................................................................90
ACADEMIC AND RESEARCH INSTITUTES ..................................................................................................................90
NATIONAL NGOS AND CBOS..................................................................................................................................91
INTERNATIONAL NGOS ...........................................................................................................................................93
UN AGENCIES .........................................................................................................................................................94
BILATERAL DONORS................................................................................................................................................95
FOUNDATIONS .........................................................................................................................................................97
SUBREGIONAL ORGANIZATIONS ..............................................................................................................................97
ELECTRONIC DISCUSSION FORA ..............................................................................................................................97
OTHER INFORMATION SOURCES ..............................................................................................................................97

HIV/AIDS in Ethiopia 4
Preface
This research was undertaken as part of the Country AIDS Policy Analysis Project, which is
managed by the AIDS Policy Research Center at the University of California San Francisco. The
project is funded by the U.S. Agency for International Development, Cooperative Agreement
PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project’s Principal Investigator. The
views expressed in this paper do not necessarily reflect those of USAID.
The overarching objective of the Country AIDS Policy Analysis Project is to inform planning
and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions
through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for
analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries’ political
economy and sociobehavioral context at household, sectoral, and macro levels. This
multidisciplinary analysis aims to:
help inform national HIV/AIDS policies
strengthen ability to plan, prioritize, and implement effective interventions
highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS
facilitate multisectoral/interministerial coordination
facilitate intercountry information sharing
increase national and subregional capacity for effective partnerships
The project develops and disseminates online, easy-to-download, continually updated analyses of
HIV/AIDS in 12 USAID Rapid Scale-Up/Intensive Focus/Basic Program countries: Ethiopia,
Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil,
Cambodia, and India .
The primary audience for the country analyses is in-country HIV/AIDS planners, including those
from government ministries and agencies, multi- and bilateral donors, international and local
NGOs, health care institutions, prevention programs, academia, faith-based organizations,
affected communities, and the private sector. International investigators and policymakers also
report using the analyses in their work.
All country analyses undergo peer review at the AIDS Research Institute of the University of
California San Francisco. In addition, two in-country experts from each profiled country serve as
peer reviewers. A scientific advisory board also reviews all analyses.
Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support.
Analyses also include extensive links to related resources. An online database comprising 73
HIV/AIDS and socioeconomic indicators for 168 countries and 13 regions is also being
developed and will allow users to conduct a variety of comparative analyses.
Project staff are in regular contact with national HIV/AIDS professionals who provide and verify
data as needed. Staff continually assess and incorporate new data to maintain the timeliness of
the analyses.
Acknowledgments

HIV/AIDS in Ethiopia 5
The following individuals served as peer reviewers and provided valuable inputs to this paper:
Dr. Assefaw Tekeste Ghebrekidan, Institute for Global Health, University of California San
Francisco & University of California Berkeley; Dr. Yared Mekonnen and Dr. Mathias Aklilu,
both of the Ethio-Netherlands AIDS Research Project, Ethiopian Health and Nutrition Research
Institute, Addis Ababa. They are not responsible for any errors of fact or judgment.

HIV/AIDS in Ethiopia 6
Executive Summary
Epidemiology
The first HIV infections in Ethiopia were identified in 1984, and the first AIDS cases reported in
1986. In 1987, the government established an HIV/AIDS department within the Ministry of
Health, and in 1988, an HIV surveillance system was established. In 1989, the Health Bureau of
the Addis Ababa City Administration began HIV sentinel surveillance. Currently, there are 34
HIV sentinel surveillance sites reporting to the MOH. As the overwhelming majority of them are
in urban areas, an enormous segment of the rural population remains uncovered by the current
system, despite that 85 percent of the population lives in rural areas.
HIV/AIDS increased rapidly during the 1990s. By 1989, HIV prevalence among the general
adult population was estimated at 2.7 percent, increasing to 7.1 percent in 1997 and to 7.3
percent in 2000. In 2001, this figure was 6.6 percent. However, the MOH does not believe that
this fall indicates that the HIV epidemic in Ethiopia is declining; rather, it is primarily a result of
the reclassification of one sentinel site. The MOH estimates that 2.2 million Ethiopians were
living with HIV/AIDS in 2001, of whom 2 million were adults.
During the early stages of the HIV/AIDS epidemic, there was a major effort to conduct
serosurveys in Addis Ababa and other major urban centers among core transmitter groups.
However, post-1990, there are very few data to indicate the level or progression of the epidemic
among sex workers and truck drivers, as well as traders/merchants and the military.
The Ethiopian Red Cross Society-Blood Transfusion Service (ERCS-BTS) has been collecting
and reporting HIV prevalence data among blood donors since 1987. There are indications that
HIV prevalence among blood donors has decreased; however, it is difficult to determine whether
this trend is an accurate measure or is due to increasingly effective prescreening procedures in
the transfusion services.
Data indicate that heterosexual and MTCT transmission account for almost all HIV infections in
the country. The few data available have not found an association between harmful traditional
practices and acquisition of HIV. HIV transmission via unsafe injections appears to be very low.
AIDS case reporting began soon after the establishment of the HIV/AIDS department within the
MOH in 1987. AIDS cases are grossly underreported. Among women, AIDS cases peak
between ages 20 and 29; for men, between ages 25 to 34.
According to ANC data, the group with the highest HIV prevalence in the country is women
ages 15 to 24. Data from blood donors, visa applicants, and police and army recruits indicate that
HIV prevalence among men peaks between ages 25 and 29. This is likely related to age mixing,
wherein young women have older male sex partners, primarily for economic reasons.
It appears that the HIV/AIDS epidemic in most of urban Ethiopia began in the mid-1980s,
plateauing in the mid-1990s and stabilizing thereafter. In rural Ethiopia, the epidemic began in

HIV/AIDS in Ethiopia 7
the early 1990s. It is now progressing rapidly and is likely only in its early stages. Data are
highly inadequate to capture the epidemic's dynamics in rural areas.
There have been major gaps and variances in Ethiopia's HSS data collection, thus impeding trend
analysis. The representativeness of ANC attendees has been questioned. There are also concerns
regarding the validity of reported HSS results, with indications that the quality of HSS is low and
laboratory quality control measures inadequate.
Political Economy and Sociobehavioral Context
The relationship between HIV prevalence and socioeconomic factors is highly complex.
Increasingly, risk of HIV infection is recognized as related to, inter alia, one's socioeconomic
status as well as the socioeconomic profile of the community in which one is situated.
Additionally, Ethiopia's political history, civil war, conflicts with Eritrea, and current food crisis
also affect HIV/AIDS dynamics.
Ethiopia is one of the world's oldest continuous civilizations and one of the few in Africa that
was never colonized. It is also one of the world's poorest countries, with a 2000 per capita
income of US$100. Ethiopia's population, estimated at 68 million in mid-2002, is the second
largest in sub-Saharan Africa and is projected to continue to grow by over 2 percent annually
through 2025. Ethiopia's population is young and ethnically diverse.
Ethiopia's political past has been marked by Italian occupation (1936-41), the removal of the
Emperor Haile Selassie in 1974, and a Marxist military government that was in power from
1974-91. Civil war led to the overthrow of the Marxist regime and establishment of a transitional
government in 1991. In 1994, Ethiopia held elections for a constituent assembly and adopted a
new constitution. The present government t has promoted a policy of ethnic federalism,
devolving significant powers to regional, ethnically based authorities. Although Ethiopians enjoy
greater political participation, some fundamental freedoms, including freedom of the press, are
limited.
In 1993, Eritrea became independent. In 1998, an Ethiopian-Eritrean border conflict erupted into
a full-scale war. After nearly two years of fighting, Eritrea and Ethiopia signed a comprehensive
peace agreement. However, tensions between them remain high, and there are fears that the
peace accord will be broken.
Ethiopia's mobile populations include the rapidly increasing number of rural residents seeking
employment in urban areas; military personnel; those displaced by war, drought, and/or
environmental degradation; male transport workers; sex workers; émigrés; traders; orphans and
vulnerable children; humanitarian and relief workers; and prisoners.
During the 1990s, the government embarked on a program of structural reform. GDP growth
rose during the 1990s, and the country has begun to attract much-needed foreign investment.
However, per capita income in Ethiopia fell during the decade. Public expenditure on health
increased only slightly, from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998. (As a percent of
GDP, military spending in Ethiopia is almost eight times greater than public spending on health.)
Several major health indicators either fell or stagnated during the decade. The scope of poverty
in the country remains enormous.

HIV/AIDS in Ethiopia 8
About 16 percent of Ethiopians are facing starvation. The current food crisis is on a par with (or
may even exceed) that of the 1984-85 famine. Unlike in southern Africa, HIV/AIDS is not a
major factor underlying the Ethiopian food crisis. However, the search for food and migration to
food aid distribution points does spur population dislocation, which may be accompanied by
regroupings of family units and exposure to new sexual networks. Malnutrition (already high in
Ethiopia) is increasing and further weakening the immune systems of PWHA. Famine is likely to
raise the opportunity cost of sending children to school. Girls, in particular, are affected. Lack of
food, coupled with a subsequent breakdown in family structure, may place more children on the
streets where they may be at higher risk of mistreatment, sexual exploitation, and physical and
emotional abuse.
Ethiopia's health expenditure per capita (both public and private) was less than US$5 during the
1990s. The health system in Ethiopia is severely underdeveloped. Transport constraints are
severe. Ethiopians' general health status is poor both in absolute terms and in comparison with
other African countries. A major concern is that as the central government reduces its role in
health care delivery, with decentralization and privatization to fill the gap, safety nets for the
poor (especially those in rural areas and women) may be threatened.
There are no accurate serial prevalence data on STIs in Ethiopia. Several recent studies indicate
that prevalence of herpes simplex virus type 2 (HSV-2) is high and may be fueling the
HIV/AIDS epidemic.
Gender disparities in enrolment ratios and educational attainment levels are high. The country's
high maternal mortality ratio is also an indication not only of poor reproductive health, but of
women's low status and poor access to basic health services. Many Ethiopian women have little
power in sexual negotiation with their husbands. Almost 14 percent of currently married women
in Ethiopia are in a polygynous union. About 80 percent of have been circumcised. Poverty and
unemployment are leading to a dramatic increase in the trafficking of Ethiopian women. Other
issues that render Ethiopian women vulnerable to HIV include rape, abduction, and early
marriage.
Knowledge of HIV/AIDS is high among Ethiopians. However, as is the case in many countries,
women are less likely than men to have heard of HIV/AIDS. Women are also much less
knowledgeable than men about programmatically important ways to avoid contracting HIV.
HIV/AIDS-related stigma is high.
There is an acute need for data on sexual behavior trends in Ethiopia. During 2001-02, Ethiopia
undertook its first behavioral surveillance survey, involving over 30,000 respondents (official
findings have not yet been released). Generally, condom use in Ethiopia is low. Recreational
drug consumption is increasing, including among street children.
Impact
There are few data on the impact of HIV/AIDS in Ethiopia. AIDS is now recognized as the
leading cause of adult morbidity and mortality in the country. Ethiopia's population will be up to
16 percent smaller than it would have been in a "no-AIDS" scenario. AIDS will reduce life

HIV/AIDS in Ethiopia 9
expectancy by 9 to 13 percent through 2050. AIDS has already increased the number of deaths in
Ethiopia by 6 percent. Between 2000 and 2015, it will increase the number of deaths in Ethiopia
by 27 percent. By the end of 2002, 1.7 million Ethiopians had died because of AIDS. By 2014,
there will be a cumulative total of 5.3 million AIDS deaths.
There have been almost no studies of the impact of the epidemic on loss of skilled or unskilled
labor, lost productivity because of illness or funeral attendance, or increased health care costs.
The impact of AIDS on the rural economy is unknown.
Currently, up to 42 percent of all hospital beds in the country are estimated to be occupied by
AIDS patients. Ethiopia has the sixth-highest number of TB cases in the world. About 42 percent
of adult (15-49) TB cases were HIV-positive during 2000.
There are no reports on the impact of AIDS on Ethiopian households, particularly its effect on
the extended family system. Given deep and persistent poverty in Ethiopia, HIV/AIDS will
further strain coping mechanisms through its enormous and complex impact. At the end of 2001,
there were 1.2 million AIDS orphans in Ethiopia. This number is projected to rise to 1.8 million
by 2007 and to 2.5 million in 2014. There are insufficient social services for orphans, including
health care, school fee subsidies, and shelter. Consequently, many become street children.
Response
In 1985 (before the first AIDS case had been officially diagnosed), the government of Ethiopia
established a national HIV/AIDS task force. It issued the first AIDS control strategy at the end of
1985. In 1987, the government established an HIV/AIDS department within the Ministry of
Health. The MOH developed a short-term plan in 1987 and medium-term plans in 1987 and
1992. As in many countries, these interventions were inadequate in scale; largely ineffective in
implementation; lacked sufficient stakeholder involvement in planning and implementation,
especially at the community level; were poorly or not at all coordinated and integrated across
sectors and among service providers; and received relatively low priority within government,
society in general, and in the international community, with a resultant low level of allocated
financial and human resources.
In 1989, the MOH drafted a four-point policy statement on AIDS prevention. The first draft of a
national policy was created in 1991, though not approved until 1998. The National AIDS
Prevention and Control Council was established in 2000 and is charged with implementing the
Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004. The
council, chaired by the president of Ethiopia and comprising members from government, NGOs,
religious bodies, and civil society, has declared HIV/AIDS a national emergency.
The Ministry of Education has yet to provide clear guidelines for a comprehensive HIV
education curriculum. Despite that the agricultural and livestock sectors account for over 85
percent of the labor force, the Ministry of Agriculture is not actively involved in HIV prevention.
Although Ethiopia began the HIV/AIDS policy process in 1989 far earlier than most other
countries it took nine years to complete. Moreover, the process involved almost no

HIV/AIDS in Ethiopia 10
participation by actors outside government. There was little high-level political involvement in
HIV/AIDS during the 1990s. By 1999, however, President Negasso Gidada had become an
active spokesman in the fight against HIV/AIDS. Current President Girma Woldegiorgis has also
made high-profile statements about the epidemic. Ethiopia's response is constrained by
extremely limited human, financial, technical, material, and management capacities. The
country's health care infrastructure is massively underequipped to address HIV/AIDS,
particularly outside Addis Ababa. The country's size and poor transport infrastructure are also
key factors. Bureaucratic constraints are impeding the response. Although much more funding is
required, building additional human capacity in the health sector, improving coordination, and
using existing funds efficiently and effectively are paramount. That the HIV/AIDS program is so
highly dependent on donors also raises concerns about its future sustainability. Responsibility for
implementing HIV/AIDS interventions rests with regional and local entities. In the long term,
this system is likely to enhance delivery of HIV/AIDS interventions. In the short term, however,
it is expensive, requires large numbers of qualified staff to carry out programs at different levels
of government, and renders coordination difficult.
The National HIV/AIDS Policy states that PWHA "shall not be subject to special restrictions on
employment, education, access to public facilities, or housing." However, there are no specific
laws to enforce the policy. Although Ethiopia's 1994 Constitution outlaws discrimination of any
form, it does not address HIV/AIDS-related discrimination. Existing laws are nondiscriminatory
with regard to PWHA, but there is evidence of discriminatory practices in the workplace, health
care facilities, schools, and housing. Enforcement of current laws (including the National Policy
for Women) is paramount. The need for new legislation to specifically address HIV/AIDS must
also be examined.
Numerous donors fund HIV/AIDS activities in Ethiopia. The Global Fund to Fight AIDS, TB &
Malaria has approved a grant of US$139.4 million to address HIV/AIDS in the country. Ethiopia
was one of the first countries to receive funding from the World Bank's Multicountry HIV/AIDS
Program for Africa (US$64.3 million).
Given years of centralized power, civil society in Ethiopia remains weak and underdeveloped.
Nevertheless, it has started mobilizing against HIV/AIDS. NGOs are largely concentrated in and
around major cities. Two national and various local PWHA associations are providing an array
of HIV/AIDS services. Some influential religious leaders appear to be publicly supporting action
against HIV/AIDS (though not condom promotion and use), and faith-based organizations are
providing HIV/AIDS services. Numerous NGOs and CBOs are providing support to AIDS
orphans and other vulnerable children.
Many Ethiopians with AIDS are likely to use traditional medicine to alleviate symptoms of OIs.
The MOH has encouraged the involvement of traditional healers in AIDS care and a national
committee comprising scientists and traditional healers has been formed.
Only 50 clients received PMTCT services in Ethiopia during 2001. In 2002, national guidelines
on PMTCT were released and a pilot PMTCT program initiated by the MOH.

HIV/AIDS in Ethiopia 11
In 2002, the country had 23 VCT centers, at which 10,000 clients were seen. Almost all VCT
services are located in Addis. There is a severe lack of trained HIV/AIDS counselors and
concomitant high demand for VCT services.
There are national guidelines on HIV/AIDS care and support. Some NGOs have been providing
home-based care since 1992. However, there is great disparity with regard to resources between
Addis and other regions of the country. Access to HIV/AIDS-related care and support services in
Addis, other urban areas, and rural areas is deemed minimal. Although national guidelines on
clinical management of HIV infection in adults and children have been in use for two years, they
require updating.
The Confederation of Ethiopian Trade Unions and the Addis Ababa Chamber of Commerce are
beginning to design workplace interventions. The Ethiopian military is often cited as being at
the forefront of HIV prevention. It has developed an extensive HIV/AIDS workplan. A major
initiative under way is deploying demobilized soldiers as HBC providers.

HIV/AIDS in Ethiopia 12
Epidemiology
At a Glance
The At a Glance section summarizes the more detailed data found below it.
Background
The first HIV infections in Ethiopia were identified in 1984. In 1986, the first AIDS cases
were reported. In September 1987, the government established an HIV/AIDS department
within the Ministry of Health, and in 1988, an HIV surveillance system was established. In
1989, the Health Bureau of the Addis Ababa City Administration began HIV sentinel
surveillance.
Currently, there are 37 HIV sentinel surveillance sites (31 urban, 6 rural), though only 34
report data to the MOH.
As the overwhelming majority of HSS sites are in urban areas, an enormous segment of the
rural population remains uncovered by the current HIV sentinel surveillance system.
Moreover, the six rural sites represent only two regions. This despite that 85 percent of the
population lives in rural areas.
Findings from ANC Data
Soon after detection of the first AIDS cases in 1986, high HIV prevalence was detected along
Ethiopia's main trading routes. It increased rapidly during the 1990s. By 1989, HIV
prevalence among the general adult population was estimated at 2.7 percent, increasing to 7.1
percent in 1997.
In 2000, analysis of the ANC data indicated that the national adult HIV prevalence was 7.3
percent. In 2001, this figure was 6.6 percent. However, the MOH does not believe that this
fall indicates that the HIV epidemic in Ethiopia is declining; rather, it is primarily a result of
the reclassification of one sentinel site.
The 2001 ANC data indicated that HIV prevalence among the adult urban population is 13.7
percent. Prevalence among adults in rural areas is estimated at 3.7 percent. However, the
current HSS system in highly inadequate to measure the level of infection in rural areas.
The MOH estimates that 2.2 million Ethiopians were living with HIV/AIDS in 2001. Of
them, 2 million were adults.
HIV Prevalence among Core Populations, Blood Donors, and Visa Applicants
During the early stages of the HIV/AIDS epidemic in Ethiopia, there was a major effort to
conduct serosurveys in Addis Ababa and other major urban centers among core transmitter
groups. In 1990, prevalence among sex workers in five urban areas ranged from 36.4 to 55.0
percent. A 1989 survey among truck drivers and their assistants found HIV prevalence of
17.3 percent.
However, post-1990, there are very few data to indicate the level or progression of the
epidemic among sex workers and truck drivers, as well as traders/merchants and the military.

HIV/AIDS in Ethiopia 13
The Ethiopian Red Cross Society-Blood Transfusion Service (ERCS-BTS) has been
collecting and reporting HIV prevalence data among blood donors since 1987.
There are indications that HIV prevalence among blood donors has decreased; however, it is
difficult to determine whether this trend is an accurate measure or is due to increasingly
effective prescreening procedures in the transfusion services.
Addis Ababa Regional Health Bureau regularly collects, analyses, and reports HIV
prevalence data among visa applicants, over 90 percent of whom are young women. HIV
prevalence among visa applicants rose from 7.2 percent in 1993 to 9.1 percent in 1999. There
are indications that reports on visa applicants underestimate prevalence by as much as 50
percent because of testing and reporting protocols.
Transmission Patterns
Data indicate that heterosexual and MTCT transmission account for almost all HIV
infections in the country.
The few data available have not found an association between harmful traditional practices
and acquisition of HIV.
HIV transmission via unsafe injections appears to be very low.
UNAIDS Estimates
At the end of 2001, UNAIDS estimates that there were 2.1 million Ethiopians living with
HIV/AIDS (estimate range: 1.5 million to 2.7 million). There were 1.9 million HIV-positive
adults, over half of whom (1.1 million, 57.9 percent) were women.
UNAIDS estimated that adult prevalence in 2001 was 6.4 percent.
AIDS Cases
AIDS case reporting began soon after the establishment of the HIV/AIDS department within
the MOH in 1987.
AIDS cases are grossly underreported.
Among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34.
Age and Gender
Data from ANC surveys and from blood donors indicate that people below age 24 represent a
major proportion of HIV infections among the general population.
According to ANC data, the group with the highest HIV prevalence in the country is women
ages 15 to 24 (12.1 percent).
Data from blood donors, visa applicants, and police and army recruits indicate that HIV
prevalence among men peaks between 25 and 29. This is likely related to age mixing,
wherein young women have older male sex partners, primarily for economic reasons.
According to UNAIDS, HIV prevalence among women ages 15 to 24 was 5.65 to 9.99
percent at the end of 2001; among men in the same age group, the range was 3.17 to 5.62
percent.

HIV/AIDS in Ethiopia 14
AIDS Mortality
AIDS is now recognized as the leading cause of adult morbidity and mortality in Ethiopia.
By 2000, 1.1 million Ethiopians had died because of AIDS. In 2001, UNAIDS estimated that
were 160,000 adult and child AIDS deaths in the country.
According to the U.N. Population Division, AIDS has already increased the number of deaths
in Ethiopia by 6 percent. It projects that by 2015, 5.2 million Ethiopians will have died
because of AIDS; by 2050, this figure will reach 14.9 million.
Progression of the HIV Epidemic
It appears that the HIV/AIDS epidemic in most of urban Ethiopia began in the mid-1980s,
plateauing in the mid-1990s and stabilizing thereafter.
In rural Ethiopia, the epidemic began in the early 1990s. It is now progressing rapidly and is
likely only in its early stages. Data are highly inadequate to capture the epidemic's dynamics
in rural areas, where 85 percent of the population lives.
An analysis of five rounds of ANC surveys in Addis between 1995 and 2001 found that HIV
prevalence among women ages 15-24 attending the inner city HSS sites declined from 24.2
to 15.1 percent. No change was observed for older age groups or in the outer city health
centers, indicating stabilization of HIV prevalence. Although encouraging, these findings
require validation using population-based and behavioral surveillance data.
Data Quality Issues
There have been major gaps and variances in Ethiopia's HSS data collection, thus impeding
trend analysis.
The representativeness of ANC attendees has been questioned because of reported
discrepancies between results of population-based surveys and ANC-based surveillance
systems in Addis Ababa. Subfertility of women with HIV may play a role.
There are also concerns regarding the validity of reported HSS results, with indications that
the quality of HSS is low and laboratory quality control measures inadequate.
HIV Sentinel Surveillance
Background
The first seven HIV infections in Ethiopia were identified in 1984. In 1986, the first AIDS cases
were reported. 1 In September 1987, the government established an HIV/AIDS department within
the Ministry of Health and charged it with directing and coordinating the implementation of the
AIDS control strategy. 2 In 1988, the MOH established an HIV surveillance system. In 1989, the
Health Bureau of the Addis Ababa City Administration began HIV sentinel surveillance (HSS). 3
, 4
During 1992-93, national HIV sentinel surveillance based on women attending antenatal clinics
(ANCs) was established in four urban sites in collaboration with the country's regional health

HIV/AIDS in Ethiopia 15
bureaus: Addis Ababa, Metu, Bahir Dar, and Dire Dawa. These sites were subsequently
discontinued. In Addis Ababa, ANC surveillance was reestablished in 1996. 5
In late 1998, an agreement was reached between regional health bureaus and the MOH to restart
the ANC system in all regions, utilizing national guidelines released by the MOH in March 1999.
These guidelines required that sites be selected on the basis of availability of functional
laboratories, equipment, supplies, personnel, and adequate patient volume (250-400) over a 12-
week period. This effectively excluded almost all rural areas and a significant number of urban
areas. 6
Moreover, the actual number of HSS sites established was also limited. This is particularly of
concern in a nation as large and diverse as Ethiopia, which has nine regional states, two urban
administrations, 64 zones, and 550 districts (discussed in more depth in the following section).
For large regional states such as Amhara and Oromiya, only two and four sites, respectively,
were originally established. 7 (In 2001, these figures had increased to four and six, respectively. 8 )
For the Southern Nations, Nationalities and Peoples Region (SNNPR), which includes 45 distinct
and unique indigenous ethnic population groups spanning nine zones and five special districts,
there are still only four HSS sites. 9 , 10
In 2000, 15 surveillance sites representing six regions reported their data to the MOH. In 2001,
this figure increased to 34, of which 28 sites were urban and 6 rural (see figure 1). A total of
12,689 women ages 15 to 49 were surveyed in the 2001 HSS. 11 (Currently, there are 37 sentinel
HIV surveillance sites [31 urban, 6 rural] in the country, 12 though only 34 reported data to the
MOH for the 2001 HSS.)
As the overwhelming majority of HSS sites are in urban areas, an enormous segment of the rural
population remains uncovered by the current HSS system. 13 Moreover, the six rural sites
represent only two regions (more detail below). This despite that 85 percent of the population
lives in rural areas. 14 Researchers from Addis Ababa University and the Ethio-Netherlands AIDS
Research Project report that "Data from areas outside of Addis Ababa are patchy and
incomplete." 15 The HSS system is inadequate to capture the epidemic's dynamic in rural areas,
compounded by a general scarcity of data on HIV/AIDS in rural areas. 16 (The MOH is planning
to include more rural sites in future surveillance. 17 )
Of all sites, only Addis Ababa participated in ANC surveys during all rounds except for 1998. 18
The lack of ANC data from Addis in 1998 was due to difficulties in obtaining the required
approval from the ethics committee of the Ethiopian Science and Technology Commission. In
1995, the Ethio-Netherlands AIDS Research Project (ENARP), based in the Ethiopia Health and
Nutrition Research Institute (EHNRI), was established. Since 1995, it has been collaborating
with the Health Bureau of the Addis Ababa City Administration to conduct HSS. 19 , 20
Blood Donors
The Ethiopian Red Cross Society-Blood Transfusion Service (ERCS-BTS) has been collecting
and reporting HIV prevalence data among blood donors since 1987. Apart from Addis Ababa,
there are nine regional blood transfusion centers spanning six regions. Four regional states (Afar,

HIV/AIDS in Ethiopia 16
Somali, Gambella, and Benishangul-Gumuz) do not have such services. Regional transfusion
services send their reports to the ERCS-BTS, although these reports have not as yet been sent to
the MOH. Since 1989, serial prevalence data for the 10 blood transfusion centers have been
available. In 1987, the ERCS-BTS instituted donor prescreening procedures. 21
Ad Hoc Serosurveys
Several ad hoc serosurveys among sex workers and other core groups in urban areas were
undertaken between 1988 and 1990. These were followed by serosurveys among the general
population in six rural sites during 1992-93. Samples collected in a citywide serosurvey in Addis
Ababa were also utilized to report on the prevalence of HIV in the general population. A smaller
survey among residents of a district in Addis Ababa was also completed in 1996. Subsequently,
similar surveys were conducted among factory workers in Akaki and Wonji . There have been no
reports of serosurveys based on random samples of the general population in rural areas since
1993. 22
Methodology
HSS sites span ANCs located within hospitals and health centers. For health facilities to qualify
as HSS sites, they must meet the following criteria:
sustainable antenatal services
access to a functional laboratory (ensuring adequacy of personnel, equipment,
and supplies)
adequate client volume for a required sample size (250 to 400)
regular blood drawing for other routine services
sustainable supply of rapid plasma reagin tests for syphilis screening
commitment of the regional and zonal and woreda health bureaus to coordinate and conduct
HSS in a sustainable manner at specified intervals 23
Ethiopia's HSS uses the unlinked, anonymous method recommended by WHO. 24

HIV/AIDS in Ethiopia 17
Figure 1. HIV Sentinel Sites, 2001
Source: Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia. 4th edition.
Addis Ababa: October 2002
Ethiopia uses EPI-Info software to enter data and EpiModel to estimate prevalences. Prevalences
are exported to the SPECTRUM Model, which includes DemProj (a population projection
model) and AIM (AIDS Impact Model), both developed by the POLICY Project of The Futures
Group International. The latter estimates the current and projected number of adults and children
infected with HIV. 25
Findings
There are no data on HIV prevalence among the general adult population in the 1980s. A
retrospective analysis of blood samples from outpatients and blood donors collected in 1982-83
found no HIV infections. Sera collected in 1984 from 167 patients with Bell's palsy showed the
first two HIV infections reported in Ethiopia. 26
After detection of the first AIDS cases in 1986, high HIV prevalence among truck drivers and
sex workers along Ethiopia's main trading routes was found during the late 1980s and early
1990s. By 1989, HIV prevalence among the general adult population was estimated at 2.7
percent. Prevalence increased rapidly during the 1990s; by 1997, 7.1 percent of all adults were
estimated to be HIV-positive (extrapolating from HSS data). 27
In 2000, analysis of ANC data indicated that national adult HIV prevalence was 7.3 percent. In
2001, this figure was 6.6 percent. Ethiopia's MOH notes that prior to 2001, Estie, a town in
South Gondar Zone, was considered a rural sentinel site, on the assumption that a large share of
its health center's ANC clients were from the surrounding countryside. However, this assumption
was later proved false by a special expert group convened to analyze the 2001 data, which
reclassified Estie as an urban site. In 2001, HIV prevalence at the Estie site was 10.7 percent.
The reclassification of Estie led to a 2001 estimate of adult HIV prevalence of 6.6 percent and,

HIV/AIDS in Ethiopia 18
according to the MOH, is the primary reason why the national adult HIV prevalence reported in
2001 is less than that reported in 2000. The MOH does not believe that this fall indicates that the
HIV epidemic in Ethiopia is declining. 28 (For further discussion, see the Data Quality Issues
section below.)
As shown in table 1, the highest HIV prevalence in Ethiopia found within the 2001 ANC survey
was at the Bahir Dar health center site (23.4 percent) followed by Jigiga (19 percent) and
Nazareth (18.7 percent). 29
The 2001 HIV prevalence for Addis Ababa was 15.6 percent. This figure represents average
prevalence across the four sentinel sites located in the city (Teklehymanot, Kazanchis, Higher
23, and Gulele). The mean prevalence for the 24 urban areas other than Addis Ababa is 12.8
percent; the mean prevalence for all urban sentinel sites including Addis Ababa is 13.2 percent.
Extrapolating these data for the total urban population indicated an urban prevalence rate of 13.7
percent. 30

HIV/AIDS in Ethiopia 19
Table 1. Percentage of Pregnant Women Testing HIV-Positive in 28 Urban Sentinel
Surveillance Sites, 2001
Source: Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia. 4th edition.
Addis Ababa: October 2002
As mentioned, data on rural prevalence were collected from only six sites for the 2001 round
(table 2). Of them, one was located in SNNP Region and five in the Oromiya Region. Omitting
Estie, the mean prevalence of the six rural sites was 2.3 percent in 2001, a decline from 3.9
percent in 2000. However, the MOH cautions that these data might not represent a realistic
picture of the rural situation. In seeking to corroborate these data, the MOH consulted data on
HIV prevalence among 64,000 army recruits ages 18 and 25 from rural areas spanning the
country. The estimated HIV prevalence for this group was 3.8 percent. MOH extrapolated the
data from the rural ANC sites and the army recruits survey onto the total rural population using
EpiModel, from which it estimated that HIV prevalence among adults in rural areas is 3.7
percent. 31

HIV/AIDS in Ethiopia 20
Table 2. Percentage of Pregnant Women Testing HIV-Positive at Rural Sentinel
Surveillance Sites, 2001
Source: Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia. 4th edition.
Addis Ababa: October 2002
Using the above data, MOH estimates that 2.2 million Ethiopians were living with HIV/AIDS in
2001. Of them, 2 million were adults. 32
HIV Prevalence among Core Populations, Blood Donors, and Visa Applicants
During the early stages of the HIV/AIDS epidemic in Ethiopia, there was a major effort to
conduct serosurveys in Addis Ababa and other major urban centers among core transmitter
groups. In 1988, HIV prevalence among sex workers in Addis (n=2,617) was 24.7 percent. In 18
other urban areas, it ranged from 5.3 to 38.1 percent. In 1989, surveys conducted in six urban
areas (excluding Addis) found prevalences of 12.1 to 49.1 percent. In 1990, a survey found
prevalence among sex workers in Addis at 54.3 percent; in four other urban areas, it ranged from
36.4 to 55.0 percent. Surveys among truck drivers and their assistants found HIV prevalence of
13.0 percent in 1988 (n=677) and 17.3 percent in 1989 (n=391). 33
However, post-1990, there are very few data to indicate the level or progression of the epidemic
among sex workers and truck drivers, as well as traders/merchants and the military. In 1998,
researchers from the Department of Community Health at Addis Ababa University undertook a
survey among 372 sex workers attending two health centers in Addis Ababa. They found that
HIV prevalence was 73.4 percent. Several factors were significantly associated with an increased
risk of being HIV-infected (among others, working in "shared rooms," high number of clients,
use of injectable contraceptives, and positive TPPA serology), and others with a decreased risk
(being born in Addis Ababa, high level of education, peer education on sex work, condom use,
use of oral contraceptive, and use of condoms for contraception). Sex workers who were using
condoms for contraception were, compared with others, more likely to use condoms consistently
(65 versus 24 percent, respectively; p < 0.001), and less likely to be HIV-infected (55 versus 86
percent, respectively; p < 0.001). In multivariate analysis, being born in Addis Ababa (PR =
0.74; 95% CI, 0.61-0.91), using condoms for contraception (PR = 0.73; 95% CI, 0.64-0.85), and
a positive TPPA serology (PR = 1.21; 95% CI, 1.09-1.36) remained significantly associated with
HIV infection. 34 However, as the researchers caution, survey participants were selected from

HIV/AIDS in Ethiopia 21
women attending two health centers for STI-related symptoms; therefore, self-selection of the
participants may not fully represent the general population of sex workers in the city. 35
In Addis Ababa, prevalence among blood donors rose from 2.3 percent in 1987 to 9.0 percent in
1995, falling to 6.4 percent in 1999. In Dire Dawa, prevalence fell from 14.9 percent in 1992 to
6.5 percent in 1998. Similar declines during the 1990s were found in Arba Minch, Dessie, and
Mekele. During the decade, prevalence fluctuated in Harar, Jimma, Yirgalem, and Gondar but
remained fairly unchanged between 1990 and 1999. Despite indications that HIV prevalence
among blood donors has decreased, it is difficult to determine whether this trend is an accurate
measure or is due to increasingly effective prescreening procedures in the transfusion services, as
researchers from Addis Ababa University and the Ethio-Netherlands AIDS Research Project
stress. 36
Another self-selected group of individuals for whom data on HIV prevalence are available is
adult visa applicants. Addis Ababa Regional Health Bureau regularly collects, analyses, and
reports HIV prevalence data among visa applicants. Reporting of prevalence data disaggregated
by age and sex began in July 1997, indicating that over 90 percent of visa applicants are young
women, most of whom apply to immigrate to Middle Eastern countries for employment as
domestic workers. Data on residence have not been made available, although most applicants are
likely from Addis Ababa. HIV prevalence among visa applicants rose from 7.2 percent in 1993
(n=3,222) to 9.1 percent in 1999 (n=10,930). There are indications that the prevalence reports
from visa applicants are underestimated by as much as 50 percent because of testing and
reporting protocols. Applicants who test positive on the first HIV test are requested to appear for
another test. Only about one-third do so. Reports to the MOH, however, are based on confirmed
test results (thus disregarding the first test results). Therefore, prevalence estimates are
underestimated. 37
Transmission Patterns
Data indicate that heterosexual and MTCT transmission account for almost all HIV infections in
the country. 38 There are, however, no data to describe the magnitude of MTCT in Ethiopia. 39
There are few data on harmful traditional practices and the risk of HIV infection in Ethiopia.
Harmful traditional practices include female genital mutilation (discussed below) and
procedures, particularly in rural areas, that involve cutting the skin to permit bleeding as a
purification/healing process, with the potential for reuse of blades and razors. An association
between these practices and acquisition of HIV has not been found. 40 , 41
There are also few data on unsafe medical practices and the risk of acquiring HIV infection. The
MOH reports that most blood is screened for HIV and that only a small number of new
infections are due to contaminated blood transfusions. 42 Injections are patients' preferred method
of receiving medicines, and they are administered by trained and untrained persons, with the
potential for reuse of needles and syringes; however, the MOH reports that HIV transmission via
unsafe injections is minor. 43 The Ethio-Netherlands AIDS Research Project has examined the
association between some medical practices and the risk of HIV infection but did not find any
significant association. 44 , 45

HIV/AIDS in Ethiopia 22
UNAIDS Estimates
At the end of 2001, UNAIDS estimates that there were 2.1 million Ethiopians living with
HIV/AIDS (estimate range: 1.5 million to 2.7 million). There were 1.9 million HIV-positive
adults, over half of whom (1.1 million, 57.9 percent) were women. UNAIDS estimated that adult
prevalence was 6.4 percent. (See the discussion above and in the Data Quality section below
concerning caveats regarding prevalence figures.) The number of people living with HIV/AIDS
in Ethiopia was the sixth-highest in the world, following South Africa, India, Nigeria, Kenya,
and Zimbabwe. 46
AIDS Cases
Surveillance reports based on AIDS case reporting began soon after the establishment of the
HIV/AIDS department within the MOH in 1987. 47 Since 1984, a cumulative total of 107,575
AIDS cases have been reported to the MOH. In 2001, there were 15,202 AIDS cases reported to
the MOH; however, the MOH estimates that the actual number of new AIDS cases in 2001 was
219,400. Reasons for underreporting include:
The current reporting system is inefficient.
Delayed reports by regions are common.
Most Ethiopians never seek medical care for AIDS.
Some people with AIDS may die of other diseases before they are diagnosed as having
AIDS.
Most rural hospitals and district health care facilities are unable to test for HIV.
Most private laboratories do not provide data to the MOH.
Most AIDS diagnoses are presumptive, not definitive.
There is a lack of laboratory facilities and of trained lab personnel (see below). 48 , 49 , 50
Among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34. 51
This is likely related to age mixing, wherein young women have older male sex partners,
primarily for economic reasons. 52
The median incubation period for Ethiopians is over eight years. The Ethio-Netherlands AIDS
Research Project has recently found that the median incubation period is 10 years with
survival. 53
Age and Gender
According to ANC data, the highest number of HIV-infected persons is found in the age groups
20-24 and 25-29. However, the group with the highest HIV prevalence in the country is women
ages 15 to 24 (12.1 percent). (Data from blood donors, visa applicants, and police and army
recruits indicate that HIV prevalence among men peaks between 25 and 29. 54 )
Moreover, the number of women with HIV ages 15 to 19 is much higher than the number of
males in the same age group. It also appears that in this age cohort, there are more women who
have had sexual intercourse than there are men. Ethiopia's 2000 Demographic and Health Survey

HIV/AIDS in Ethiopia 23
found that 69.3 percent of women ages 15-19 report never having had intercourse; among men in
this age group, 84.6 percent report never having had intercourse. 55
(The 2000 Ethiopia Demographic and Health Survey is the first nationally representative sample
survey on population and health. It was conducted between February and May 2000 and included
15,367 women ages 15-49 and 2,607 men ages 15-59. It was implemented by the Central
Statistical Authority under the aegis of the MOH. Macro International Inc. provided technical
assistance through its MEASURE EDHS+ Project. The survey was principally funded by the
Essential Services for Health in Ethiopia Project through USAID; additional funding was
provided by UNFPA.)
According to UNAIDS, HIV prevalence among women ages 15 to 24 was 5.65 to 9.99 percent at
the end of 2001; among men in the same age group, the range was 3.17 to 5.62 percent. 56
Data from ANC surveys and from blood donors indicate that young people (below age 24)
represent a major proportion of HIV infections among the general population. 57
AIDS Mortality
AIDS is now recognized as the leading cause of adult morbidity and mortality in Ethiopia. 58 The
MOH projects that by 2004, AIDS may account for about 460 deaths each day among 15- to 49-
year-olds. 59
According to the U.N. Population Division, AIDS has already increased the number of deaths in
Ethiopia by 6 percent. By 2000, 1.1 million Ethiopians had died because of AIDS. 60 In 2001,
UNAIDS estimated that were 160,000 adult and child AIDS deaths in Ethiopia. 61 Ethiopia's
MOH estimates that by the end of 2002, 1.7 million Ethiopians had died because of AIDS. It
projects that by 2014, there will be an additional 3.6 million deaths because of AIDS, bringing
the cumulative total to about 5.3 million by 2014. 62
This projection is about equal to those of the U.N. Population Division, which projects 5.2
million cumulative AIDS deaths through 2015. The UN projects that by 2050, 14.9 million
Ethiopians will have died because of the epidemic. 63 (See Impact section for more detailed
discussion.)
Prevalence Projections
In February 2003, the U.N. Population Division estimated that Ethiopia's HIV adult prevalence
had already peaked, at 6.5 percent in 2000, and that prevalence would fall to 2.8 percent by
2050. 64
(A September 2002 report by the U.S. National Intelligence Council estimated that the current
number of Ethiopians living with HIV/AIDS is between 3 and 5 million. It projects that this
range will rise to 7 to 10 million by 2010 and that adult prevalence will be between 19 and 27
percent. The NIC report was widely quoted in the popular press; however, the report did state
that its projections entailed a "relatively high margin of error." 65 )

HIV/AIDS in Ethiopia 24
Progression of the HIV Epidemic
The data currently available indicate that the HIV/AIDS epidemic has affected a large segment
of the urban population. However, currently available data are extremely inadequate to measure
the level of infection in the rural population, where 85 percent of Ethiopians live. 66
According to a recent review undertaken by the Ethio-Netherlands AIDS Research Project of the
Ethiopian Health and Nutrition Research Institute, the progression of HIV/AIDS in the country
indicates that the epidemic in most of urban Ethiopia began in the mid-1980s, plateauing in the
mid-1990s and stabilizing thereafter. In rural Ethiopia, however, the epidemic began in the early
1990s. It is now progressing rapidly and is likely only in its early stages. 67
Apart from the paucity of rural HSS data, a brief analysis of ANC data for rural sites suggests
that there may have been problems in ANC data collection or analysis in some of these sites. For
example, in Attat, ANC prevalence was 0.8 percent in 1998, 4.0 percent in 1999-2000, and 1.5
percent in 2001, leading one to infer that data collection and/or analysis in one or more of these
rounds might have been flawed. In Gambo Oromiya, prevalence rose from 0.7 percent in 1999-
2000 to 1.1 percent in 2001. Data for the other rural sites (Aira Oromiya, Borena Dadim
Oromiya, Borena Gosa Oromiya, and Ambo-Toke Oromiya) were not collected pre-2001. 68
Thus, trend analysis across HSS sites is constrained by major data gaps.
The most consistent HSS data are for Addis Ababa, where four health centers are involved in
ANC surveys. The two outer city health centers, Gulele and Higher 23, became HSS sites after
1996. The inner city health centers (Kazanchis and Teklehymanot) have traditionally had higher
HIV prevalences compared to the outer city health centers. 69 In 1989, HIV prevalence at the two
inner city health centers was 4.6 percent, rising to 11.2 percent in 1992-93, and to 21.2 percent in
1995. 70
The Ethio-Netherlands AIDS Research Project analyzed the five rounds of HSS conducted in
Addis between 1995 and 2001. It found that during this period, HIV prevalence among women
ages 15-24 attending the inner city HSS sites declined from 24.2 to 15.1 percent (prevalence
ratio for an increase in one calendar year, 0.91; 95% confidence interval, 0.87-0.95). No change
was observed for older age groups or in the outer city health centers, indicating stabilization of
HIV prevalence. The decline in the prevalence of active syphilis was more pronounced among
and also restricted to the 15-24 age group in the inner city (from 7.6 percent in 1995 to 1.3
percent in 2001; prevalence ratio, 0.69; 95% confidence interval, 0.59-0.80). The researchers
noted that although declining trends in HIV (and syphilis) prevalence among those 15-24
attending ANCs in the inner city are encouraging, these findings require validation using
population-based and behavioral surveillance data. 71
Further, such declines have not been observed in other urban sites (although, again, trend
analysis is constrained). For example, in 1999-2000, HIV prevalence at the Bahir Dar health
center site was 20.8 percent; in 2001, it reached 23.4 percent, the highest prevalence recorded at
any HSS site in the country. (Data for Jigiga and Nazareth, which had the second and third,
respectively, highest prevalences in the country in 2001, were not collected pre-2001.) Dire
Dawa health center registered an HIV prevalence of 12.3 percent during 1992-93, rising to 13.6

HIV/AIDS in Ethiopia 25
percent in 1999-2000 and 15.2 percent in 2001. In Metu, prevalence was 10.7 percent in 1992-
93; data were not collected again until 1999-2000, when prevalence was 4.0 percent; in 2001, it
was 10.5 percent, 72 leading one to infer that data collection and/or analysis in the 1999-2000
HSS round might have been flawed.
Lower-prevalence urban sites, such as Awassa and Dilla (which did not participate in HSS in
1999-2000) have seen declines since 1998 (the first year for which data were collected in them).
In Awassa, HIV prevalence declines from 14.4 percent in 1998 to 10.0 percent in 2001; for Dilla,
the decline during this period was 14.5 to 9.8 percent. 73
As discussed above, data from the 2001 HSS indicated a national adult HIV prevalence of 6.6
percent, a decline from 7.3 percent for 1999-2000. MOH was firm that this fall should not be
interpreted to mean that the HIV/AIDS epidemic in Ethiopia is declining. It stresses that the 2001
HSS was more extensive and that the reclassification of Estie as an urban site played a major
role. The MOH's caution is warranted, especially as trend analysis is so constrained by data gaps
and inadequate rural data. Moreover, as the MOH observes, it must also determine how AIDS
mortality is affecting prevalence. 74
Data Quality Issues
Currently available data are severely inadequate to measure the level of HIV infection in the
general population, given scarce HSS data from rural areas, where 85 percent of Ethiopians live.
Data on the level of infection in specific subgroups are also extremely insufficient, as are those
related to trends; burden of disease; and the impact of preventive interventions in urban, rural,
regional, and zonal areas. Accurate serial prevalence data on STIs are also lacking. 75
There have been major gaps and variances in Ethiopia's HSS data collection, thus impeding trend
analysis. 76 ANC data currently serve as Ethiopia's primary sentinel surveillance of HIV/AIDS.
Though ANC data are widely used, they are imperfect (see box 1). There have been reported
discrepancies between results of population-based surveys and ANC-based surveillance systems
in Addis Ababa, thus calling into question how representative ANC attendees are of the general
female population. 77 One factor may be subfertility. Comparative studies have shown that the
HIV prevalence among pregnant women in sub-Saharan Africa underestimates prevalence in
Box 1. HIV Sentinel Surveillance: Evaluating Data from Antenatal Clinics
In many developing countries, estimates on the magnitude of and trends in the HIV epidemic are obtained through
HIV seroprevalence surveys. These surveys are primarily conducted using sentinel populations. The most frequently
used sentinel populations are women attending antenatal clinics and persons attending clinics for diagnosis and
treatment of sexually transmitted infections. The objectives of sentinel seroprevalence surveys include:
1. obtaining information on the prevalence of HIV infection in the sentinel population
2. monitoring trends in HIV prevalence in the sentinel population
3. providing information for estimating future number of AIDS cases
4. providing information for program planning and evaluation of interventions
Seroprevalence surveys are usually conducted annually at preselected clinics or hospitals. Surveys of women
attending antenatal clinics can provide a reasonable estimate of HIV prevalence within the general population. The
surveys are conducted among women ages 15 to 49 years attending the antenatal clinic for the first time during a

HIV/AIDS in Ethiopia 26
current pregnancy. Surveys are usually conducted in an unlinked manner, in which serum remaining from routine
syphilis screening is tested for HIV infection after all personal identifying information is removed from the
specimen. Sampling is usually conducted during an 8- to 12-week period, and all eligible women are sampled
consecutively until the desired sample size is achieved. In general, samples of 250 and 400 women are usually
sufficiently large as to provide reasonable estimates of HIV prevalence over time.
Although these surveys are extremely useful, there are several limitations to consider when interpreting the survey
results. The surveys are not based upon a probability sample and therefore may not be representative of the
population as a whole. True population-based surveys have found antenatal clinic data may overestimate or
underestimate HIV prevalence.
Moreover, the ANC studies do not provide information on mortality or HIV-associated morbidity. In addition,
although monitoring trends in HIV prevalence provide information on the magnitude of the HIV epidemic, trends in
prevalence cannot be relied upon to indicate trends in HIV incidence. However, examining trends in HIV prevalence
in younger populations, particularly 15- to 19-year-olds, may provide some indication of trends in recently acquired
HIV infection , as this group is unlikely to have been infected for a long period of time.
Prepared by Sandy Schwarcz, MD, MPH
Director, HIV/AIDS Statistics and Epidemiology Section, San Francisco Department of Public Health
Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, University of California San
Francisco
women of reproductive age because fertility among HIV-positive women is substantially lower
than among uninfected women. 78 For example, Gregson et al. have found 25 to 40 percent lower
fertility in women with HIV in high-prevalence African countries; they attribute about half of
this "subfertility" directly to HIV infection. 79
Another issue is laboratory quality control and reliability of HIV testing. Researchers from Addis
Ababa University and the Ethio-Netherlands AIDS Research Project stress that outside Addis
Ababa, where HSS is operational, systems are not fully supported by quality control. Thus, there
are concerns regarding the validity of reported results. There are anecdotal indications that the
quality of HIV surveillance data is low. There have been examples of reports submitted to the
MOH with grossly inaccurate prevalence estimates calculated from raw data. 80 A study presented
at the XIV International AIDS Conference in Barcelona in July 2002 examined syphilis
serodiagnosis, but the lessons may have import for HIV testing as well. The researchers, part of
the Ethio-Netherlands AIDS Research Project, found a high false positivity rate, with
shortcomings in quality control for data registration and tube handling, concluding that "the
interpretation of specific serological tests remains a challenge for both clinician and
microbiologist." 81
(Recently, the MOH and regional health bureaus have licensed several private, commercial
clinics and laboratories to undertake HIV testing (and counseling). In addition, the National
HIV/AIDS Referral Laboratory at the Ethiopian Health and Nutrition Research Institute and
regional public laboratories conduct HIV testing. Periodic reporting by these public and
commercial labs is required, although most commercial labs do not do so. 82 , 83 )
Poverty, conflict, drought, and famine may be affecting the population that attends ANCs. For
example, these phenomena spur population dislocation and affect household activity, as the
search for food and/or migration to food aid distribution points take priority. There are currently

HIV/AIDS in Ethiopia 27
no data on whether these phenomena have any relationship to the profile of women attending
ANCs, but they may merit monitoring.
Finally, Ethiopia is a highly diverse country, with over 80 ethnic groups. 84 It comprises 18
distinct agroecological zones, ranging from mountains to deserts. 85 Analysis of HIV prevalence
in the context of regional characteristics, religion, ethnicity, and occupation is lacking (the major
exceptions are the Ethio-Netherlands AIDS Research Project's longitudinal study of factory
workers and a few small studies of sex workers). Studies of mobile populations are also
generally lacking, as are those that examine HIV/AIDS in the context of chronic food insecurity.
Despite that Ethiopia, according to UNAIDS, has the sixth-highest number of people living with
HIV/AIDS in the world, 86 only 48 abstracts of the 8,824 presented at the XIV International AIDS
Conference in Barcelona in July 2002 contained the word Ethiopia. (By comparison: South
Africa: 524 abstracts; India: 788; Nigeria: 158; Kenya: 257; Zimbabwe: 153). There were 130
abstracts with the word Tanzania (seventh-highest number of people with HIV/AIDS) and 139
for Zambia (eighth-highest number of people living with HIV/AIDS). Strengthening surveillance
and filling research gaps are critical.

HIV/AIDS in Ethiopia 28
Political Economy and Sociobehavioral Context
At a Glance
The At a Glance section summarizes the more detailed data found below it.
Overview
Many of the factors discussed in this section exist in countries whose HIV prevalence is
lower than that of Ethiopia; these include poverty, gender inequality, and chronic food
insecurity.
The relationship between HIV prevalence and socioeconomic factors is highly complex.
Increasingly, risk of HIV infection is recognized as related to, inter alia, one's socioeconomic
status as well as the socioeconomic profile of the community in which one is situated.
Additionally, Ethiopia's political history, civil war, conflicts with Eritrea, and current food
crisis also affect HIV/AIDS dynamics.
This section does not seek to demonstrate causality; rather, it aims to analyze key political
economy and sociobehavioral contextual elements to highlight the range of sectoral policies
and interventions that may affect or be affected by HIV/AIDS.
Ethiopia is one of the world's oldest continuous civilizations and one of the few in Africa that
was never colonized. It is also one of the world's poorest countries, with a 2000 per capita
income of US$100.
Ethiopia's population, estimated at 68 million in mid-2002, is the second largest in sub-
Saharan Africa and is projected to continue to grow by over 2 percent annually through 2025.
Ethiopia's population is young and diverse. Eighty-five percent of the population lives in
rural areas.
Ethiopia's political past has been marked by Italian occupation (1936-41), the removal of the
Emperor Haile Selassie in 1974, and a Marxist military government that was in power from
1974-91.
Civil war led to the overthrow of the Marxist regime and establishment of a transitional
government in 1991. In 1994, Ethiopia held elections for a constituent assembly and adopted
a new constitution.
The present government t has promoted a policy of ethnic federalism, devolving significant
powers to regional, ethnically based authorities.
Although Ethiopians enjoy greater political participation, some fundamental freedoms,
including freedom of the press, are limited.
In 1993, Eritrea became independent. In 1998, an Ethiopian-Eritrean border conflict erupted
into a full-scale war. After nearly two years of fighting, Eritrea and Ethiopia signed a
comprehensive peace agreement. However, tensions between them remain high, and there are
fears that the peace accord will be broken.
Population Mobility

HIV/AIDS in Ethiopia 29
Ethiopia's mobile populations include:
The rapidly increasing number of rural residents seeking employment in urban areas
military personnel, including international peacekeepers
persons displaced by war, drought, and/or environmental degradation
male transport workers
sex workers
migrant workers
miners
individuals leaving Ethiopia to live/work overseas
merchants/traders/vendors
orphans and vulnerable children (e.g., street children)
humanitarian and relief workers
prisoners
Economy
The agricultural and livestock sectors account for over 85 percent of the labor force. Coffee
represents about 70 percent of the country's foreign exchange earnings.
During the 1990s, the government embarked on a program of structural reform. GDP growth
rose during the 1990s, and the country has begun to attract much-needed foreign investment.
However, per capita income in Ethiopia fell during the decade. Public expenditure on health
increased only slightly, from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998. Several
major health indicators either fell or stagnated during the decade. The scope of poverty in the
country remains enormous.
Poverty
At the end of the 1990s, 44 percent of the population lived below the national poverty line. In
1995, 31 percent of the population was living below US$1 a day and 76 percent below US$2
a day.
Repeated and frequent shocks (such as drought and war) have meant that household assets
have been diminished if not depleted.
Public Expenditure Trends
As a percent of GDP, military spending in Ethiopia is almost eight times greater than public
spending on health.
Debt
During the 1970s and 1980s, Ethiopia's servicing of its public and publicly guaranteed debt
ranged from 4 to 17 percent of central government revenues.
In November 2001, Ethiopia qualified for debt relief under the Enhanced Heavily Indebted
Poor Countries Initiative (HIPC). HIPC is not debt cancellation; rather it is a restructuring of
debt repayment through provision of grants. Under HIPC, an estimated US$1.93 billion was
committed to Ethiopia as total debt relief from all its creditors.
Several social justice NGOs have calculated that Ethiopia will be paying almost as much in
debt service payments under HIPC as it was before HIPC.

HIV/AIDS in Ethiopia 30
They also express concerns that the assumptions underlying HIPC are unrealistic.
Food Security
In March 2003, the World Food Program reported that 11 million Ethiopians (about 16
percent of the population) are currently targeted for food distribution between April and July
2003. An additional 3 million people are at risk of starvation.
The current food crisis is on a par with (or may even exceed) that of the 1984-85 famine.
Unlike in southern Africa, HIV/AIDS is not a major factor underlying the Ethiopian food
crisis. However, the search for food and migration to food aid distribution points does spur
population dislocation, which may be accompanied by regroupings of family units and
exposure to new sexual networks. Malnutrition (already high in Ethiopia) is increasing and
further weakening the immune systems of PWHA, thereby contributing to higher rates of
morbidity and mortality.
Famine is likely to raise the opportunity cost of sending children to school. Girls, in
particular, are affected.
Lack of food, coupled with a subsequent breakdown in family structure, may place more
children on the streets where they may be at higher risk of mistreatment, sexual exploitation,
and physical and emotional abuse. Women and girls may undertake sex work to survive.
They may also offer sex to workers involved in transporting and distributing food aid to try
and obtain preferential treatment in the distribution of supplies and services.
Human Development
Ethiopia ranks 168 out of the 173 countries for which UNDP has calculated a human
development index value.
Although Ethiopia's child and infant mortality rates have fallen over the last 30 years, they
remain extremely high. Maternal mortality is also high.
Health
Ethiopia's health expenditure per capita (both public and private) was less than US$5 during
the 1990s.
The health system in Ethiopia is severely underdeveloped. Transport constraints are severe.
Given low incomes, low levels of education, poor access to health services, and a highly
uneven distribution of health facilities favoring urban areas, Ethiopians' general health status
is poor both in absolute terms and in comparison with other African countries.
A major concern is that as the central government reduces its role in health care delivery,
with decentralization and privatization to fill the gap, safety nets for the poor (especially
those in rural areas and women) may be threatened.
Sexual & Reproductive Health
UNFPA ranks Ethiopia a category "A" country, meaning that it is furthest from achieving the
sexual and reproductive health and rights goals of the 1994 International Conference on
Population and Development held in Cairo.

HIV/AIDS in Ethiopia 31
Ethiopia's MMR is extremely high, as are fertility levels. Childbearing begins early.
Awareness of contraception is high; however, current use of modern contraceptive methods
is only 6 percent. There is high unmet need for family planning.
The incidence of unsafe abortions is high and constitutes a major cause of maternal morbidity
and mortality.
A key issue is delivering sexual & reproductive health information and services to young
people, including those who are unmarried. This is particularly crucial as there has been an
increase in the percentage of never-married women over the last 10 years.
Sexually Transmitted Infections
There are no accurate serial prevalence data on STIs in Ethiopia.
Several recent studies indicate that prevalence of herpes simplex virus type 2 (HSV-2) is high
and may be fueling the HIV/AIDS epidemic.
Gender
UNDP ranks Ethiopia 142 out of 146 countries on its Gender-related Development Index.
Although the constitution of 1994 guarantees gender equality and permits affirmative action,
implementation of the National Policy for Women is hindered by varying degrees of
commitment across regions.
Gender disparities in enrolment ratios and educational attainment levels are high. The
country's high MMR is also an indication not only of poor reproductive health, but of
women's low status and poor access to basic health services.
Many Ethiopian women have little power in sexual negotiation with their husbands.
Almost 14 percent of currently married women in Ethiopia are in a polygynous union.
Female circumcision is widespread in Ethiopia: 80 percent of all women have been
circumcised.
There is also widespread support for female circumcision among Ethiopian women.
Poverty and unemployment are leading to a dramatic increase in the trafficking of Ethiopian
women.
Other issues that render Ethiopian women vulnerable to HIV include rape, abduction, and
early marriage.
Knowledge of HIV/AIDS
Knowledge of HIV/AIDS is high among Ethiopians. However, as is the case in many
countries, women are less likely than men to have heard of HIV/AIDS.
In some regions, the majority of women do not believe that HIV can be avoided.
Women are much less knowledgeable than men about programmatically important ways to
avoid contracting HIV.
About 63 percent of women do not believe that a healthy looking person can have
HIV/AIDS; among men, this figure is 45 percent.
Another major knowledge gap is mother-to-child transmission of HIV. Only 58 percent of
women (and 72 percent of men) know that HIV can be transmitted from mother to child.

HIV/AIDS in Ethiopia 32
Of those who have heard of HIV/AIDS, 26 percent of women and 48 percent of men
currently married or living with a partner have discussed HIV prevention with their spouse or
partner.
Stigma
Among those who have heard of AIDS, nearly twice as many women as men believe that the
HIV positive status of a family member should remain a secret.
About 45 percent of women and 50 percent of men report that they are willing to care for
relatives with HIV in their house.
Concerns about casual transmission despite knowledge persist. In a recent study, 61
percent of respondents reported that although they know that HIV is not transmitted casually,
they would not buy food from a vendor with HIV. Many would separate utensils, linens, and
other household items used by PWHA from those used by other household members.
Much of the stigmatizing language and description of stigmatizing and discriminatory
behavior centers on the sexual transmission of HIV. The belief that HIV is a divine
punishment for sins committed is particularly strong. Nevertheless, many community
members feel that PWHA deserve sympathy or support.
Some stigmatizing behavior is caused by limited resources and fatigue. Although family and
community members provide care, they often regard PWHA as a burden. Those who provide
care to PWHA are often themselves stigmatized.
Sexual Behavior
There is an acute need for data on sexual behavior trends in Ethiopia.
Between December 2001 and June 2002, Ethiopia undertook its first behavioral surveillance
survey, involving over 30,000 respondents in rural and urban areas in every region of the
country, including in- and out-of-school youth, female sex workers, military personnel,
farmers and pastoralists, long-distance drivers, and factory workers. Official findings have
not yet been released.
According to the 2000 EDHS, the median age at first intercourse for women ages 20-49 is
16.4 years and the median age at first marriage 16.0.
The median age at first sexual intercourse among men is 20.3 years, three years lower than
their median age at first marriage (23.3 years).
Among those unmarried, 13 percent of women and 22 percent of men reported sexual
intercourse in the last year.
Among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34.
This is likely related to age mixing, wherein young women have older male sex partners,
primarily for economic reasons.
There are no data on transactional sex in Ethiopia. Poverty, conflict, drought, and famine
may increases instances in which sex is traded for food or other necessities.
Condoms
According to the 2000 EDHS, only 35 percent of all women know about condoms; the
comparable figure for men is 68 percent.

HIV/AIDS in Ethiopia 33
Only 12 percent of women know a source for condoms and only 11 percent report that they
could obtain condoms for themselves. The rural-urban differential is very wide: 7 percent vs.
37 percent on source and 6 percent vs. 34 percent on ability to obtain.
Generally, condom use in Ethiopia is low, although the BSS appears to have found that it is
high among sex workers. According to the 2000 EDHS, the use of condoms during last
sexual intercourse with a spouse or cohabiting partner was negligible among both women
and men. With a noncohabiting partner, 13 percent of women and 30 percent of men reported
condom use at last intercourse.
Sex Work
Several HIV serosurveys among sex workers have been conducted since the beginning of the
epidemic. The most recent, a 1998 study of 372 sex workers in Addis Ababa, found that most
SWs were from the city's slums and that about 35 percent lived in "shared rooms," renting a
small room in which three to five women live. These SWs must give about half their income
to the owner of the room.
Family Health International notes that estimates of the number of sex workers in Addis
Ababa range from a few thousand to 150,000. There is an acute lack of data on sex worker
networks.
Alcohol and Drug Use
Recreational drug consumption in Ethiopia is increasing, including among street children in
Addis Ababa and in the city's slum areas.
Although there are no data on drug abuse and the Ethiopian-Eritrean conflict, the U.N. does
highlight that armed conflicts throughout the world have led to rapid spread of drug control
problems in affected zones.
Male Circumcision
There are no data on male circumcision in Ethiopia. Some observational studies from sub-
Saharan Africa have indicated that male circumcision may reduce the risk of HIV
acquisition, though circumcision does not appear to affect transmission from HIV-positive
men to their partners.
Many of the factors discussed in this section exist in countries whose HIV prevalence is lower
than that of Ethiopia; these include poverty, gender inequality, and chronic food insecurity. The
relationship between HIV prevalence and socioeconomic factors is highly complex. Increasingly,
risk of HIV infection is recognized as related to, inter alia, one's socioeconomic status as well as
the socioeconomic profile of the community in which one is situated. Additionally, Ethiopia's
political history, civil war, conflicts with Eritrea, and current food crisis also affect HIV/AIDS
dynamics.
This section does not seek to demonstrate causality; rather, it aims to analyze key political
economy and sociobehavioral contextual elements to highlight the range of sectoral policies and
interventions that may affect or be affected by HIV/AIDS.

HIV/AIDS in Ethiopia 34
Country Overview
Ethiopia is one of the world's oldest continuous civilizations and one of the few in Africa that
was never colonized (though it was occupied). 87 It is also one of the world's poorest countries,
with per capita income of US$100. 88 The depth and breadth of poverty are enormous. Ethiopia's
population, estimated at 67.7 in mid-2002, 89 is the second largest in sub-Saharan Africa
(following Nigeria) and is projected to continue to grow by over 2 percent annually through
2025. 90
Ethiopia's population is young, with 44 percent under age 15. 91 In 2000, the median age of the
population was 16.9. 92 Eighty-five percent of the population lives in rural areas. 93 Ethiopia
comprises 18 distinct agroecological zones, ranging from mountains to deserts. 94 There are wide
disparities in demographic and socioeconomic indicators between urban and rural areas, as well
as among the nation’s nine regional states, Addis Ababa City Administration, Dire Dawa
Administrative Council, 64 zones, 550 districts (woredas), and over 1,000 community-level
associations (kebeles).
There are over 80 ethnic groups in Ethiopia; the major ones are Oromo (35 percent), Amhara (30
percent), Tigre (6 to 8 percent), and Somali (6 percent). 95 Christianity and Islam are the main
religions: 51 percent of the population is Orthodox Christian, 33 percent Muslim, and 10 percent
Protestant. 96 Generally, most Christians live in the highlands, whereas Muslims and adherents of
traditional African religions tend to inhabit lowland regions. Amharic is the official language;
Tigrinya, Oromifa, and Somali are also used. English is the most widely spoken foreign
language. 97
In 1936, the reign of Emperor Haile Selassie the last emperor of a dynasty claiming descent
from the biblical Solomon was disrupted when Italian Fascist forces invaded and occupied
Ethiopia. Haile Selassie was forced into exile in England. Five years later, the Italians were
defeated by British and Ethiopian forces, and the emperor returned to the throne. 98
After a period of civil unrest that began in February 1974, Haile Selassie was deposed in
September 1974, and a provisional administrative council of soldiers, known as the Derg
(committee) seized power and installed a Marxist military government headed by Lt. Colonel
Mengistu Haile Mariam. 99 , 100 Mengistu's years in office were marked by totalitarian
government and massive militarization, financed by the Soviet Union and the Eastern Bloc and
assisted by Cuba. 101
Droughts, famine, and insurrections particularly in the northern regions of Tigray and Eritrea
brought about the Derg's collapse. In 1989, the Tigrayan People's Liberation Front (TPLF)
merged with other ethnically based opposition movements to form the Ethiopian Peoples'
Revolutionary Democratic Front (EPRDF). In May 1991, EPRDF forces advanced on Addis
Ababa. Mengistu Haile Mariam fled the country and was granted asylum in Zimbabwe. 102
In July 1991, the EPRDF, the Oromo Liberation Front (OLF), and others established the
Transitional Government of Ethiopia (TGE), comprising an 87-member Council of
Representatives and guided by a national charter that functioned as a transitional constitution.
The TGE pledged to oversee the formation of a multiparty democracy in Ethiopia. An election

HIV/AIDS in Ethiopia 35
for a 547-member constituent assembly was held in June 1994; in December of that year, the
assembly adopted the constitution of the Federal Democratic Republic of Ethiopia. 103
The elections for Ethiopia's first popularly chosen national parliament and regional legislatures
were held in May 1995 and June 1995, respectively. Most opposition parties chose to boycott
these elections, ensuring a landslide victory for the EPRDF. However, international observers
and NGOS believed that opposition parties would have been able to participate had they chosen
to do so. 104
The Government of the Federal Democratic Republic of Ethiopia was installed in August 1995.
The EPRDF-led government has promoted a policy of ethnic federalism, devolving significant
powers to regional, ethnically based authorities. Ethiopia's semiautonomous administrative
regions have the power to raise and spend their own revenues. Although Ethiopians enjoy greater
political participation, some fundamental freedoms, including freedom of the press, are limited
(discussed in more depth in Governance section below). 105
In May 1991, the Eritrean People's Liberation Front (EPLF) assumed control of Eritrea and
established a provisional government. This provisional government independently administered
Eritrea until April 1993, when Eritreans voted overwhelmingly for independence in a UNmonitored
referendum. 106 In May 1998, an Ethiopian-Eritrean border conflict erupted into a fullscale
war. After nearly two years of fighting, Eritrea and Ethiopia signed a cessation of hostilities
agreement and a comprehensive peace agreement, and a contingent of U.N. peacekeepers was
deployed in a 25-km wide temporary security zone (TSZ) running the length of the border. 107
However, tensions between Ethiopia and Eritrea remain high, and there are fears that the peace
accord will be broken. 108
Governance
There have been no studies on governance and HIV/AIDS in Ethiopia. However, a general
overview of governance might provide a sense of the context in which the epidemic is unfolding,
as well as in which it is being addressed.
In 1991, Ethiopia emerged from three decades of protracted civil war and a repressive, centrally
planned economy, which undermined poverty reduction efforts, among others. 109 Transparency
International posits that Ethiopia's current coalition government is "generally held together by
the ability of the ruling party to keep the pockets of its partners oiled, while it openly suppresses
the opposition." Civil society's ability to fight corruption is hampered by the restrictions on press
freedoms. 110
Ethiopia passed legislation in May 2001 establishing the Federal Ethics and Anticorruption
Commission (FEACC). Transparency International believes that this was largely a result of
donor pressure. In one of its first major cases, the FEACC filed corruption charges against 41
past and present officials of the Ethiopian Commercial Bank. Charges were also brought against
12 former heads of government institutions and businessmen arrested in May 2001. One of the
accused was the leader of a dissident group within the ruling party. To what degree FEACC will
be effective, given its underfunding and ties to the ruling party, is unclear. 111
Population Mobility

HIV/AIDS in Ethiopia 36
As mentioned above, there are very few data on HIV/AIDS and Ethiopia's mobile populations,
which include:
the rapidly increasing number of rural residents seeking employment in urban areas
military personnel, including international peacekeepers
persons displaced by war, drought, and/or environmental degradation
male transport workers (see Epidemiology section)
sex workers (see Epidemiology section)
migrant workers
miners
individuals leaving Ethiopia to live/work overseas (see Epidemiology section)
merchants/traders/vendors
orphans and vulnerable children (e.g., street children)
humanitarian and relief workers
prisoners
In March 2003, Ethiopia's Ministry of Federal Affairs highlighted that the country is facing a
massive urban population explosion as families move from rural areas to cities. Against the
backdrop of drought and food crisis, Ethiopia is experiencing one of Africa's highest rates of
migration from villages to urban areas. 112
In October 2002, the UN Office for the Coordination of Humanitarian Affairs estimated that
there were at least 235,000 internally displaced Ethiopians, rendered mobile by war, famine, and
drought. 113 (Note that this figure does not take account of the current food crisis, see below.) The
International Committee of the Red Cross is assisting families in Eastern Tigray on the border
with Eritrea who were displaced by the Ethiopia-Eritrea war. Some were unable to return to their
home areas because of landmines or other security concerns. Other families that did return found
that their homes had been partially or completely destroyed. Some of the families in this region
are also moving in search of better soils on which to farm. 114
War
The U.S. National Intelligence Council report discussed in the Epidemiology section states that
war has "significantly contributed" to HIV transmission in Ethiopia. This is a crucial point to
examine, though the report does not back up its assertions with any data (at least declassified
data). NIC contends that "many" soldiers contracted HIV during the civil war in the 1980s and
when that war ended in 1991, subsequently transmitted HIV to their sex partners in their home
villages and towns. Sex workers who followed the military also moved when the civil war
ended. 115
David Shinn, former U.S. ambassador to Ethiopia and contributor to the NIC report, states that
HIV prevalence among military personnel in front-line positions along the border with Eritrea is
about 15 percent; it declines 12 percent behind the front lines and 7 percent where soldiers are
living with or near their spouses in a "fairly normal" living environment. 116 Shinn did not

HIV/AIDS in Ethiopia 37
provide a source for these data, though they may have been provided to him by the Ethiopian
Ministry of Defense.
According to the U.N. Office for the Coordination of Humanitarian Affairs, Ethiopia's 1998-
2000 war with Eritrea displaced 1 million people, of whom 76,000 still have not returned to their
homes. 117 Since the December 2000 peace accord and April 2002 border decision, issued by the
independent Boundary Commission, 150,000 Ethiopian soldiers have been demobilized 118 , 119 .
There is also a UN peacekeeping mission in Ethiopia and Eritrea (UNMEE). 120 Thus, mobility of
military personnel within Ethiopia remains high. Ethiopia itself has not yet participated in UN
peacekeeping operations. However, in early 2003 it announced that it was sending about 800
soldiers to Burundi as part of a pan-African peacekeeping force that would observe the Burundi
ceasefire until U.N. peacekeepers arrive. 121
The Response section examines how UNMEE and the Ethiopian military are addressing
HIV/AIDS.
Transportation Corridors
A landlocked country, Ethiopia uses the seaports of Assab and Massawa in Eritrea. Ethiopia also
uses the port of Djibouti, connected to Addis Ababa by rail, for international trade. 122 In addition
to commercial transport companies, humanitarian and relief workers also use these corridors; for
example, the World Food Program is employing over 2,000 truck drivers to deliver food aid
from the Port of Djibouti to distribution points throughout Ethiopia. 123
The CDC undertook a small, rapid study of the Ethio-Djibouti corridor using focus group
discussions, in-depth interviews, and key informant interviews with sex workers, truckers, their
assistants, military personnel, construction workers, job-seeking women, and bar owners. The
study was conducted on the two main highways and 14 towns along the corridor. It found that
mobility was very high. For example, many women gravitate to the area seeking work, including
sex work. Others are trafficked into sex work by brokers. Sex workers had the most positive
attitude toward use of condoms, whereas most men had a negative attitude. Although condoms
are accessible to respondents, their utilization is low, especially among soldiers, young men, and
truckers. The main places where high-risk activities occur are liquor-selling establishments,
nightclubs, bars, hotels, and brothels. 124
Prisoners
The only data on HIV prevalence among prisoners are from 1990 in Dire Dawa (n=450),
indicating prevalence of 6.0 percent. 125
Economy
Ethiopia has one of the lowest exports per capita in the world. Gold, marble, limestone, and
small amounts of tantalum are mined in Ethiopia. Other resources with potential for commercial
development include large potash (potassium carbonate) deposits, natural gas, iron ore, and
possibly oil and geothermal energy. Although Ethiopia has good hydroelectric resources, which
power most of its manufacturing sector, it is completely dependent on imports for oil. 126

HIV/AIDS in Ethiopia 38
Agriculture accounts for 40 percent of GDP and includes coffee (which represents 65 to 75
percent of the country's foreign exchange earnings), teff (a grain native to Ethiopia), wheat,
barley, sorghum, millet, maize, khat (a shrub whose leaves and buds provide a habituating
stimulant when chewed or used as a tea), meat, hides, and skins. Industry accounts for 13.7
percent of GDP and includes textiles, processed foods, construction, cement, and hydroelectric
power. 127
The agricultural and livestock sectors account for over 85 percent of the labor force. Given the
country's agriculture-centered economy, Ethiopia is particularly vulnerable to the adverse effects
of fluctuations in commodity prices (especially coffee), and drought, which is frequent. 128 (See
Food Security section below.) Soil degradation caused by overgrazing, deforestation, high
population density, and poor infrastructure also render it difficult and expensive to get goods to
market. 129
Ethiopia’s current land rights system derives from the 1994 constitution, which states that land is
exclusively state property. The constitution further specifies that rural residents can have user
rights over the land. The administration of land and, thus, the specific rules and regulations
governing land tenure lie with the regions, which have the right to reallocate land. In recent
years, lease papers have been issued in some regions that provide some land tenure security for a
specified period. Lease papers cannot be sold or used as collateral. However, the sublease of land
is allowed and is frequent. Regions also provide leaseholding permits for urban land. 130
Studies indicate that farmers are not encouraged to invest in or conserve their land due to the
insecurity of land tenure. Related to this is growing population pressure that contributes to
diminishing farm size and soil degradation. 131 Landlessness, particularly among young people, is
a growing concern and a major determinant of rural poverty. Among the consequences of
landlessness is increased migration of landless youth to nearby cities, placing considerable
pressure on urban social services. 132
During the 1990s, the government embarked on a program of structural reform, including
privatization of state enterprises and rationalization of government regulation. Although the
process is still ongoing, the reforms have begun to attract much-needed foreign investment. 133
According to the World Bank, the extensive system of price controls has been almost entirely
dismantled, tax rates have been lowered, and some restrictions on the private sector have been
removed. 134 GDP growth did rise during the 1990s, from 2 to 5 percent. 135 However, per capita
income in Ethiopia fell during the 1990s. 136 Public expenditure on health increased only slightly,
from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998. 137 Several major health indicators either
fell or stagnated during the decade (see Health section below). The largely subsistence economy
cannot support high military expenditures (see Public Expenditure Trends section below),
drought relief, an ambitious development plan, and crucial imports such as oil; it therefore
remains highly dependent on foreign assistance. 138 The scope of poverty in the country remains
enormous.
Poverty
According to Ethiopia's 1999-2000 Household Income and Consumption Expenditure Survey, 44
percent of the population lives below the national poverty line. 139 With regard to international
poverty lines, in 1995, 31.3 percent of the population was living below US$1 a day and 76.4

HIV/AIDS in Ethiopia 39
percent of the population was living below US$2 a day. 140 As mentioned above, per capita
income in Ethiopia fell during the 1990s. In 1990 it was US$160, in 1995 US$110, and in 2000,
US$100. 141 Concurrently, official aid fell by over 20 percent between 1995 and 2000. 142
Repeated and frequent shocks (such as drought and war) have meant that household assets have
been diminished if not depleted.
Ethiopia's poor tend to live in large households with high dependency ratios and relatively young
and uneducated household heads. Most poor households are in rural areas and depend almost
exclusively on agriculture for their income, with a few assets in the form of livestock holdings.
The poor in urban areas depend on casual labor and petty trade for their livelihoods. 143
Public Expenditure Trends
As a percent of GDP, military spending in Ethiopia is almost eight times greater than public
spending on health. According to UNDP, public expenditure on health increased only slightly
during the 1990s, from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998. However, military
expenditure as a percent of GDP rose from 8.5 in 1990 to 9.4 in 2000. 144 This rise is doubtlessly
related to the war with Eritrea as well as continuing tensions with the National Islamic Front in
Sudan and several groups in Somalia. 145
Examining military expenditures as a percent of the central government budget finds that in
1990, Ethiopia spent 39.8 percent of the budget on the military; this figure fell to 29.1 percent in
1990. However, this is still a massive percentage, as the accompanying indicator table
demonstrates. Arms imports in 2000 accounted for 20.5 percent of all imports, again an
extraordinarily large percentage when compared to regional and global figures. 146
Debt
During the 1970s and 1980s, Ethiopia's servicing of its public and publicly guaranteed debt
ranged from 4.2 to 16.9 percent of central government revenues. 147 In November 2001, Ethiopia
qualified for debt relief under the Enhanced Heavily Indebted Poor Countries Initiative (HIPC).
HIPC is not debt cancellation; rather it is a restructuring of debt repayment through provision of
grants. Ethiopia is required to continue servicing its debt. Moreover, HIPC does not preclude that
a country will have to continue to borrow indefinitely. Ethiopia, for example, is and will continue
to be heavily dependent on donors and foreign creditors. Several social justice NGOs, including
Christian Aid and Oxfam U.K., have calculated that Ethiopia will be paying almost as much in
debt service payments under HIPC as it was before HIPC. 148
Under HIPC, an estimated US$1.93 billion was committed to Ethiopia as total debt relief from
all its creditors. This is equal to US$1.275 billion in net present value (the present value of future
cash), of which bilateral donors are providing US$482 million, multilateral donors US$763
million, the IMF US$34 million, and the World Bank US$463 million. 149 The World Bank
projects that under HIPC, Ethiopia will save about US$96 million annually until 2021. It projects
that debt service as a percentage of exports will fall by over half, declining from 16 percent to 7
percent by 2003, and declining steadily thereafter to below 4 percent by 2021. The resources
made available by debt relief provided under the HIPC Initiative will be allocated to key

HIV/AIDS in Ethiopia 40
antipoverty programs, outlined in Ethiopia's poverty reduction strategy paper (which some claim
is simply a new name for structural adjustment programs). Poverty-targeted expenditures are
projected to increase from 10.9 percent of GDP in 2000-01 to 14.7 percent in 2001-02 and 15.5
percent 2002-03. 150
All these projections are predicated on assumptions made by the IMF and World Bank that
Ethiopia's real GDP growth will grow annually by 6.5 percent on average over the next 20 years
and that the country's export earnings will increase as coffee prices recover from 2002-03
onward after five years of steady decline. Other assumptions include that food and military
imports will decline. (See Public Expenditure Trends section below.) Gross domestic investment
flows are projected to increase steadily from 17 percent of GDP in 2000-01 to 22 percent by
2015-16. Foreign direct investment is projected to rise from 0.8 percent of GDP in 2000-01 to 1
percent by 2010-11 and to 1.4 percent by 2018-19. 151
Many NGOs have argued that these assumptions are highly unrealistic. Jubilee Plus, for
example, notes that HIPC assesses whether a country can afford to pay its debts by looking
primarily at its export earnings and often making very optimistic assumptions about them. For
countries such as Ethiopia, heavily dependent on one export commodity (coffee), this is
unrealistic, as it is vulnerable to external shocks such as changes in the price of and demand for
coffee as well as climatic fluctuations. 152 , 153
In September 2002, the World Bank and IMF themselves noted that although most commodity
prices are forecast to rise over the medium term:
...recovery would be slow and key export commodity prices of the HIPCs would remain
below the levels projected two years ago for quite some time. This will have adverse
effects on future export earnings of the HIPCs and hence on the debt and debt service-toexports
ratios. 154
The World Bank and IMF consider debt sustainable if its net present value is less than 150
percent of export earnings. In September 2002, the World Bank and IMF also noted that about
half of the 20 countries in the HIPC interim period (including Ethiopia) are expected to show
NPV of debt-to-export ratios in excess of the HIPC sustainability threshold at their completion
(or final approval) points, 155 again highlighting the fallibility of the assumptions that underlie
HIPC.
In its quest to qualify for HIPC, Ethiopia has had to undertake some activities that at least on
paper have resulted in increased attention to the poor, social services, and HIV/AIDS, as well
as consultation with civil society. For example, it was required to produce a poverty reduction
strategy paper (PRSP) and demonstrate how funds from HIPC would be used to finance social
sector services. Panos reports that in Ethiopia, some civil society groups believe that the
government undertook the PRSP solely to obtain debt relief rather than out of genuine
antipoverty commitment. They point to the lack of solid analysis and gaps in areas such as urban
poverty and conflict-prone pastoral areas. 156 As discussed in the Stigma section below, the PRSP
analysis of HIV/AIDS was flawed. However, the Ethiopian government would hardly be the first
that has sought to meet conditions imposed by the international financial institutions to obtain
financial assistance.

HIV/AIDS in Ethiopia 41
Ethiopia is currently in its interim HIPC period, 157 meaning that to qualify for the full amount of
debt relief available via HIPC, it must successfully implement its PRSP for at least a year. Other
criteria include:
strengthen public expenditure management, with an emphasis on reconciling monetary
and fiscal accounts starting in fiscal year 2001-02, and consolidate federal and regional
budgets for each fiscal year starting in 2002-03
introduce value-added tax by January 2003
complete financial restructuring of the Commercial Bank of Ethiopia and increase
competitiveness of the financial sector through a number of specific actions
improve competitiveness and efficiency of the fertilizer input market
increase the gross enrollment rate for girls in primary level from 40 to 50 percent and
reduce repetition rate at primary levels
increase DPT vaccination coverage to 50 percent and achieve a higher utilization rate of
health outreach facilities
combat HIV/AIDS through complementing the government's overall strategy with
increased distribution of condoms (by 6 million) throughout the country 158
These are all critical actions, but whether it is realistic to assume that they will be met in the near
term and permit release of HIPC funds to Ethiopia is questionable.
Food Security
In March 2003, the World Food Program reported that 11 million Ethiopians (about 16 percent
of the population) are currently targeted for food distribution between April and July 2003. An
additional 3 million people are at risk of starvation. 159
The current food crisis is on a par with (or may even exceed) that of the 1984-85 famine. 160 The
crisis has been triggered by rain failure. 161 Oxfam U.K. and the International Food Policy
Research Institute also point to structural causes of the famine, including:
1. poverty
2. (primarily past) poor governance (see below)
3. population pressure
4. vulnerability of Ethiopian farmers: Ethiopia's millions of small-scale farmers remain
rooted in subsistence agriculture. They are almost entirely dependent on the weather, and
the country is prone to drought three to four years out of every ten. Little investment has
been made in irrigation or other systems to manage water supply; only about 5 percent of
potentially irrigable land is irrigated.
5. poorly functioning markets 162 , 163
Ethiopia's transport and telecommunications infrastructure is among the least developed in the
world. There is no public market information system and no system for inspecting and certifying
products. There is virtually no commercial legal system available for enforcing contracts.

HIV/AIDS in Ethiopia 42
Consequently, transaction costs of marketing are very high. Only one-quarter of food produced
reaches the market. 164
Unlike in southern Africa, HIV/AIDS is not a major factor underlying the Ethiopian food crisis.
However, as mentioned in the Epidemiology section, the search for food and migration to food
aid distribution points does spur population dislocation, which may be accompanied by
regroupings of family units and exposure to new sexual networks. Malnutrition (already high in
Ethiopia) is increasing and further weakening the immune systems of people living with
HIV/AIDS, thereby contributing to higher rates of morbidity and mortality. 165 Famine is likely
to raise the opportunity cost of sending children to school. Girls, in particular, are affected. Lack
of food, coupled with a subsequent breakdown in family structure, may place more children on
the streets where they may be at higher risk of mistreatment, sexual exploitation, and physical
and emotional abuse (discussed in depth below). Women and girls may undertake sex work to
survive. They may also offer sex to workers involved in transporting and distributing food aid to
try and obtain preferential treatment in the distribution of supplies and services.
After a late 2002 mission to Ethiopia, Carol Bellamy, executive director of UNICEF, reported
that:
Clearly families are affected. They are first losing their livestock, secondly their crops.
Thus far, the human life component had not been as dramatically affected as the crop and
livestock [components], but the crops and the livestock are what will sustain human life.
166
Oxfam U.K. missions to Ethiopia have already reported massive livestock losses, rising grain
prices, the distress sale of household assets and livestock at depressed prices, migration,
increased labor competition leading to reduced wages, and rising malnutrition. 167
According to Save the Children U.K., in the northeastern highlands:
[T]here are fewer people now whose livelihoods are sustainable, there is an increasing
number who are vulnerable to external shocks and there is an unacceptably high number
who are basically destitute. We really do need to understand, it is not as if Save the
Children and other agencies and the Ethiopian government haven’t put in a lot of support
over the years but nevertheless the situation is still going in the wrong direction. 168
Human Development
One method of tracking human development in Ethiopia is to analyze trends in its Human
Development Index. The HDI was created by UNDP to measures average achievements in life
expectancy at birth; adult literacy and combined primary, secondary, and tertiary gross
enrollment ratios; and GDP per capita (most U.N. agencies are now calling this gross national
income [GNI]; details on its calculation can be obtained from the World Bank). An HDI of 0.800
or above = high human development; 0.500 - 0.799 = medium human development; less than
0.500 = low human development. 169

HIV/AIDS in Ethiopia 43
In 2000, Ethiopia's HDI value was 0.327, placing it among "low-human development" countries
and ranking it 168 out of the 173 countries for which UNDP calculated an HDI. Ethiopia's HDI
value is lower than that of the median for the world's least-developed countries (0.445) as well as
for sub-Saharan Africa (0.471). 170
A critical indicator of the well-being of children is the under-five mortality rate. In 2000,
UNICEF reports that Ethiopia had the world's 21st-highest under-five mortality rate: 174 deaths
per 1,000 live births. Although this is a vast improvement over the 1960 figure of 269, Ethiopia's
under-five mortality rate for 2000 exceeds that of all the world's least-developed countries (161)
and is about equal to the figure for sub-Saharan Africa (175). 171
Infant mortality, another key human development indicator, fell between 1960 (180) and 2000
(117). However, it still exceeds that of all the least-developed countries (102) and of sub-Saharan
Africa (108). 172
Another critical human development indicator is the maternal mortality ratio (MMR), the
number of deaths to women per 100,000 live births that result from conditions related to
pregnancy, delivery, and related complications. The 2000 EDHS estimated that the maternal
mortality ratio during 1994-2000 was 871 deaths per 100,000 women. (As the accompanying
indicator table shows, UNFPA estimates that Ethiopia's 2001 MMR was 1,800. This figure is a
continually revised consensus estimate of WHO, UNICEF, and UNFPA. 173 )
Health
Ethiopia's health expenditure per capita (both public and private) was US$4 to US$5 during the
1990s. This is far below the average for the region (US$37) and for all low- & middle-income
countries (US$73). 174 As mentioned above, public spending on health rose only slightly during
the 1990s, from 0.9 percent of GDP in 1990 to 1.2 of GDP in 1998. In 1998, private health
expenditure accounted for 2.4 percent of GDP. 175
The health system entails four tiers comprising primary health care units (PHCU), district
hospitals, zonal hospitals, and specialized hospitals. The PHCU is the frontline health facility and
is composed of one health center with five satellite health posts. 176 Ethiopia has three medical
training centers: Addis Ababa University, Jimma Institute of Health Sciences, and Gondar
College of Medical Sciences. It has 87 hospitals (11,685 beds), 257 health centers, 196 private
clinics, and 1,483 physicians 177 (about 1 for every 45,651 population). Brain drain is a major
problem, as many trained medical personnel leave the country after their required in-country
service. Reasons for emigration include low pay, difficult working conditions, lack of
opportunity for professional development, and insufficient autonomy. 178 AIDS-related morbidity
and mortality among health care staff may also be increasing workloads.
The health system in Ethiopia is severely underdeveloped. Transport constraints are severe. 179
According to WHO, only about 55 percent of Ethiopians have access to (i.e., live within 10 km
of) general health services. 180 The majority of the population resides in rural areas and has little
access to any type of modern health institution. 181 Given low incomes, low levels of education,
poor access to health services, and a highly uneven distribution of health facilities favoring urban

HIV/AIDS in Ethiopia 44
areas, Ethiopians' general health status is poor both in absolute terms and in comparison with
other African countries. 182 (See the accompanying indicator table.)
As the table shows, only 24 and 15 percent of the population, respectively, have access to safe
water and sanitation. 183 Only 10 percent of births are attended by trained health staff. 184 Against
a backdrop of chronic food insecurity, the nutritional status of the population is low; 47 percent
of children under five are malnourished. 185 The coverage for ante- and postnatal care is generally
very low. A large proportion of health workers are male, which further limits use of reproductive
health services by women. 186 During the 1990s, immunization coverage (DPT) fell from 49 to 21
percent and for measles, from 38 to 27 percent. 187 Also during that decade, life expectancy for
both males and females did not improve. 188 As discussed in the Human Development section,
infant and under-five mortality have fallen over the past 30 years, but still remain very high. 189
Approximately 75 percent of Ethiopia's land mass is malarious, rendering over 40 million people
at risk. Malaria affects about 4 to 5 million Ethiopians annually. 190
TB is discussed in the Impact section. Other major health problems include leishmaniasis,
leprosy, respiratory diseases, polio, measles, and diarrheal disease.
The health situation is particularly of concern as Ethiopia's population continues to grow rapidly.
Because of continued high fertility and declining (albeit still high) mortality (and despite
substantial AIDS mortality, discussed in the Impact section below), Ethiopia's population will
increase to over 170 million by 2050. The annual population growth rate is projected to be over 2
percent through 2025, after which it will fall to 1.3 during 2045-2050. 191
According to the MOH, national health service coverage has risen to 51 percent, from 30 percent
a decade ago. It notes that the accelerated training of health professionals has yielded
encouraging signs of deployment to rural areas. It states that the health system's major weakness
"lies primarily in its failure to bringing about behavioral change in the attitude of [the majority
of] Ethiopians toward personal and environmental hygiene." 192
This remark appears to place most responsibility for the health system's weaknesses on the
general population. It ignores the very low government spending on/investment in health care,
particularly in light of high military spending and of increased educational spending that favors
the better-off, as discussed below. It also ignores the myriad constraints the government and its
citizens face; for example, according to the U.N., Ethiopia has one of the lowest amounts of
water availability in the world. 193
Certainly, behavior change is a crucial component of improved health care, but the systemic
weakness of the public health care delivery infrastructure must also be noted. The central
government's devolution of responsibility for health care to regions and local entities has many
positive elements. However, whether regional and local governments can take on the
responsibility is questionable, given their own burdens. As private expenditure on health
represents 66 percent of all health care spending, 194 a major concern is that as the central
government reduces its role in health care delivery, with decentralization and privatization to fill
the gap, safety nets for the poor (especially those in rural areas and women) may be threatened.

HIV/AIDS in Ethiopia 45
Sexual & Reproductive Health
UNFPA ranks Ethiopia a category "A" country, meaning that it is furthest from achieving the
sexual and reproductive health and rights goals of the International Conference on Population
and Development (ICPD), held in Cairo in 1994. Group A countries have the greatest need for
external assistance and the lowest capabilities for mobilizing domestic resources to close this
gap. 195
As mentioned in the Human Development section above, Ethiopia's MMR is extremely high.
Fertility levels are also high; the total fertility rate (TFR: average number of children a woman
would have assuming that current age-specific birth rates remain constant throughout her
childbearing years, usually considered to be ages 15 to 49) during 2000-2005 is 6.75. 196 Ethiopia
is still in the early stages of demographic transition. 197 According to the U.N. Population
Division, the TFR will fall to 5.29 during 2010-2015, to 4.29 during 2020-2025; and to 2.55
during 2045-2050. 198
Childbearing begins early in Ethiopia. Physiological immaturity and inexperience associated
with child care practices influence maternal and infant health. Early childbearing also greatly
reduces women's educational and formal employment opportunities. According to the 2000
Ethiopian Demographic and Health Survey (EDHS), 16 percent of women ages 15-19 have
already become mothers or are currently pregnant with their first child. The percentage of
women who have begun childbearing increases rapidly with age, from 1 percent among women
age 15, to 40 percent among women age 19. Twice as many teenagers residing in rural areas as
in urban areas have begun childbearing. The level of teenage parenthood is also more than twice
as high among women with no education than among women with primary or higher levels of
education. Childbearing among teenagers is lowest in Addis Ababa (5 percent) and highest in the
Gambela Region (26 percent). 199
Over 50 percent of women age 30 and above first gave birth in their teens; even among the
cohort 20-24, a sizable proportion (44 percent) have had a birth before age 20. The median age at
first birth is 20 years for the youngest age cohort (age 25-29) for whom a median could be
computed and varies between 18 and 19 for the older cohorts, indicating a rise in the median age
at first birth during the most recent period. The median age at first birth is higher in urban areas
than in rural areas. Addis Ababa has the highest median age at first birth (21.7), followed closely
by Dire Dawa (21.4). The Amhara Region has the lowest median age at first birth (18). The
median age at first birth is 19 years among women with no education and increases to 20 years
among women with primary education and to 23 years among women with at least secondary
education. 200
Awareness of contraception is high: 81.5 percent of all women ages 15-49 and 86.1 percent of all
men ages 15-59 know at least one method of family planning. 201 However, current use of modern
contraceptive methods is very low at 6 percent (though this is double the figure of 3 percent for
1990). The major reason for nonuse of contraceptives is the desire for more children: among
those currently married, 41.8 percent of women and 64.7 percent cite this reason. Moreover,
when the 2000 EDHS surveyed currently married women nonusers of contraception who intend
to use in the future which methods they prefer to use, only 0.1 percent replied that they intended

HIV/AIDS in Ethiopia 46
to use the condom. (Men were not asked this question.) Hormonal methods (injectables and pill)
were the most frequently cited methods. 202
Granted, the condom is not particularly effective for family planning; however, it has been
central to HIV/STI prevention. Thus, dual protection (pregnancy and HIV/STI) and male
condom acceptability as a prevention method are critical issues for examination in Ethiopia.
The unmet need for family planning is very high: 35.8 percent of currently married women have
an unmet need for family planning, with 21.8 percent having an unmet need for spacing and 13.9
percent having an unmet need for limiting. Unmet need is higher among rural than urban women
(37.3 percent and 25.0 percent, respectively). The difference is more pronounced for unmet need
for spacing than for limiting. The overall unmet need for family planning is the highest in the
Amhara Region (40.9 percent) and the lowest in the Affar Region (12.3 percent). 203
The incidence of unsafe abortions is high and constitutes a major cause of maternal morbidity
and mortality. 204 According to WHO, more women die in Ethiopian hospitals from
complications arising from (illegal) abortions than from any other cause except TB. WHO
officials estimate that 70 percent of women admitted to Ethiopian hospitals after undergoing an
illegal abortion will die, and most of these deaths occur among women ages 16 to 20. 205
As mentioned, Ethiopia's population is young, with 44 percent under age 15. 206 A key issue is
delivering sexual & reproductive health information and services to young people, including
those who are unmarried. This is particularly crucial as the 2000 EDHS found that there has been
an increase in the percentage of never-married women over the last 10 years, from 18.0 percent
in the 1990 National Family and Fertility Survey to 24.0 percent in the 2000 EDHS. According
to the 2000 EDHS, among women, 70.0 percent of those ages 15-19, 26.9 percent of those ages
20-24, and 9.6 of those ages 25-29 have never been married. Among men, these figures are 96.6,
76.3, and 29.2 percent, respectively. 207
Sexually Transmitted Infections
There are no accurate serial prevalence data on STIs in Ethiopia. 208 STI surveillance is
practically nonexistent. Trend figures for STIs are available only for the Oromiya Region, where
the number of reported STI cases has declined continuously from 1994 to 1999. Data from RPR
testing for syphilis among ANC sentinel surveillance participants in Addis Ababa also show a
declining trend in syphilis infections (ENARP records); however, these estimates are based on
serial data for only three years. 209
Several recent studies indicate that prevalence of herpes simplex virus type 2 (HSV-2) is high
and may be fueling the HIV/AIDS epidemic. For example, studies conducted by researchers
from Addis Ababa University found high prevalence of HSV-2 in Addis and HSV-2 association
with HIV infection. Using two cross-sectional surveys, one community-based (June to
September 1996, n=506) and one factory-based (February to November 1997, n=657), they
found that in the first study, HSV-2 prevalence increased with age until 25 years, then leveled off
at 50 percent for both women and men. The same independent predictors of HSV-2 infection
were identified in men and women: older age, higher lifetime number of sexual partners, positive
HIV serology, and positive syphilis serology. 210

HIV/AIDS in Ethiopia 47
Only MSF-Belgium is supporting the syndromic management approach, which is currently
available in two regions: Addis Ababa (20 health centers) and the Tigrai region. The national STI
treatment guidelines, based on the WHO syndromic management guidelines, were developed in
May 2001. However, they have not been adequately introduced for national use. CDC-Ethiopia,
in collaboration with the MOH and the Ethiopian Health and Nutrition Research Institute, is
currently conducting research on validating the syndromic approach and developing clinical
algorithms and treatment guidelines. 211
Education
From the mid-1980s through the mid- to late 1990s, Ethiopia increased spending on education,
from 3.1 percent of GDP in 1985-87 to 4.0 percent of GDP during 1995-97. Education's share of
the government budget also rose, from 9.3 to 13.7 percent. 212 During the 1990s, Ethiopia
reduced illiteracy rates. Among adult males, the illiteracy rate fell from 62 to 53 percent; among
women, from 80 to 69 percent. Among young women, illiteracy fell from 66 to 52 percent, and
among young men, from 48 to 39 percent. However, as the accompanying indicator
demonstrates, illiteracy rates are still much higher than those for the entire sub-Saharan Africa
region, as well as for all low- and middle-income countries. 213
A worrisome trend is that within public expenditure on education, spending on preprimary and
primary education fell, from 51.5 in 1986-87 to 46.2 during 1995-97. Spending on secondary
education also fell during this period, from 28.3 to 23.7 percent of all public expenditure on
education. However, spending on tertiary education rose, from 14.4 to 15.9 percent. 214 Children
attending primary school are more likely to be from the poorest groups than from better-off
groups; those who are not yet or able to be in school are also disproportionately poor. Secondary
education shares this pattern, though the effect is not as pronounced as in primary education. The
poor do not benefit from the substantial subsidies to university education.
The education system in Ethiopia is characterized by inefficiency and low quality, with high
dropout rates, poor cognitive performance at all levels, low and declining levels of teacher
qualification, inadequate facilities, and scarce teaching materials. 215 The education sector is
undergoing rehabilitation. During the 1990s, enrollment stagnated, but it is beginning to increase.
The government's new educational policy places greater emphasis on technical and vocational
education at the secondary level. 216
Gender
Status of Women
UNDP measures gender inequality by using the unweighted average of three component indices:
life expectancy, education, and income. Its Gender-related Development Index (GDI) value
ranges from 0 (lowest gender equality) to 1 (highest gender equality). In 2000, UNDP calculated
Ethiopia's GDI value at 0.313, ranking it 142 out of 146 countries on this index. (For
comparison, GDI values range from 0.263 [Niger] to 0.956 [Australia].) 217

HIV/AIDS in Ethiopia 48
Although the constitution of 1994 guarantees gender equality and permits affirmative action,
implementation of the National Policy for Women is hindered by varying degrees of
commitment across regions. 218
Gender disparities in enrolment ratios and educational attainment levels are high, as seen in the
accompanying indicator table. According to the 2000 EDHS, the majority of Ethiopians have
little or no education, with females much less educated than males. Sixty-two percent of males
and 77 percent of females have no education, and 27 percent of males and 17 percent of females
have only some primary education. Less than 3 percent of males and 1 percent of females have
completed primary education only, and 6 percent of males and 4 percent of females have
attended, but not completed, secondary school. Only 3 percent of males and 1 percent of females
have completed secondary school or higher. The male-female gap in education is more obvious
at lower levels of education primarily because the proportion of males and females attending
higher levels of education is so small. 219
The status of women is low, both in absolute terms and when compared with men. 220 The
country's high MMR (see above) is also an indication not only of poor reproductive health, but of
women's low status and poor access to basic health services.
Sexual Negotiation
Data from the 2000 EDHS suggest that many Ethiopian women have little power in sexual
negotiation with their husbands. A sizable majority (84.5 percent) believe that a husband is
justified in beating his wife for at least one of the following reasons: if she burns the food, argues
with him, goes out without telling him, neglects the children, or refuses sexual relations with
him. Of all women, 50.9 percent believed that a husband is justified in beating his wife if she
refuses sexual relations. The differences are more notable by level of education and urban-rural
residence. 221
Polygyny is also a factor. The 2000 EDHS measured the extent of polygyny in Ethiopia by
asking currently married women whether their husband or partner had other wives and if so, how
many. Overall, 13.7 percent of currently married women in Ethiopia are in a polygynous union,
that is, married to a man who has more than one wife. Older women are more likely to be in a
polygynous union than younger women, presumably because husbands are more likely to marry
again when their wives get older. Polygyny is also higher among rural than among urban women
(14.6 percent and 7.0 percent, respectively). There are substantial regional variations in the
extent of polygyny. Polygyny is widely practiced in the Gambela (28.9 percent), Affar (24.4
percent), and SNNP (21.9 percent) regions. In the Amhara Region and in Addis Ababa, 2.1 and
2.4 percent of currently married women, respectively, are in a polygynous union. Among women
with no education, 14.6 percent are in a polygynous union; with primary education: 10.1 percent;
and with secondary or higher education: 5.1 percent. 222
Economic Autonomy
The 2000 EDHS found that younger women (ages 15-24) and older women (ages 40-49) are
somewhat more likely to make independent decisions about their earnings than women in the
middle age groups. Among currently married women, 62 percent reported that they alone make

HIV/AIDS in Ethiopia 49
the decisions about how their earnings will be used, whereas 32 percent replied that decisions are
made jointly with their husband/partner. Women with no children are more likely than women
with one or more children to make independent decisions on the use of their earnings and are
also more likely than other women to make joint decisions with someone other than their
husband. There are no significant differences between urban and rural women regarding
decisions about how their earnings will be spent. However, regional differences exist, with the
proportion of women making independent decisions ranging from 82 percent in the SNNP
Region to 35 percent in the Benishangul-Gumuz Region. Women were more likely to decide
jointly with their husband on how to spend the money they earn if they had completed at least
secondary school than if they had only primary education. 223
Other issues that render Ethiopian women vulnerable to HIV include rape, abduction, early
marriage, and female circumcision.
Harmful Traditional Practices
Female circumcision is widespread in Ethiopia: 79.9 percent of all women have been
circumcised. Urban (79.8 percent) versus rural (79.9) percent residence, education (no education:
80.4 percent; primary education: 78.4 percent; secondary or higher education: 78.2 percent); and
work status (not employed: 79.5 percent; employed for cash: 84.4 percent; employed but not for
cash: 77.3 percent) do not make any notable difference in the practice of female circumcision.
However, the practice is slightly lower among younger women. 224
There is also widespread support for female circumcision among Ethiopian women. Support is
greatly influenced by residence and level of education. Rural women (66.1 percent) are twice as
likely to support the practice as urban women (31.0 percent). Women living in Addis Ababa
(16.2 percent) and in the Tigray (25.3 percent) and Gambela (26.8 percent) regions are relatively
less likely to support the continuation of the practice than women in other regions. Women with
secondary and higher levels of education (18.6 percent) are also significantly less likely to
support the practice, compared with women with no education (67.0 percent) and primary
education (48.5 percent), as are women working for cash (56.1 percent), compared to
unemployed women (59.1 percent) and women employed but not for cash (62.7 percent) 225
Women interviewed in the 2000 EDHS who had at least one living daughter were asked about
the circumcision experience of their daughters. Over half of the women reported that at least one
of their daughters has been circumcised. Older, rural, and less-educated women are more likely
to have at least one circumcised daughter, compared with other women. Women with secondary
education or higher are least likely (26 percent) to have a circumcised daughter, compared with
56 percent among uneducated women and 36 percent among those with primary education.
There is substantial variation by region in the percentage of women with at least one circumcised
daughter, ranging from 94 percent among women in the Affar Region to 37 percent in the SNNP
Region. Women who are not employed are less likely than women who are employed to have at
least one circumcised daughter. Over half of the daughters were reported by their mothers to
have been circumcised before age one. Ninety-two percent of circumcisions were performed by a
traditional circumciser; a traditional birth attendant performed 6 percent; and less than 1 percent
were performed by another health professional. 226

HIV/AIDS in Ethiopia 50
In an effort to obtain basic information on the severity of female circumcision, women who have
been circumcised were asked whether their vaginal area was sewn closed. The same information
was asked about their most recently circumcised daughters. Only 2.9 percent of circumcised
women and 3.4 of their most recently circumcised daughters had had their vaginal area sewn
closed, suggesting that the most severe form of circumcision is not common in Ethiopia. 227
Trafficking of Women
Ethiopia's Ministry of Labor and Social Affairs recently reported that poverty and unemployment
are leading to a dramatic increase in the trafficking of Ethiopian women. 228 Trafficked women
are especially vulnerable to fraud and exploitation, including sexual abuse; lack of freedom of
movement; and poor access to sanitation, nutrition, and health care. Moreover, they are separated
from their families and spouses or regular sex partners. Disillusionment, despair, loneliness,
racial and cultural discrimination, marginalization, dangerous and demeaning work, lack of
recreational outlets, and uncertainty about employment and legal status can lead to risk
behaviors, such as casual sex without a condom and alcohol and drug use. All these factors
render them vulnerable to acquiring HIV. Trafficked women have little or no access to HIV/STI
information, VCT, or health services. Cultural and linguistic barriers exacerbate their lack of
access to such services.
The section below highlights gender disparities in knowledge of HIV/AIDS.
Knowledge of HIV/AIDS
General Knowledge
According to the 2000 EDHS, knowledge of HIV/AIDS is high among Ethiopians. However, as
is the case in many countries, women are less likely to have heard of HIV/AIDS (84.7 percent)
than men (95.5 percent). Among rural women, this figure is 81.9 percent, among urban women,
97.2 percent. Among rural and urban men, these figures are 94.9 and 98.8 percent, respectively.
Women residing in the Somali Region, and men residing in the Gambela Region are less likely
than residents of urban areas and other regions to have heard of HIV/AIDS. (In Addis, 99.0
percent of women and 97.9 percent of men have heard of HIV/AIDS.) 229 (Note that the
preliminary findings of Ethiopia's first behavioral surveillance survey also found high knowledge
of HIV/AIDS.)
Among those ages 15-19, 78.9 percent of women and 87.8 percent of men had heard of
HIV/AIDS. For ages 20-24, these figures rose to 85.4 and 97.3 percent, respectively. Among
those never married, 80.6 percent of women and 91.3 percent of men had heard of HIV/AIDS.
Among those who have ever had sex, 95.7 percent of women and 99.1 percent of men had heard
of HIV/AIDS. 230
Among those who had heard of HIV/AIDS, 72.2 percent of women and 89.5 percent of men
believed that HIV/AIDS can be avoided. In rural areas, these figures fell to 67.5 for women and
88.1 for men. The majority of women in Affar (54.5 percent) and Somali (58.5 percent) regions
do not believe that HIV can be avoided. Regionally, the highest percentage of men who did not

HIV/AIDS in Ethiopia 51
believe that HIV could be avoided was in Affar (38.1). Among never-married women, 30.9
percent did not believe that HIV could be avoided; among never-married men, 16.5 percent.
Among those ages 15-19, 66.6 percent of women and 79.8 percent of men believe that there is a
way to avoid infection. Among those ages 20-24, these figures rose to 73.8 and 89.3 percent,
respectively. Across the board, education improved respondents’ knowledge of HIV/AIDS and
belief that it could be avoided. 231
Most respondents (52.6 percent of women and 69.6 percent of men) spontaneously replied that
having sex with only one partner was the single most effective way to avoid contracting HIV.
Men were twice as likely as women to mention using condoms (35.6 percent and 17.1 percent,
respectively). Very few mentioned avoidance of mosquito bites (0.1 percent for women and 0.2
percent for men) or seeking of protection from a traditional healer (0.4 percent of women and 0.3
percent of men). However, 2.1 percent of women and 1.0 percent of men did mention avoidance
of kissing, and a sizable percentage of women and men also mentioned avoiding the sharing of
razors/blades (26.0 percent and 30.7 percent, respectively). 232
More men than women spontaneously responded that abstaining from sex (17.1 vs. 10.8 percent,
respectively), and avoiding sex with sex workers (18.4 vs. 10.2 percent) can help prevent the risk
of acquiring HIV. Abstaining from sex, using condoms, and limiting the number of sexual
partners have been identified as programmatically important ways to avoid the spread of
HIV/AIDS. Women were much less knowledgeable about programmatically important ways to
avoid contracting HIV than men. Only 36.8 percent of women (compared to 63.3 percent of
men) knew of two or three programmatically important ways to avoid HIV/AIDS. With regard to
specific ways to avoid HIV/AIDS, 33.5 percent of women and 60.0 percent of men mentioned
the use of condoms; 65.4 percent of women and 88.0 percent of men mentioned limiting number
of partners. Residence and education were the two most influential background characteristics on
respondents’ knowledge of programmatically important ways to avoid contracting HIV/AIDS.
Women and men residing in urban areas were much more likely to know of at least two
programmatically important ways, as were those with at least secondary education. 233
A major knowledge gap is mother-to-child transmission of HIV. Only 58.2 percent of women
(and 72.1 percent of men) knew that HIV can be transmitted from mother to child. 234 Another is
that 62.8 percent of women did not believe that a healthy looking person can have HIV/AIDS;
among men, this figure was 45.3 percent.
Source of Knowledge
For both women and men who had heard of HIV/AIDS, community meetings were the most
important source of information on HIVAIDS (80 percent and 71 percent, respectively). Men
were much more likely than women to have heard of AIDS on the radio and television. Friends
and relatives were also an important source of information on AIDS for both men and women, as
were health workers. Exposure to AIDS information on the radio was nearly four times as high
among urban than rural women and twice as high among urban than rural men. 235
Younger respondents were more likely to mention school as a source of information on AIDS.
Among all women and men, those never-married who had ever had sex, lived in urban areas, and

HIV/AIDS in Ethiopia 52
had some education were more likely to receive information on AIDS from the media than other
women and men. 236
Of those who have heard of HIV/AIDS, 25.5 percent of women and 48.4 percent of men
currently married or living with a partner have discussed HIV prevention with their spouse or
partner. Women ages 20-39 and men ages 25-49 are more likely to have discussed HIV
prevention with their spouse or partner. Discussion on this topic was also more common among
highly educated respondents than others. Twice as many urban than rural women and one and
half times as many urban than rural men had discussed HIV prevention with their spouse or
partner. Residents of Addis Ababa were the most likely to have had this discussion. 237
Stigma
Shinn reports that HIV "is essentially a verboten discussion topic even among relatives and
friends. The culture of secrecy, at least among those from the highlands, almost certainly
contributes to this situation. Talking openly and frankly about personal subjects is not part of
Ethiopian culture." 238
According to the 2000 EDHS, nearly twice as many women (16.3 percent) as men (9.1 percent)
who have heard of AIDS believed that the HIV positive status of a family member should remain
a secret. Younger women (15-24), those never-married, those residing in rural areas and in
Benishangul-Gumuz and Gambela regions, and those with little or no education are more likely
than others to believe that this information should be kept secret. Similar patterns are observed
for men by age and marital status, but in contrast to women, urban men and men with at least
secondary education are more likely to oppose making this information public. 239
Among those who have heard of AIDS, 45.3 percent of women and 50.1 percent of men are
willing to care for relatives with HIV in their house. Young respondents (15-19), never-marrieds,
urban residents, those living in Addis Ababa, and respondents with at least secondary education
are more willing than others to care for relatives with HIV/AIDS in their house. 240
The International Center for Research on Women is conducting research on HIV/AIDS-related
stigma in Ethiopia. It is working in Melka Oda, Shashemene Woreda, Oromiya Region as well as
in Addis Ababa, using key informant interviews with community leaders, in-depth interviews
with community members, and FGDs. Preliminary data found that 61 percent of those surveyed
reported that although they know that HIV is not transmitted casually, they would not buy food
from a vendor with HIV. Many respondents, again despite their knowledge, would separate
utensils, linens, and other household items used by the PWHA from those used by other
household members. 241
The persistence of concerns about casual transmission despite knowledge is linked to strong
fears of death and the severity of suffering that accompanies AIDS. The fear of death is so strong
that people avoid those suspected of having HIV, even when they know that HIV is not
transmitted casually. 242
Much of the stigmatizing language and description of stigmatizing and discriminatory

HIV/AIDS in Ethiopia 53
behavior centers on the sexual transmission of HIV. Respondents report that "those" with HIV
contract it through their own bad behavior, namely sexual activity that is not socially sanctioned
or goes against religious teachings. Respondents describe behaviors such as pre- and extramarital
sex and multiple partners as immoral and leading to HIV. Those who have HIV are
“promiscuous,” “careless,” or “unable to control themselves” and have brought HIV upon
themselves; they are also blamed for bringing it into the community. The belief that HIV is a
divine punishment for sins committed is particularly strong. 243
Over 70 percent of respondents in the ICRW study believe that PWHA are at fault, deserve what
they got, or should feel guilty; yet at the same time, they feel that PWHA deserve sympathy or
support. There is a call for PWHA to go public and “teach” and be an “example” to others.
Concurrently, respondents note that most people would fear disclosing an HIV-positive status
because of how they would be treated and viewed by others. They feel that family and
community need to be more open and supportive to make disclosure easier. Respondents state
that people rarely find out about someone’s HIV-positive status through a PWHA's own
disclosure and usually infer status through change in behavior, symptoms, or weight loss. 244
ICRW highlights that these contradictions are an indication of the "elusive and pervasive nature
of stigma and how it will be difficult to diminish." Some of this stigmatizing behavior is caused
by limited resources and fatigue. Although family and community members provide care, they
often regard PWHA as a burden. The feeling of burden is fueled by the knowledge that there is
no cure and the belief that PWHA will soon die. Communities tend not to acknowledge the
capabilities of PWHA. In some cases, PWHA are described as “useless” and “worthless.” The
perception of PWHA's being “worthless” is attributed to the commonly held belief that they
could not or should not work hard because of the detrimental impact on their health. 245 The
Medical Missionaries of Mary Counseling & Social Services Center, which provides support to
PWHA and their families in Addis, has also found that those who provide care to PWHA are
themselves stigmatized. 246
In discussing HIV/AIDS in its 2002 poverty reduction strategy paper, Ethiopia's Ministry of
Finance and Economic Development advocates that "There should be a mechanism for close
follow-up of commercial sex workers since they are the most vulnerable and risk group of the
society [sic]." 247 No other group is singled out for any such follow up. Indeed, several
paragraphs down, the PRSP states:
m) Emphasis on High-Risk Groups
To fully cover and provide educational and preventive efforts to high risk groups such as
commercial sex workers [bold is part of original document] and their clients, mobile
groups (long distance truck drivers, military personnel) youth groups, street children,
refugee, prisoners and others within the coming five years. This strategy will have
positive impact on the economy higher proportions of the transmissions occurs in these
groups. 248
Further down, the PRSP states that SWs are "more likely to abuse substances," 249 although there
is no reference provided. This assertion is not found in MOH documents or in any other
materials the present author consulted on HIV/AIDS in Ethiopia. It may be an unpublished,

HIV/AIDS in Ethiopia 54
preliminary finding from Ethiopia's first behavioral surveillance study (see below), which did
find that 47 percent of respondents (which included sex workers) had ever tried drugs. 250
However, why sex workers were singled out on drug use in the PRSP is unclear.
This treatment of SWs in a key, national document one on which debt relief and other
assistance from the World Bank and IMF are predicated is worrisome, as it appears to lay
blame for HIV transmission on SWs and thus women. It also minimizes married, monogamous
women's risk of acquiring HIV.
This type of demonization of SWs is not present in the Ethiopian MOH's two most recent major
AIDS reports. 251 , 252 This suggests that although the Ministry of Finance and Economic
Development states that it consulted with a wide array of stakeholders in creating the PRSP, its
consultation with the MOH and HIV/AIDS experts was very superficial and/or it simply is not
interested in understanding the epidemic. Either scenario does not bode well for ensuring that
HIV/AIDS is integrated into the country's macroeconomic and poverty reduction planning.
Sexual Behavior
There is an acute need for data on sexual behavior trends in Ethiopia. Two large, nationwide
studies on sexual behavior were conducted in 1987-88 and 1993; however, their findings are not
comparable because of differing methodology and survey instruments. Some serial data on the
proportion of students who use condoms are available for Addis Ababa and Gondar only;
however, again, the various (small-scale) studies did not follow similar methods and did not use
similar instruments.
Ethio-Netherlands AIDS Research Project Factory Worker Cohort
The Ethio-Netherlands AIDS Research Project followed a cohort of male workers (n=1,124) at
two factories near Addis Ababa between February 1997 and December 1999. In early 2003, the
project published data demonstrating a decline in risky sexual behaviors reported by cohort
participants; part of this decline occurred independently of cohort interventions. At baseline, the
prevalence of casual sex in the past year, sex with sex worker, condom use with last casual
partner, history of genital discharge in the past five years, and history of genital ulcer in the past
five years were 9.7, 43.4, 38.8 (Akaki site only), 10.6, and 2.1 percent, respectively. At the
Wonji site, the baseline prevalence of casual sex, sex with sex worker, and history of genital
discharge decreased significantly by calendar year between 1997 and 1999. At both sites
combined, between the first and the fourth follow-up visits, there was a decline in the proportion
of males reporting recent casual sex (from 17.5 to 3.5 percent, p < 0.001), sex with sex worker
(from 11.2 to 0.75 percent, p < 0.001), and genital discharge (from 2.1 to 0.6 percent, p =
0.004). 253
Behavioral Surveillance Survey
Between December 2001 and June 2002, Ethiopia undertook its first behavioral surveillance
survey. Addis Ababa University’s Department of Community Health implemented the first round
of the BSS with technical support from Family Health International. The BSS involved over

HIV/AIDS in Ethiopia 55
30,000 respondents in rural and urban areas in every region of the country, including in- and outof-school
youth, female sex workers, military personnel, farmers and pastoralists, long-distance
drivers, and factory workers. Preliminary findings include:
About 98 percent of the study population is aware of HIV/AIDS.
Almost all groups know at least one HIV prevention method.
Nearly 60 percent know all three programmatically important prevention methods.
Knowledge of prevention methods increases with the number of media source for AIDS
messages.
Nearly two out of three young people out of school reported that they are sexually active
and had sex with two or more partners in the last year.
In some areas, sexually active girls out of school are more likely than boys to report
multiple partners.
Condom accessibility and cost are not barriers to condom use among most groups.
Condom use is high among sex workers.
Significant proportions of respondents do not always use condoms with nonregular
partners, though they know that condoms can prevent HIV transmission.
A little over one out of five married respondents who have had multiple sex partners in
the last 12 months do not always use a condom.
Forty-seven percent of respondents have ever tried drugs.
About two-thirds of respondents who consume khat at least weekly and drink alcohol
once a week have had recent unprotected sex with a nonmarital partner.
Commercial sex is more common among mobile men with money.
Noncommercial sex is relatively very high among in and out of school youth.
Misconceptions about HIV/AIDS transmission remain high in almost all groups and
regions.
Misconceptions about HIV/AIDS are high irrespective of level of knowledge.
Own-risk perception is very low in almost all target groups.
Most respondents who had unprotected sex with nonmarital partners do not feel that they
are at risk.
Despite a high level of knowledge, a significant proportion of the population, particularly
youth, is at high risk of HIV infection. 254
Once the BSS findings are released, they will be integrated into this paper. Below are findings
from Ethiopia's 2000 Demographic and Health Survey.
2000 EDHS
Age at First Sexual Intercourse
According to the 2000 EDHS, the median age at first intercourse for women ages 20-49 is 16.4
years. Among these women, 27.2 percent of women have had sexual intercourse by age 15, 64.2
percent by age 18, and 87.6 percent by age 25. Over two-thirds (69.3 percent) of women ages 15-
19 report never having had intercourse. This proportion declines to 24.6 percent for women ages
20-24 and to 7.4 percent for ages 25-29. 255

HIV/AIDS in Ethiopia 56
The median age at first sexual intercourse among men is 20.3 years, three years lower than their
median age at first marriage (23.3 years). Among those 15-19, 84.6 percent report never having
had intercourse, falling to 46.8 percent for ages 20-24 and 14.9 percent for 25-29. 256
The median age at first intercourse is lower among women in rural areas than in urban ones. The
age at first sexual intercourse increases with women’s education but decreases with men’s
education. For example, women with at least some secondary education initiate sex four years
later than women with no education; however, men with at least secondary education initiate sex
two years earlier than men with no education. 257
Age at First Marriage
The median age at first marriage for all women ages 25-49 is 16.0. The median age at first
marriage among women in Ethiopia has risen slowly over the last two decades, from 15.8 for
women ages 30-49 to 17.2 for women ages 25-29 and to 18.1 for women ages 20-24. There has
been a sharp decline in the proportion of women married in their early teens; the percentage of
women married by age 15 has declined from 35.1 percent among women ages 35-39 to 14.4
percent among those currently between 15 and 19. 258
Overall, urban women ages 20-49 marry about 1.5 years later than rural women. The median age
at first marriage among women ages 25-49 varies significantly by region, ranging from 14.3
years in Amhara to 19.4 years in Dire Dawa. There is a strong relationship between education
and age at marriage. Women ages 25-49 with at least secondary education marry 5.4 years later
than women with no education. 259
The median age at first marriage for men is 23.3 years. Men in all age groups tend to marry
much later than women; for example the median age at first marriage for men ages 25-29 is 23.2
years, compared with 17.2 years for women in the same age group. 260
Sexual Activity
In Ethiopia, 62.8 percent of all women and 55.7 percent of all men are currently married. Among
women, 2.5 percent are divorced, 6.2 percent separated, and 3.6 percent widowed. For men,
these figures are 1.0, 2.6, and 0.5 percent, respectively. 261
About one-half (50.8 percent) of all women were sexually active during the four weeks
preceding the 2000 EDHS, and 22.8 percent had never had sexual intercourse. The proportion of
women who were sexually active in the four weeks prior to the survey increases with age up to
30-34 and declines thereafter. Higher proportions of rural women (54.8 percent) were sexually
active than urban women (32.6 percent). (NB: A higher proportion of urban women ages 15-49
are unmarried than rural women.) Among men, 47.0 percent were sexually active in the four
weeks prior to the survey, 29.2 percent had never had sex. 262
Among those married, 98.5 percent of women and 92.6 of men reported sexual intercourse only
with their spouse in the 12 months preceding the survey. Sexual intercourse with multiple
partners was higher among women ages 15-19 and men ages 40-49, urban women and rural men,
female residents of the Benishangul-Gumuz Region, and male residents of the Gambela Region.
There was little difference in sexual activity by educational level of women; however, men with

HIV/AIDS in Ethiopia 57
little or no education were more likely to have had sexual intercourse with multiple partners than
men with at least secondary education. 263
Among those unmarried, 12.9 percent of women and 22.3 percent of men reported sexual
intercourse in the last year. Of them, 1.1 percent of women and 5.4 percent of men had two or
more sex partners. Multiple partners among unmarried persons was relatively more common
among women age 20 and above than among women ages 15-19, urban women, those residing in
the Amhara and Affar regions, and women with little or no education. Among men, sexual
intercourse with multiple partners was more common among those ages 20-49, in urban areas,
among those residing in the Affar Region, and among those with at least secondary education. 264
Transactional Sex
As previously mentioned, among women, AIDS cases peak between ages 20 and 29; for men,
between ages 25 to 34. 265 This is likely related to age mixing, wherein young women have older
male sex partners, primarily for economic reasons. 266
There are no data on transactional sex in Ethiopia. 267 , 268 Poverty, conflict, drought, and famine
may increases instances in which sex is traded for food or other necessities.
Condoms
Knowledge
According to the 2000 EDHS, only 34.8 percent of all women know about condoms; the
comparable figure for men was 67.8 percent. For urban women, this figure was 86.0 percent and
for rural women, 23.5 percent; for men, the comparable figures were 97.1 and 62.8 percent,
respectively. Women ages 25-29 had the highest knowledge of condoms (39.6 percent), followed
by those ages 20-24 (37.3 percent). For men, those ages 25-29 also had the highest knowledge of
condoms (76.0 percent), but were followed by those ages 30-39 (75.6 percent). 269
Among never-married women, 41.7 percent knew of condoms, whereas this figure was 66.0
among men. Among those who had ever had sex, 82.7 percent of women and 84.9 percent of
men knew about condoms. For both men and women, knowledge was highest in Addis (97.0 and
94.2 percent, respectively) followed by Dire Dawa (where the gender difference became more
pronounced: 92.6 percent of men vs. 74.8 percent of women). For men, the regions with the next
highest percentages of those who knew about condoms were Tigray (82.9 percent) and Harari
(78.5 percent); for women, Harari (64.5 percent) and Tigray (53.4 percent). 270
Knowledge of condoms varied widely by background characteristics. Respondents who were
urban, ages 25-39, never-married, who had ever had sex, and with at least secondary education
were more likely than their counterparts to know about condoms. 271
Women were also asked whether they knew a source for condoms and could obtain condoms for
themselves. Only 12.1 percent of women knew a source for condoms and only 11.1 percent
reported that they could obtain condoms for themselves. The rural-urban differential was very

HIV/AIDS in Ethiopia 58
wide (6.6 percent vs. 36.6 percent on source and 6.0 percent vs. 34.2 percent on ability to
obtain). Regionally, the lowest figures were found in SNNP (5.6 percent on source and 4.9
percent on ability to obtain). Education was positively associated with both these variables,
although note that still, among women with at least secondary or higher education, only 41.3
knew a source for condoms and only 38.2 could obtain one. 272 These findings appear to diverge
from those of the BSS. Again, once the final BSS findings are released, they will be incorporated
into this paper.
Use
Generally, condom use in Ethiopia is low. (NB: The BSS appears to have found that it is high
among sex workers.) According to the 2000 EDHS, the use of condoms during last sexual
intercourse with a spouse or cohabiting partner was negligible among both women (0.4 percent)
and men (0.1 percent). With a noncohabiting partner, 13.4 percent of women and 30.3 percent of
men did use a condom at last intercourse. Condom use with a noncohabiting partner was much
more common among men and women who were never-married, urban, and had at least
secondary education; women under 30 and men ages 30-39 were also more likely to have used a
condom with a noncohabiting partner at last intercourse. 273
Currently, over 80 percent of condom sales and distribution are handled through DKT-Ethiopia.
Since 1990, there has been a progressive increase in the sale and distribution of condoms, from a
baseline figure of 699,500 to 41.8 million in 1999. About 20 percent of all sales and distribution
occur in Addis Ababa. 274
Sex Work
Several HIV serosurveys among sex workers have been conducted since the beginning of the
epidemic (as discussed in the Epidemiology section). The most recent, the 1998 study of 372 sex
workers in Addis Ababa, found that most SWs were from the city's slums and that about 35
percent lived in "shared rooms," renting a small room in which three to five women live. These
SWs must give about half their income to the owner of the room. 275
Family Health International notes that estimates of the number of sex workers in Addis Ababa
range from a few thousand to 150,000. To address the lack of data on numbers of sex workers,
their networks, and organization, FHI is working with local partners to conduct a mapping of sex
workers in Addis Ababa. 276
Alcohol and Drug Use
In March 2003, Dr. Bulti Gutema, who heads the Children, Youth and Family Welfare
Department in the Ministry of Labor and Social Affairs, stated that:
The problems of Ethiopian youth are many, complex and inter-related. Because of their
limited access to training and educational opportunities and the acute shortage of
recreation and sport centers, they fall victims to drug and alcohol abuse, delinquency and
criminal activities. 277

HIV/AIDS in Ethiopia 59
According to the U.N. Office on Drugs and Crime, recreational drug consumption in Ethiopia is
increasing, including among street children in Addis Ababa and in the city's slum areas. Young
people are the main consumers of cannabis (which is illegal), used for recreation as well as in
certain religious rites and for curative purposes. Khat has been used for centuries in the eastern
part of the country, and is currently consumed throughout Ethiopia. Cultivation and consumption
of khat which are increasing are legal, though the government discourages them. Khat
abuse begins at a young age. Some heroin abuse has been recorded, though to a very limited
extent vis-à-vis cannabis and khat. 278
Although the U.N. does not believe that Ethiopia is important with regard to money laundering,
precursor chemicals, or production of narcotic drugs, it is a prime target for drug trafficking
(most drugs transiting Ethiopia are mainly destined for Europe and, to a lesser extent, the U.S.).
The country has no central body coordinating antidrug activities; resources allocated to antidrug
activities are grossly insufficient. 279
Although there are no data on drug trafficking and abuse and the Ethiopian-Eritrean conflict, the
U.N. does highlight that armed conflicts throughout the world have led to rapid spread of drug
control problems in affected zones, with the military often involved in illicit trafficking and
selling; another result of conflict has sometimes been the growing drug abuse of inhabitants of
affected regions. 280
Male Circumcision
There are no data on male circumcision in Ethiopia. 281 , 282 Some observational studies from sub-
Saharan Africa have indicated that male circumcision may reduce the risk of HIV acquisition, 283 ,
284 though circumcision does not appear to affect transmission from HIV-positive men to their
partners. 285 The limitations of these studies have been highlighted, and further study is needed
on both biomedical and sociobehavioral issues before promoting male circumcision as a public
health intervention.

HIV/AIDS in Ethiopia 60
Impact
At a Glance
The At a Glance section summarizes the more detailed data found below it.
There are few data on the impact of HIV/AIDS in Ethiopia.
Demographic
AIDS is now recognized as the leading cause of adult morbidity and mortality in the
country.
Ethiopia's population will be up to 16 percent smaller than it would have been in a "no-
AIDS" scenario. Factors include AIDS deaths, as well as reduction in fertility due to condom
use to prevent infection, fewer births because of a smaller reproductive age population, and
fertility reduction associated with HIV infection.
AIDS will reduce life expectancy by 9 to 13 percent through 2050.
AIDS has already increased the number of deaths in Ethiopia by 6 percent. Between 2000
and 2015, it will increase the number of deaths in Ethiopia by 27 percent.
By the end of 2002, 1.7 million Ethiopians had died because of AIDS. By 2014, there will be
a cumulative total of 5.3 million AIDS deaths.
Macroeconomic
There have been almost no studies of the impact of the epidemic on loss of skilled or
unskilled labor, lost productivity because of illness or funeral attendance, or increased health
care costs. The impact of AIDS on the rural economy is unknown.
Health Sector
Currently, up to 42 percent of all hospital beds in the country are estimated to be occupied by
AIDS patients.
According to WHO, Ethiopia has the sixth-highest number of TB cases in the world.
TB notification rates (all cases) increased from 40,096 in 1980 to 91,101 in 2000.
WHO estimates that 42 percent of adult (15-49) TB cases were HIV-positive during 2000.
Household
There are no reports on the impact of AIDS on Ethiopian households, particularly its effect
on the extended family system. Given deep and persistent poverty in Ethiopia, HIV/AIDS
will further strain coping mechanisms through its enormous and complex impact.
As AIDS severely affects the most economically active members of the household, income
and consumption patterns are likely to change dramatically, reducing or depleting income,
savings, and remittances, and increasing expenditures on care and funerals.

HIV/AIDS in Ethiopia 61
Drought is depleting households assets, which may in turn be further reduced to pay for
AIDS care (especially as most health care expenditure in Ethiopia is in the private sector);
transport to reach care providers; burials; and household necessities.
HIV/AIDS also exacts an enormous psychosocial toll. Those who are most involved in care
of AIDS patients may be more prone to stress and anger, emotions that may be made
manifest in ways that convey stigma or discrimination toward PWHA.
Households that are headed by a single parent, have only one breadwinner, and/or have more
than one HIV-infected member are particularly vulnerable to economic and psychosocial
shocks.
Female-headed households tend to be poorer than those headed by men and thus have fewer
resources with which to respond to HIV/AIDS. In Ethiopia, 24 percent of households are
headed by women; in rural areas, this figure is 35 percent.
Moreover, women are traditional caregivers and thus take on additional responsibilities when
family members become ill. And in single-parent households or those in which one parent
has already died, girls are more likely than boys to provide care. Curtailing girls' education
(and thus potential for formal labor force participation) may render them more vulnerable to
acquiring HIV.
Orphans and Other Vulnerable Children
At the end of 2001, there were 1.2 million AIDS orphans in Ethiopia. This number is
projected to rise to 1.8 million by 2007 and to 2.5 million in 2014. There are insufficient
social services for AIDS orphans, including health care, school fee subsidies, and shelter.
Consequently, many become street children.
Orphans are particularly vulnerable to malnutrition, illness, abuse, child labor, and sexual
exploitation. Concurrently, they suffer HIV/AIDS-related stigma and discrimination, not just
from their relatives and communities, but also health service providers and teachers.
In Ethiopia, there are few governmental institutions for orphans, as extended families have
usually taken them in. These families are themselves likely to be poor and must therefore
stretch already inadequate resources to provide for both orphans and their own children.
As extended families' own AIDS burdens constrain their ability to foster orphaned children,
orphans may be become heads of households and responsible for caring for younger siblings.
There are few data on the impact of HIV/AIDS in Ethiopia. Shinn reflects that "persons who
follow the issue closely are unanimous that the impact has been horrendous. They just do not
know how horrendous." 286
Demographic
Ethiopia's mid-2002 population was 67.7 million; 287 50.3 percent of the population is female. 288
The U.N. Population Division examined population under a "no-AIDS" scenario. Because of
continued high fertility and declining (albeit still high) mortality, Ethiopia's population will
continue to increase substantially, to over 170 million by 2050. However, the population will be
up to 16 percent smaller than it would have been in a "no-AIDS" scenario. (tables 3 and 4). 289
Factors include AIDS deaths, as well as reduction in fertility due to condom use to prevent

HIV/AIDS in Ethiopia 62
infection, fewer births because of a smaller reproductive age population, and fertility reduction
associated with HIV infection. 290
Table 3. Projected Population with and without AIDS, 2000, 2015, and 2050 (Thousands)
Period
2000 2015 2050
With AIDS Without AIDS With AIDS Without AIDS With AIDS Without
AIDS
65,590 66,973 93,845 101,835 170,987 203,423
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
Population
Reduction
(Thousands)
Table 4. Projected Population Reductions, 2000, 2015 AND 2050
Period
2000 2015 2050
Percentage Population Percentage Population
Reduction Reduction Reduction Reduction
(Thousands)
(Thousands)
1,383 2 7,989 8 32,436 16
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
Percentage
Reduction
Life Expectancy
Table 5 indicates that although Ethiopia's life expectancy is projected to increase, AIDS will
reduce life expectancy by 9 to 13 percent through 2050. 291
Table 5. Life Expectancy with and without AIDS, 2000-2005, 2010-2015, and 2045-2050
Period
2000-2005 2010-2015 2045-2050
With Without Reduction Percentage With Without Reduction Percentage With Without Reduction
AIDS AIDS in Life Reduction AIDS AIDS in Life Reduction AIDS AIDS in Life
Expectancy
Expectancy
Expectancy
45.5 52.5 7 13 48.2 56.5 8 15 63.2 69.5 6 9
Percentage
Reduction
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002
Revision. Highlights. New York: February 2003
(NB: The figures for 2000-2005 and 2010-2015 in the table above are higher than those
estimated by the U.S. Bureau of the Census. The Census Bureau figures, released in July 2002,
indicate that life expectancy in Ethiopia was 41.6 in 2002, whereas it would have been 53.1
without AIDS; the comparable Census figures for 2010 were 40.1 and 56.3, respectively. 292 )

HIV/AIDS in Ethiopia 63
AIDS Mortality
AIDS is now recognized as the leading cause of adult morbidity and mortality in the country. 293
The MOH projects that by 2004, AIDS may account for about 460 deaths each day among 15- to
49-year-olds. 294
According to the U.N. Population Division, AIDS has already increased the number of deaths in
Ethiopia by 6 percent. By 2000, 1.1 million Ethiopians had died because of AIDS. 295 In 2001,
UNAIDS estimated that were 160,000 adult and child AIDS deaths in Ethiopia. 296 Ethiopia's
MOH estimates that by the end of 2002, 1.7 million Ethiopians had died because of AIDS. It
projects that by 2014, there will be an additional 3.6 million deaths because of AIDS, bringing
the cumulative total to about 5.3 million by 2014. 297
This projection is roughly equal to the latest estimates of the U.N. Population Division, which
projects 5.224 million cumulative AIDS deaths through 2015. Between 2000 and 2015, AIDS
will increase the number of deaths in Ethiopia by 27 percent. The U.N. projects that by 2050,
14.851 million Ethiopians will have died because of the epidemic. (tables 6 and 7.) 298
Table 6. Projected Number of Deaths with and without AIDS, 1980-2000, 2000-2015, and
2015-2050 (Thousands)
Period
1980-2000 2000-2015 2015-2050
With AIDS Without AIDS With AIDS Without
AIDS
With AIDS Without
AIDS
18,957 17,864 19,652 15,521 50,071 40,444
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
Excess
Deaths
(Thousands)
Table 7. Excess Deaths Because of AIDS, 1980-2000, 2000-2015, and 2015-2050
Period
1980-2000 2000-2015 2015-2050
Percentage
Percentage
Increase
Increase
Excess
Deaths
(Thousands)
Excess
Deaths
(Thousands)
1,092 6 4,132 27 9,627 24
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
The U.S. Bureau of the Census's projection of the impact of HIV/AIDS on infant and child
mortality in Ethiopia is found in Table 8.
Percentage
Increase

HIV/AIDS in Ethiopia 64
Table 8. Infant and Child Mortality with and without AIDS, 2002
and 2010
Indicator 2002 2010
With
AIDS
Without
AIDS
With
AIDS
Without
AIDS
Infant Mortality Rate (deaths per 104.3 92.1 94.9 77.9
1,000 live births)
Under-Five Mortality Rate (deaths 169.9 150.0 150.8 123.3
per 1,000 live births)
Source: K. A. Stanecki. The AIDS Pandemic in the 21st Century. Washington, DC:
U.S. Bureau of the Census, July 2002. Draft report prepared for the XIV
International AIDS Conference, Barcelona, July 7-12, 2002
.
Research undertaken by UNAIDS and WHO found that for Ethiopia, the HIV-attributable under-
5 mortality rate (per 1,000 and corrected for competing causes of mortality) was 15.8 during the
1990s. (Rates among the 39 countries studies ranged from Madagascar [0.2] to Botswana [57.7].)
The HIV-related population proportional attributable risk of dying before age 5 (i.e., the
proportion of all-cause under-5 mortality attributable to HIV) was 8.1 percent; the average for
the 39 sub-Saharan African countries studies was 7.7 percent, ranging from 0.1 percent in
Madagascar to 42.4 percent in Botswana. 299
Although the impact of AIDS in Ethiopia has been far less intense than that seen in the hardesthit
southern Africa countries, it has been substantial and has eroded critical gains in human
development.
Macroeconomic
There was a study conducted on 1994-95 on the direct and indirect costs of HIV/AIDS. Kello
estimated that for 1997-2000, the direct medical costs of HIV/AIDS ranged from US$32 million
to US$49 million (low-cost scenario). Income loss as a result of premature death was estimated
at 23 to 42 percent of GNI. (The present author was not able to secure details on the methodolgy
used by Kello.) Since the Kello study, there have no others on the effect of the epidemic on loss
of skilled or unskilled labor, lost productivity because of illness or funeral attendance, or
increased health care costs. The impact of AIDS on the rural economy is unknown. 300
In Ethiopia's 2002 poverty reduction strategy paper, the Ministry of Finance and Economic
Development stated:
HIV/AIDS will also put a significant pressure on the country's limited foreign exchange
reserves. As the epidemic accelerates, the country will be forced to import more and more
of antiretroviral drugs which will certainly crowd out other imports of the country in a
situation where the foreign exchange generating capacity of the economy shows no sign
of significant improvement. 301

HIV/AIDS in Ethiopia 65
Certainly, the foreign exchange requirements to import drugs would be very large if all AIDS
patients received complete drug treatment. 302 However, the Ministry of Finance and Economic
Development's statement seems odd, as the government has not as yet provided ART and has not
released firm numbers with regard to projected coverage. Moreover, any ART expenditures, at
least in the next five years or so, would seemingly be heavily subsidized by loans or grants from
the World Bank and the Global Fund to Fight AIDS, TB & Malaria (discussed below).
Health Sector
Currently, up to 42 percent of all hospital beds in the country are estimated to be occupied by
AIDS patients. By 2004, the MOH projects that over half (54 percent) of all hospital beds will be
occupied by AIDS patients (assuming current number of hospital beds remains constant). 303
HIV and Tuberculosis
According to WHO, Ethiopia has the sixth-highest number of TB cases in the world. In the
Africa region, it is second only to Nigeria. In 2000, there were 249,457 active, reported TB cases
(of which 104,734 were smear-positive). TB incidence (all cases) in 2000 was 397 per 100,000
population. The case rate was 114 per 100,000 population in 1980, 177 in 1985, 187 in 1990, 47
in 1995, and 145 in 2000. TB notification rates (all cases) have increased from 40,096 in 1980 to
71,731 in 1985 to 88,634 in 1990 to 91,101 in 2000. The notification rate for new, smearpositive
cases rose from 11 per 100,000 population in 1993 to 48 in 2000. 304
WHO estimates that 42 percent of adult (15-49) TB cases were HIV-positive during 2000. 305 TB
is the most common OI in Ethiopia.
DOTS was introduced in 1995. 306 At the end of 2001, about 875 of 2,563 (34 percent) health
facilities were using DOTS. Given that only about 55 percent of Ethiopians have access to (i.e.,
live within 10 km of) general health services, DOTS expansion will be very difficult. 307 WHO
has also identified the following constraints:
TB and HIV teams are not collaborating sufficiently.
The TB Program is highly donor-dependent and its future sustainability questionable
NGOs, including the private sector, are not actively involved in TB control.
Chronic understaffing of the central TB unit and regional health bureaus has hampered
regular supervision. Staff turnover is high.
There is insufficient provision of continuing medical education to health workers at various
levels.
Training manuals, modules, and supervision guidelines are inadequate.
There are serious delays in drug procurement and distribution.
There is long delay in supply of laboratory materials.
Quality control measures are not fully operational.
There is a lack of emphasis on information, education, and communication at community
level. 308
Household

HIV/AIDS in Ethiopia 66
Given deep and persistent poverty in Ethiopia, HIV/AIDS will further strain coping mechanisms
through its enormous and complex impact on households. There are no reports on the impact of
AIDS on Ethiopian households, particularly its effect on the extended family system. 309 The
impacts below are being seen in other hard-hit countries and thus may have import for Ethiopia.
As AIDS severely affects the most economically active members of the household, income and
consumption patterns are likely to change dramatically, reducing or depleting income, savings,
and remittances, and increasing expenditures on care and funerals. Families may have to sell
assets or increase their labor to pay for care (especially as most health care expenditure in
Ethiopia is in the private sector); transport to reach care providers; burials; and household
necessities.
Household income often declines though (1) illness and death of the breadwinner, (2) wages lost
by other household members who stop (or reduce) working to care for the sick, and/or (3) wages
lost by (or opportunity cost of) attending funerals. Lost employment may be accompanied by
loss of insurance and medical benefits. Household members including its oldest and youngest
members may have to enter or remain in the workforce longer to compensate for the loss of the
main breadwinner’s earnings. Exacerbating this scenario is that more than one household
member is often infected with HIV/AIDS. 310
As the Stigma section indicated, HIV/AIDS also exacts an enormous psychosocial toll. Those
who are most involved in care of AIDS patients may be more prone to stress and anger, emotions
that may be made manifest in ways that convey stigma or discrimination toward PWHA.
As mentioned in the Food Security section, drought is depleting household assets, which may in
turn be further reduced to pay for AIDS care and/or supplement lost income of breadwinners. To
survive, female household members may engage in activities such as sex work, increasing their
risk of exposure to HIV.
In some households, the death of a family member to AIDS may result in a loss of remittances, if
that member is a government employee or trader who sends money back to the family. The death
of a family member because of AIDS also leads to a reduction in savings and investment. 311
Households that are headed by a single parent, have only one breadwinner, and/or have more
than one HIV-infected member are particularly vulnerable to economic and psychosocial shocks.
Female-headed households, for example, tend to be poorer than those headed by men and thus
have fewer resources with which to respond to HIV/AIDS. In Ethiopia, 23.6 percent of
households are headed by women; in rural areas, this figure is 35.4 percent. 312 Moreover, women
are traditional caregivers and thus take on additional responsibilities when family members
become ill. And in single-parent households or those in which one parent has already died, girls
are more likely than boys to provide care. When family breadwinners become ill or die, girls are
often the first to be taken out of school 313 to help care for those who are ill, carry out household
chores, and/or undertake income-generating activities. Curtailing girls' education (and thus
potential for formal labor force participation) may render them more vulnerable to acquiring
HIV.

HIV/AIDS in Ethiopia 67
Orphans and Other Vulnerable Children
No statistics can adequately capture the human tragedy that orphans are facing in
Ethiopia. For those children that have lost their parents to AIDS, grief is only the
beginning of their troubles. When AIDS takes a parent, it usually takes a childhood as
well. Children must witness death and suffering. The death of a parent threatens their
psychosocial and physical well-being. Children lose love, affection, and nurturing. The
loss of a father or both parents often results in loss of income and property rights.
Children who grow up without parents may be left impoverished and unprotected. 314
UNAIDS defines an AIDS orphan as a child under age 15 who has lost one or both parents to
AIDS. 315 Many Ethiopian AIDS orphans have lost (or will soon lose) both parents to AIDS. In a
July 2002 report, UNAIDS estimated that there were 990,000 AIDS orphans living in Ethiopia at
the end of 2001. 316 Ethiopia's MOH put this figure at 1.2 million; it projects that the number of
orphans living in Ethiopia will rise to 1.8 million by 2007 and to 2.5 million in 2014. 317
Children on the Brink 2002, a report on AIDS orphans commissioned by USAID, estimated that
the percent of Ethiopia's orphans due to AIDS rose from 2.3 percent in 1990 to 25.8 percent in
2001; it projected that this percentage will rise to 35.4 percent in 2005 and 43.0 percent in
2010. 318
Before HIV/AIDS, Ethiopia had a large number of children orphaned by civil war and famine.
The MOH underscores that the increase in the number of orphans because of AIDS is likely to
exacerbate the already severe problem of homeless children who seek to subsist by working and
living in urban streets. 319 Orphans are particularly vulnerable to malnutrition, illness, abuse, child
labor, and sexual exploitation. Concurrently, they suffer the stigma and discrimination associated
with HIV/AIDS. 320 UNICEF highlights that Ethiopia's AIDS orphans face stigmatization from
not just their relatives and communities, but from health service providers and teachers. There
are insufficient social services for AIDS orphans, including health care, school fee subsidies, and
shelter. Consequently, many become street children. 321
GOAL, one of the leading NGOs working with street children in Ethiopia, reports that the scale
of the problem is immense and that the enormous number of street children has rendered
interventions highly complex. GOAL believes that greater coordination among agencies working
with street children is inadequate and must be improved. 322
In Ethiopia, there are few governmental institutions for orphans, as extended families have
usually taken them in. These families are themselves likely to be poor and must therefore stretch
already inadequate resources to provide for both orphans and their own children. 323 Drs. Marta
Segu and Sergut Wolde-Yohannes of the Boston University School of Public Health examined
AIDS orphanhood in Bahir Dar, capital of the Amhara Region, 570 km northwest of Addis
Ababa. Bahir Dar, which literally means “by the sea side,” is situated on the southern shore of
Lake Tana, the source of the Blue Nile River. It is one of the most rapidly growing cities in
Ethiopia, attracting many migrants because of its substantial tourist industry and the lack of
economic opportunity in surrounding areas. Government social services, grossly inadequate
before HIV/AIDS, are now severely overburdened and underresourced. 324

HIV/AIDS in Ethiopia 68
As extended families' own AIDS burdens constrain their ability to foster orphaned children,
orphans may be become heads of households and responsible for caring for younger siblings. 325
In many areas of Bahir Dar, for example, weakening safety nets are leading orphans to assume
the role of head of household at a very young age. Children as young as eight report caring for
younger siblings. Orphan-headed households must deal not only with survival but also with
grief, prejudice, and social exclusion. In Bahir Dah, orphan heads of households and
organizations working with them identified the following as major issues:
insufficient income to meet basic needs, including food and clothing
shortage of housing
constraints to school attendance, including inability to pay school fees and purchase school
materials and uniforms
lack of vocational and skills training
lack of employment opportunities
lack of access to health care
stigmatization and rejection by community members
lack of moral support
lack of assistance with household tasks 326

HIV/AIDS in Ethiopia 69
Response
At a Glance
The At a Glance section summarizes the more detailed data found below it.
Government Response
In 1985 (before the first AIDS case had been officially diagnosed), the government of
Ethiopia established a national task force to address prevention and control of HIV/AIDS.
The task force issued the first AIDS control strategy by the end of 1985.
In September 1987, the government established an HIV/AIDS department within the
Ministry of Health. The MOH developed a short-term plan in March 1987 and medium-term
plans in 1987 and 1992.
As in many countries, these interventions were inadequate in scale; largely ineffective in
implementation; lacked sufficient stakeholder involvement in planning and implementation,
especially at the community level; were poorly or not at all coordinated and integrated across
sectors and among service providers; and received relatively low priority within government,
society in general, and in the international community, with a resultant low level of allocated
financial and human resources.
In August 1989, the MOH drafted a four-point policy statement on AIDS prevention. The
first draft of a national policy was created in 1991, though not approved until 1998.
The policy has the overall objective of providing an enabling environment for the prevention
and mitigation of HIV/AIDS. Its specific objectives are to:
establish effective HIV/AIDS prevention and mitigation strategies to curb the spread of
the epidemic
promote a broad, multisectoral response to HIV/AIDS, including more effective
coordination and resource mobilization by government, NGOs, the private sector, and
communities
encourage government sectors, NGOs, the private sector, and communities to take
measures to alleviate the social and economic impact of HIV/AIDS
support a proper institutional, home-, and community-based health care and
psychological environment for PWHA, orphans, and surviving dependents
safeguard the human rights of PWHA and avoid discrimination against them
empower women, youth, and other vulnerable groups to take action to protect themselves
against HIV
promote and encourage research activities targeted toward preventive, curative, and
rehabilitative aspects of HIV/AIDS
The Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004
focuses on reducing the transmission of HIV and associated morbidity and mortality, and its
impact on individuals, families, and society at large. The strategy is built on four issues:
multisectoralism, participation, leadership, and efficient management (including adequate
monitoring and evaluation).

HIV/AIDS in Ethiopia 70
The National AIDS Prevention and Control Council and its secretariat were established in
2000. The council is chaired by the president of Ethiopia and comprises members from
government, NGOs, religious bodies, and civil society. The council oversees the
implementation of the Strategic Framework for the National Response to HIV/AIDS in
Ethiopia for 2000-2004, examines and approves annual plans and budgets, and monitors plan
performance and impact.
At its fourth regular session in June 2001, the National AIDS Prevention and Control Council
declared HIV/AIDS a national emergency.
Ministries outside Health
The Ministry of Education has yet to provide clear guidelines for a comprehensive HIV
education curriculum.
Despite that the agricultural and livestock sectors account for over 85 percent of the labor
force, the Ministry of Agriculture is not actively involved in HIV prevention.
The Ethiopian Ministry of Youth, Sports, and Culture is using a youth-based participatory
process to develop an HIV/AIDS and sexual health program.
Assessment of Government Response
Although Ethiopia began the HIV/AIDS policy process in 1989 far earlier than most other
countries it took nine years to complete. Moreover, the process involved almost no
participation by actors outside government.
There was little high-level, political involvement in HIV/AIDS during the 1990s. By 1999,
however, President Negasso Gidada had become an active spokesman in the fight against
HIV/AIDS. Current President Girma Woldegiorgis has also made high-profile statements
about the epidemic.
Ethiopia's response is constrained by extremely limited human, financial, technical, material,
and management capacities. The country's health care infrastructure is massively
underequipped to address HIV/AIDS, particularly outside Addis Ababa. The country's size
and poor transport infrastructure are also key factors.
Bureaucratic constraints are impeding the response. The Ministry of Health has traditionally
been one of the weakest ministries in Ethiopia, and its ability to absorb and manage new
funding has been problematic.
Although much more funding is required, building additional human capacity in the
health sector, improving coordination, and using existing funds efficiently and effectively are
paramount. That the HIV/AIDS program is so highly dependent on donors also raises
concerns about its future sustainability.
Tensions with Eritrea and drought, among others, may lessen the government's focus on
HIV/AIDS, as well as divert resources that could be used to address it.
Responsibility for implementing HIV/AIDS interventions rests with the regional HIV/AIDS
councils. These, in turn, work through the zones, woredas, and kebeles. In the long term, this
system is likely to enhance delivery of HIV/AIDS interventions. In the short term, however,
it is expensive, requires large numbers of qualified staff to carry out programs at the different
levels of government, and renders coordination difficult.

HIV/AIDS in Ethiopia 71
Human Rights
The National HIV/AIDS Policy states that PWHA "shall not be subject to special restrictions
on employment, education, access to public facilities, or housing." However, there are no
specific laws to enforce the policy.
Although Ethiopia's 1994 Constitution outlaws discrimination of any form, it does not
address HIV/AIDS-related discrimination. A study undertaken in 1999 found that although
existing laws are nondiscriminatory with regard to PWHA, there is evidence of
discriminatory practices in the workplace, health care facilities, schools, and housing.
Enforcement of current laws (including the National Policy for Women) is paramount. The
need for new legislation to specifically address discrimination of PWHA, preemployment
testing, orphan care, and other issues must also be examined.
Budgets
Ethiopia's 2002 GFATM proposal indicated that the government is annually allocating US$1
million to coordinate the national response.
The country requires at least US$166 million annually for HIV/AIDS prevention and care
(this figure does not include ART). Ethiopia's 2002 GFATM proposal stated that the
HIV/AIDS funding gap was US$120 million.
Donors
Major donors vis-à-vis HIV/AIDS include Christian Relief and Development Agency,
WHO, UNICEF, UNAIDS, UNDP, World Bank, USAID, Ireland Aid, DFID,
Netherlands, Norway, CDC, and GTZ. Japan and Italian Cooperation are also funding
HIV/AIDS activates in Ethiopia.
Ethiopia was one of the first countries to receive funding from the World Bank's
Multicountry HIV/AIDS Program for Africa (MAP). The US$64.3 million MAP project
is meant to finance a portion of the government's 2000-2004 HIV/AIDS strategic plan.
Almost half of the loan is earmarked for community-based activity at the woreda and
kebele level.
Global Fund to Fight AIDS, Tuberculosis & Malaria
Ethiopia has been approved for US$139,403,241 for HIV/AIDS, US$26,980,649 for TB, and
US$76,875,212 for malaria. As of March 2003, no funds from either the first or second
round had yet been released.
NGOs
Given years of centralized power, civil society in Ethiopia remains weak and
underdeveloped. Since the country has moved toward a multiparty democracy, civil society is
becoming increasingly crucial to the country's socioeconomic development; however,
compared to other African countries, Ethiopia's NGO sector is small and has limited
capacity.

HIV/AIDS in Ethiopia 72
Nevertheless, civil society has started mobilizing against HIV/AIDS. Most NGOs
concentrate on HIV/AIDS awareness. Activities are largely concentrated in and around major
cities and, thus far, have had little impact on rural populations. They are also on a limited
scale, reaching only a small fraction of the population in need of services. They are not
inadequately funded and are often intermittent because of irregular and insufficient funding.
The two national PWHA associations in Ethiopia are Dawn of Hope and Mekdim Ethiopia
HIV Positive Persons and AIDS Orphans National Association, both of which are providing
an array of HIV/AIDS services. There are also local associations of PWHA.
Faith-based Organizations
According to the 2000 EDHS, only 7 percent of women and 8 percent of men cited a mosque
or church as an information source for HIV/AIDS. These data highlight a major "missed
opportunity" in terms of HIV/AIDS education.
There are, however, faith-based organizations in Ethiopia providing HIV/AIDS prevention,
care, and support.
Some influential religious leaders appear to be publicly supporting action against HIV/AIDS
(though not condom promotion and use).
Orphans
Numerous NGOs and CBOs are providing support to AIDS orphans and other vulnerable
children.
Traditional Medicine
Many Ethiopians with AIDS are likely to use traditional medicine to alleviate symptoms of
OIs. The MOH has encouraged the involvement of traditional healers in AIDS care and a
national committee comprising scientists and traditional healers has been formed.
The Department of Drug Research at the Ethiopian Health and Nutrition Research Institute
is working with traditional healers who claim to have cures for AIDS and some OIs.
Blood
The MOH has recently published a national blood service strategy that mandates the Ethiopian
Red Cross Society to operate blood transfusion services throughout the country. GFATM funding
will be used to increase the number of blood banks and initiate other improvements.
Universal Precautions and Post Exposure Prophylaxis
The MOH has prepared draft national guidelines on UP and PEP, with GFATM funding
expected to finance their implementation.
PMTCT

HIV/AIDS in Ethiopia 73
Only 50 clients received PMTCT services in Ethiopia during 2001. There were three
public/NGO sites providing basic PMTCT services in 2001, with no such services in the
commercial sector.
In January 2002, national guidelines on PMTCT were released. In addition, the national
policy on ART promotes improving the coverage of PMTCT in all parts of the country.
The MOH has initiated a pilot PMTCT program. The MOH envisions using GFATM
financing to scale up PMTCT to 50 sites spanning all regions. It is also planning to
implement PMTCT+ services.
Addis Ababa University's Medical Faculty is currently conducting a research project on the
efficacy of a longer course of NVP among breastfeeding mothers in three sites.
VCT
Only 2 percent of Ethiopian men have been tested for HIV. However, 65 percent of all men
who have not been tested for HIV want to be tested.
During 2001, only 2,400 to 3,500 clients were seen at Ethiopia's 20 publicly funded/NGO
VCT centers. (Twenty percent of VCT services were offered in the commercial sector.)
In 2002, the country had 23 VCT centers, of which 3 were government, 12 private, and 8
NGO. It estimated that 10,000 clients were seen at these facilities in 2002. With GAFTM
financing, this figure is projected to rise to 500,000 by year five.
Almost all of the country's VCT services are located in Addis. There is a severe lack of
trained HIV/AIDS counselors in the country.
Care and Support
The Ethiopian MOH and Addis Ababa University have developed national guidelines on
HIV/AIDS care and support for adults and children. There are multiple care and support
activities occurring in Ethiopia. However, there is great disparity with regard to resources for
HIV/AIDS care and support between Addis and other regions of the country.
Some NGOs have been providing home-based care since 1992. National guidelines on HBC
were developed in 2001.
ART
Although national guidelines on clinical management of HIV infection in adults and children
have been in use for two years, they require updating.
No adults with HIV/AIDS received isoniazid prophylaxis during 2001. Access to HIV/AIDSrelated
care and support services in Addis, other urban areas, and rural areas is deemed
minimal. There were no public/NGO nor private sites providing ART during 2001.
The Ethio-Netherlands AIDS Research Project is exploring alternatives to the biologic
markers used to determine initiation of ART in wealthy countries.
Military
The Ethiopian National Defense Force (ENDF) has approximately 100,000 personnel,
rendering it one of the largest military forces in Africa.

HIV/AIDS in Ethiopia 74
Ethiopian defense forces are often cited as being at the forefront of HIV prevention. The
Ethiopian military has developed an extensive HIV/AIDS workplan that includes training at
all levels, widespread distribution of condoms, information dissemination, surveillance, and
research. A major initiative under way is deploying demobilized soldiers as HBC providers.
ENDF is working with the CDC on a peer education project; other collaborators Family
Health International, the Civil-Military Alliance to Combat HIV & AIDS, the POLICY
Project of The Futures Group International, the U.S. Naval Health Research Center,
Population Services International, the U.S. Department of Defense, USAID, and UNAIDS.
The U.N. peacekeeping mission in Ethiopia and Eritrea is training troops from both
countries, as well as its own peacekeepers, to instruct fellow soldiers and civilians on HIV
prevention.
Other Mobile Populations
The World Food Program is working with local NGOs and transport companies to train over
2,000 WFP-employed truck drivers and their assistants in HIV/AIDS awareness and
prevention.
The International Organization for Migration is deploying mobile units along the Ethio-
Djibouti trucking route and in a gold mining area in Ethiopia. The units provide free services
and easy access to VCT and syndromic treatment of STIs.
Private Sector
According to the 2000 EDHS, only 4 percent of men and 1 percent of women have heard
about HIV/AIDS at their workplace. Note, however, that of "employed" women, 56 percent
work in the agriculture sector, and of these women, 94 percent work on their own land.
Among employed men, 84 percent work in agriculture. Thus, reaching those in rural areas is
crucial.
Some workplace interventions are beginning to occur. For example, the Confederation of
Ethiopian Trade Unions and the Addis Ababa Chamber of Commerce have received funding
from USAID to implement HIV prevention programs in the workplace.
Government Response
In 1985 (before the first AIDS case had been officially diagnosed), the government of Ethiopia
established a national task force to address prevention and control of HIV/AIDS. The task
force issued the first AIDS control strategy by the end of 1985. 327
In September 1987, the government established an HIV/AIDS department within the Ministry of
Health and charged it with directing and coordinating the implementation of the AIDS control
strategy. 328 In collaboration with WHO's Global Program on AIDS, the MOH developed a shortterm
plan in March 1987 and the first medium-term plan in May 1987. This latter (1987-91)
focused on public awareness, establishment of laboratory services, HIV surveillance, and
training of health workers. The second medium-term plan (1992-96) emphasized interventions to

HIV/AIDS in Ethiopia 75
stop the spread of HIV through a multisectoral approach and decentralization of HIV/STI
prevention and control activities. 329
As in many countries, these interventions were inadequate in scale; largely ineffective in
implementation; lacked sufficient stakeholder involvement in planning and implementation,
especially at the community level; were poorly or not at all coordinated and integrated across
sectors and among service providers; and received relatively low priority within government,
society in general, and in the international community, with a resultant low level of allocated
financial and human resources. 330
National HIV/AIDS Policy
In August 1989, the MOH drafted a four-point policy statement on AIDS prevention. The
minister of health convened a 13-member policy drafting committee on HIV/AIDS to create a
comprehensive national policy. The committee produced the first draft of the national policy in
1991 and forwarded it to the MOH. Between 1992 and 1993, there were numerous revisions.
However, between 1993 and 1996, there was little progress on the policy, largely because the
Ethiopian government was engaged in significant decentralization of many of its activities,
including health. The decentralization led to a drastic reduction in HIV/AIDS technical staff at
the MOH; moreover, the momentum to produce an HIV/AIDS policy declined. In August 1998,
after further revisions and review, a national HIV/AIDS policy was finally approved by the
Council of Ministers. 331
The policy has the overall objective of providing an enabling environment for the prevention and
mitigation of HIV/AIDS. Its specific objectives are to:
establish effective HIV/AIDS prevention and mitigation strategies to curb the spread of
the epidemic
promote a broad, multisectoral response to HIV/AIDS, including more effective
coordination and resource mobilization by government, NGOs, the private sector, and
communities
encourage government sectors, NGOs, the private sector, and communities to take
measures to alleviate the social and economic impact of HIV/AIDS
support a proper institutional, home-, and community-based health care and
psychological environment for PWHA, orphans, and surviving dependents
safeguard the human rights of PWHA and avoid discrimination against them
empower women, youth, and other vulnerable groups to take action to protect themselves
against HIV
promote and encourage research activities targeted toward preventive, curative, and
rehabilitative aspects of HIV/AIDS 332
The policy states that PWHA should be involved in all these efforts through education,
counseling, and peer groups to "help themselves live with HIV/AIDS and to communicate to the
community the dangers of risky behaviors." 333
The priority prevention and control measures called for in the policy include:

HIV/AIDS in Ethiopia 76
encourage people to maintain faithful sexual relationships with one partner
promote the use of condoms in situations where there may be the risk of HIV
transmission
minimize other unsafe practices such as illegal injections, harmful traditional procedures,
and drug addiction
ensure safe medical practices to protect against HIV transmission
ensure the human rights of people with AIDS 334
Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004
As the HIV/AIDS policy framework was being developed, the Ministry of Health coordinated
a process of strategic planning and program development in Ethiopia's nine regions and
two city administrations. This process involved national and regional governmental institutions,
the major regional sector NGOs and religious organizations, and other key stakeholders. The
result was the five-year Federal Level Multisectoral HIV/AIDS Strategic Plan 2000-2004 (costed
at US$11 million) and accompanying Regional Multisectoral HIV/AIDS Strategic Plans 2000-
2004 (costed at US$45 million). Together, these plans were synthesized into the Strategic
Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004. The framework
focuses on reducing the transmission of HIV and associated morbidity and mortality, and its
impact on individuals, families, and society at large. The strategy is built on four issues:
multisectoralism, participation, leadership, and efficient management (including adequate
monitoring and evaluation). 335
The strategy highlights the following priority areas for action:
Prevention
improve access to and quality of STI, TB, and HIV/AIDS prevention, care, and support
services to meet the needs of groups at increased risk of HIV infection
increase the provision of comprehensive STI/TB management in health care facilities
increase access to education in general and to HIV/AIDS education and communication in
particular
increase accessibility and availability of condoms
promote information, education, and communication messages that are continuous,
appropriate, acceptable, and effective in inducing behavior change
contribute to national and local initiatives to alleviate poverty and increase employment
opportunities, particularly for youth and women
empower women and girls to reduce their risk of HIV infection
prevent HIV transmission in hospital settings 336
Care and Support
provide clinical and home- and community-based care for PWHA
increase social support to PWHA and their families
establish an ethical, legal, and human rights framework for PWHA

HIV/AIDS in Ethiopia 77
expand and accelerate sector-specific interventions to mitigate impact
increase HIV/AIDS research and surveillance. 337
The National AIDS Prevention Council
The National AIDS Prevention and Control Council and its secretariat were established in April
2000. The council is chaired by the president of Ethiopia and comprises members from
government, NGOs, religious bodies, and civil society. The council oversees the implementation
of the Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004,
examines and approves annual plans and budgets, and monitors plan performance and impact. 338
At its fourth regular session in June 2001, the council declared HIV/AIDS a national
emergency. 339
The council has appointed the National HIV/AIDS Board of Advisors, which meet monthly. 340
The National HIV/AIDS Prevention and Control Office (HAPCO, formerly the National AIDS
Council Secretariat) was reestablished by Proclamation No. 276/2002 in July 2002 as the
executive arm of the council. HAPCO is led by an executive board comprising eight ministers
and several representatives of civil society and the private sector. 341
There are also HIV/AIDS focal persons at regional level. At district level, the focal person for
disease prevention and control covers this function. With the decentralization process, AIDS
committees have been established in all woredas. 342
As discussed in the Donor section below, the World Bank is providing Ethiopia with US$63.4
million (concessional loan) for a three-year project to help implement the Strategic Framework
for the National Response to HIV/AIDS in Ethiopia for 2000-2004. The Bank project also created
an Emergency HIV/AIDS Fund to channel grants directly to community organizations (kebeles),
NGOs, and the private sector. 343 , 344
Ministries outside Health
The Ministry of Education has yet to provide clear guidelines for a comprehensive HIV
education curriculum. Although there are several hundred anti-HIV/AIDS clubs in high
schools, their goals vary widely and they do not promote HIV prevention skills. 345
Despite that the agricultural and livestock sectors account for over 85 percent of the labor
force, 346 the Ministry of Agriculture is not actively involved in HIV prevention. 347 , 348
The Ethiopian Ministry of Youth, Sports, and Culture is using a youth-based participatory
process to develop an HIV/AIDS and sexual health program. Young people developed a
national youth charter and a three-year action plan to mobilize youth for improved sexual
health and HIV preventive behavior. The participatory process involved in-depth training for
51 youth leaders from all regions. 349
Ethiopian Airlines, a parastatal, conducts mandatory HIV testing of all staff every six
months. Those who test positive are counseled by in-house medical staff. All HIV-positive

HIV/AIDS in Ethiopia 78
cockpit crew are grounded and given other jobs. Some HIV-positive personnel take
advantage of free air tickets to visit South Africa or Thailand regularly for treatment. 350
Assessment of Current Response
Although Ethiopia began the HIV/AIDS policy process in 1989 far earlier than most other
countries it took nine years to complete, much longer than in other countries. Moreover, the
process involved almost no participation by actors outside government. 351
According to a 2002 report from the U.S. National Intelligence Council, the Ethiopian
Government "does not appear focused on AIDS, despite occasional statements on the issue."
Although the government has focused heavily on the conflict with Eritrea (and drought), this
NIC assessment does not seem entirely fair. For example, David Shinn, who served as U.S.
ambassador to Ethiopia during 1996–99 (and who contributed to the NIC study) reports that
when he assumed his post in 1996, "virtually no one in Ethiopia was taking the HIV/AIDS
problem seriously." However, by 1999, "President Negasso Gidada had become an active
governmental spokesman for HIV/AIDS....The issue finally and belatedly reached critical mass
in 1999." 352
In October 2002, as he opened Parliament, Ethiopian President Girma Woldegiorgis stated:
The alarming spread of the disease which is attacking our youngsters could be a great
deterrent to the efforts of the nation in achieving sustainable development and democratic
order....Needless to say the epidemic is badly affecting the main working force of the
nation in urban and rural areas. 353
(Some heads of state in hard-hit African countries omit any mention of AIDS in their major
speeches.)
After a 2001 return to the country, Shinn noted that constraints to the response included that the
"bureaucracy has not yet organized itself in a way to take maximum advantage of growing
financial resources. The Ministry of Health has traditionally been one of the weakest ministries
in Ethiopia. Also, the one-year-old National HIV/AIDS Council has not yet become an effective
coordinator of the many disparate efforts to counter the problem." 354
A report from the U.N. Office for the Coordination of Humanitarian Affairs in June 2002 stated
that:
The anti-HIV/AIDS campaign is being spearheaded by the National AIDS Council
Secretariat (NACS). However, the World Bank, which has contributed US $59.7 million
to fighting HIV/AIDS in Ethiopia, has criticized NACS as lacking the capability to
combat the virus. The Bank said it was "seriously concerned" by its failure to improve the
capacity of those participating in the campaign. A team of World Bank inspectors noted
"serious shortcomings" requiring urgent rectification in order to enhance the effectiveness
of anti-AIDS projects. Almost half the NACS proposals submitted for funding to fight
HIV/AIDS are still "pending" while a further 26 percent have been rejected. 355

HIV/AIDS in Ethiopia 79
A report in November 2002 raised concerns that NACS had spent only one-fifth of the Bank
funds in the last two years. 356 In an interview in November 2002, Negatu Mereke, head of the
National AIDS Secretariat, commented on the Bank's criticism:
We did not adequately establish the institutional arrangements that enabled effective
absorption of funds of that size when the loan of US $59.7 million was secured two years
back. Institutionally, we did not have that capacity to deal with the funds that came to the
country. The absorption of funds of this size was strange for us. Even if the government
and other stakeholders were very cognizant of the magnitude of the problem, and
committed to fight the spread of the pandemic and mitigate its impact, they lacked
experience and capacity to handle it in terms of funds of this size for HIV/AIDS.
In the last year, we have seen unprecedented levels of political and institutional interest in
reversing the cause of the HIV/AIDS pandemic. In fact, in the last few months or so we
were highly engaged in addressing basic policies and organizational issues. We believe
this will accelerate the implementation of HIV/AIDS prevention and control.
With our legal status proclamation [reference to HAPCO], political leadership has
improved significantly, providing a more enabling environment for the fight against the
pandemic and its effects on development. Effective institutional arrangements have been
put in place from federal level to the smallest community.
We have cleared the organizational confusion that impaired the speedy implementation of
the three-year World Bank loan. Absorption of funds has accelerated. From the first year
of the loan, less than US $1.5 million was disbursed. The following year, the amount rose
to US $12 million. Some 292 organizations and 25 government bodies have secured
funds out of 350 applications. 357
Ethiopia's response is constrained by extremely limited human, financial, technical, material, and
management capacities. The country's health care infrastructure is, as David Shinn puts it:
shockingly ill equipped to carry out a national anti-HIV/AIDS program, particularly
outside Addis Ababa. The health care infrastructure is spread thin and poorly equipped.
Equipment is often broken and no repair program is established. 358
Although much more funding is required, building additional human capacity in the
health sector, improving coordination, and using existing funds efficiently and effectively are
paramount. 359 That the HIV/AIDS program is so highly dependent on donors also raises
concerns about its future sustainability.
The tensions with Eritrea persist, such that there is concern that the peace accord may fall apart.
The country is also contending with a major drought. Certainly, these factors lessen the
government's focus on HIV/AIDS, as well as divert resources that could be used to address it.
With regard to the war with Eritrea, Carol Bellamy, executive director of UNICEF, recently
stated that:

HIV/AIDS in Ethiopia 80
[Ethiopia] is a poor country, and those limited resources could probably have been better
spent on health and education and other kinds of productive investments; investing in
conflict does not produce a return. 360
A major concern is that behavior change is seriously lagging behind knowledge. The BSS
preliminary findings indicate that behaviors that put people at risk of acquiring HIV are more
widespread than the 2000 EDHS suggests. Yet dissemination of behavior change messages is
impeded by the fact that 86.4 percent of women and 72.6 percent of men have no exposure to the
mass media. In rural areas, these figures are 93.7 and 80.3 percent, respectively. Only 20.7
percent of all Ethiopian household have a radio; only 12.8 percent of rural households have a
radio. 361 Moreover, as Shinn highlights:
Ethiopia is not only populous, but it is geographically large — the size of Texas and
California combined. Improvement of the transportation infrastructure has made
significant stride, but reaching all parts of the country in a timely way remains difficult,
especially so during the rainy season when some areas are completely cut off for short
periods of time. Even if it was a wealthy country, the inadequate transportation
infrastructure and difficult topography would pose a major challenge to an effective
health care system generally and a program to combat HIV/AIDS in particular....The war
on HIV/AIDS would be aided enormously if Ethiopian universities’ medical departments
and major research institutions and counterpart organizations outside the country had
point-to-point satellite connections. 362
Researchers from Addis Ababa University and the Ethio-Netherlands AIDS Research Project
also underscore transport constraints faced by staff at both the federal and regional health
bureaus. 363
Shinn believes that Ethiopia’s policy of ethnic federalism, adopted soon after the 1991 overthrow
of Mengistu Haile Mariam, is "both a blessing and a curse" with regard to addressing HIV/AIDS.
Although the 85-member National HIV/AIDS Council is charged with coordinating the overall
effort, responsibility for implementing the program rests with the regional HIV/AIDS councils.
These, in turn, work through the zones, woredas, and kebeles. In the long term, this system is
likely to enhance delivery of HIV/AIDS interventions. In the short term, however, it is
expensive, requires large numbers of qualified staff to carry out programs at the different levels
of government, and renders coordination difficult. 364
Human Rights
The national HIV/AIDS policy and strategic framework both address human rights and
HIV/AIDS, though in a very general manner. The National HIV/AIDS Policy states that PWHA
"shall not be subject to special restrictions on employment, education, access to public facilities,
or housing." 365 However, there are no specific laws to enforce the policy.
Although Ethiopia's 1994 Constitution outlaws discrimination of any form, it does not address
HIV/AIDS-related discrimination. A study undertaken in 1999 found that although existing laws

HIV/AIDS in Ethiopia 81
are nondiscriminatory with regard to PWHA, there is evidence of discriminatory practices in the
workplace, health care facilities, schools, and housing. Enforcement of current laws (including
the National Policy for Women) is paramount. The need for new legislation to specifically
address discrimination of PWHA, preemployment testing, orphan care, and other issues must
also be examined. 366 , 367 Ethiopia's June 2002 proposal to the GFATM stated that the "Ministry
of Justice is currently reviewing legislation relevant to HIV/AIDS." 368
Budgets
Ethiopia's 2002 GFATM proposal indicated that the government is annually allocating US$1
million to HAPCO to coordinate the national response (more detail on the timeframe was not
included). In 2001, the government earmarked US$8.5 million to HIV/AIDS; this included
financing from external donors. Data on the 2002 earmark for malaria were included in the
GFATM proposal, though not for HIV/AIDS. 369
In June 2002, Abebe Kebede of the Addis Ababa Metropolitan HIV/AIDS Secretariat reported
that the country required at least US$166 million annually for HIV/AIDS prevention and care
(this figure does not include ART). 370 Ethiopia's 2002 GFATM proposal stated that the
HIV/AIDS "national funding gap identified through the federal and regional implementation
plans stands at US$120 million." 371
Donors
The 2002 GFATM proposal provided the following information on the main donor support for
HIV/AIDS in Ethiopia:
Christian Relief and Development Agency: HIV/AIDS interventions, NGO capacity
building, advocacy: US$233,400 for 2001-2003
WHO: Technical support to health sector HIV/AIDS interventions: US$1.75 million for
2002-2003
UNICEF: Support to multisectoral HIV/AIDS interventions, PMTCT, youth prevention:
US$3.4 million for 2001 -2002
UNAIDS: Support to HAPCO, support MOH in VCT: US$486,000 for 2002-2003
UNDP: Leadership, advocacy & communication, mainstreaming in planning, human
rights, socioeconomic research: US$3 million for 2002-2006
World Bank: Funding for the Ethiopian Multisectoral AIDS Program: US$13.36 million
for 2001-2002
USAID: Prevention, care and support, BSS: no amount provided in the GFATM proposal
(USAID provided US$8.2 million in HIV/AIDS assistance to Ethiopia in FY2001, up
from $7.6 million in FY2000 372 )
Ireland Aid: Support to MOH in strengthening VCT and OI management: US$34,000 for
2002

HIV/AIDS in Ethiopia 82
DFID: Support to multisectoral response: US$35,000 for 2002
Netherlands: Ethio-Netherlands AIDS Research Project (ENARP), WHO-Netherlands
support: over US$1 million for 2002-2003
Norway: Support channeled through UNICEF, UNFPA and HAPCO: US$1.3 million for
2002
CDC: Surveillance, STI, VCT: US$10 million for 2002-2003 (more on further CDC
funding to reach military personnel below)
GTZ: Support to Amhara, Tigray, and Oromiya Regions: US$120,000 for 2002 373
Japan and Italian Cooperation are also funding HIV/AIDS activates in Ethiopia. In general,
Ethiopia's largest bilateral donors are Germany, Sweden, the European Union, Italy, and the
United States. The U.N., particularly UNICEF, has an extensive program in Ethiopia, with a
major focus on girls' education.
Ethiopia is one of the World Bank's International Development Association's (IDA) largest
clients in Africa, with a portfolio of 20 projects totaling over US$1.9 billion. 374 (IDA lends
money to the world's poorest countries at zero interest with a 10-year grace period and maturities
of 35 to 40 years.) Ethiopia was one of the first countries to receive funding from the Bank's
Multicountry HIV/AIDS Program for Africa (MAP). To quality for MAP, Ethiopia had to meet
the following criteria:
1. satisfactory evidence of a strategic approach to HIV/AIDS, developed in a participatory
manner
2. existence of a high-level HIV/AIDS coordinating body, with broad representation of key
stakeholders from all sectors, including people living with HIV/AIDS
3. government commitment to quick implementation arrangements, including channeling
grant funds for HIV/AIDS activities directly to communities, civil society, and the private
sector
4. agreement by the government to use multiple implementation agencies, especially NGOs
and CBOs 375
As mentioned above, the US$64.3 million MAP project is meant to finance a portion of the
government's 2000-2004 HIV/AIDS strategic plan. Almost half of the loan is earmarked for
community-based activity at the woreda and kebele level. The goal is to provide funding to 165
woredas during the three-year period of the loan. The money can be used to provide training for
district coordinators and help create a financial system for accountability purposes. Once a
district government has shown that it has an adequate financial system in place, it is eligible to
draw funds from the loan and forward that money to kebeles for implementation. 376
By the end of the project period, the Bank expects that:
Access to treatment for OIs will increase from 30 to 50 percent.
The number of national surveillance sites will increase by 10 percent.

HIV/AIDS in Ethiopia 83
The number of blood banks will increase by 25 percent. 377
Other objectives:
At least 70 percent of the participating woredas will have implemented their agreed action
plans.
The Emergency AIDS Fund disbursements will be at least 70 percent of plan level.
The number of affordable VCT services incorporated into ANC, TB, and STI clinics will
have increased by 10 percent. 378
More information on donors is found in the Links section.
Global Fund to Fight AIDS, Tuberculosis & Malaria
When the first round of GFATM grants was announced in April 2002, Ethiopia was approved to
receive US$26,980,649, for its five-year TB proposal. In the second round, announced in January
2003, the fund approved US$139,403,241 for Ethiopia's HIV/AIDS proposal and US$76,875,212
for malaria (again, for a five-year implementation timeframe.) (Both second-round grants were
approved pending further clarifications by the Ethiopia Global Fund Coordinating Committee
[i.e., the country coordinating mechanism].) 379 As of March 2003, no funds from either the first
or second round had yet been released.
The 2002 proposal was drafted by Ethiopia's Global Fund Coordinating Committee, which
comprises 12 members and is chaired by the minister of health. Members include representatives
from the Ministry of Finance and Economic Development, HAPCO, WHO, Christian Relief and
Development Association, USAID, Norwegian Embassy, Ethiopian Health and Nutrition
Research Institute, Ethiopian Public Health Association, and Dawn of Hope (a major PWHA
association). 380
The overarching objectives of the GFATM proposal are to reduce HIV infection by 25 percent
by 2007 and scale up baseline coverage of national strategic interventions in all regions. In
addition to the organizations already mentioned in the Donors section, other major actors with
responsibility for implementing Ethiopia's GFATM proposal include:
Family Health International
Medical Faculty of Addis Ababa University, as well as other teaching hospitals/medical
schools
CARE Ethiopia
Ethiopian Red Cross Society-Blood Transfusion Service
Johns Hopkins University
Action AID
DKT/Population Services International (social marketing of the Hiwot condom brand; also
works closely with the Ministry of Defense on training programs on HIV awareness and
proper and consistent use of condoms for military personnel posted in border areas. Worked
with military to produce a film on protecting their families from HIV/AIDS) 381

HIV/AIDS in Ethiopia 84
NGOs
Given years of centralized power, civil society in Ethiopia remains weak and underdeveloped.
Since the country has moved toward a multiparty democracy, civil society is becoming
increasingly crucial to the country's socioeconomic development; however, compared to other
African countries, Ethiopia's NGO sector is small and has limited capacity. Most NGOs are
located in Addis Ababa. 382
Nevertheless, civil society has started mobilizing against HIV/AIDS. Most NGOs concentrate on
HIV/AIDS awareness; few focus on VCT, community-based care, or social support. Activities
are largely concentrated in and around major cities and, thus far, have had little impact on rural
populations. They are also on a limited scale, reaching only a small fraction of the population in
need of services. They are not inadequately funded and are often intermittent because of irregular
and insufficient funding. 383
The World Bank believes that there is considerable scope for strengthening civil society
HIV/AIDS activities as local government (woreda, kebele) and community governance
structures have a strong relationship in Ethiopia. Ethiopian society also features prominent
traditional social groups such as the edir or mahaber, and religious committees, all of which can
be mobilized in the fight against HIV/AIDS. 384 Building on these strengths will be crucial.
However, it is unclear how much local structures can take on, given their own pressures of
poverty, drought, and AIDS morbidity and mortality.
The two national PWHA associations in Ethiopia are Dawn of Hope and Mekdim Ethiopia HIV
Positive Persons and AIDS Orphans National Association, both of which are providing an array
of HIV/AIDS services. There are also local associations of PWHA. (See the Links section for a
continually updated list of NGOs and CBOs.).
Faith-based Organizations
According to the 2000 EDHS, only 7.0 percent of women and 8.1 percent of men cited a mosque
or church as an information source for HIV/AIDS. 385 These data highlight a major "missed
opportunity" in terms of HIV/AIDS education.
There are, however, faith-based organizations in Ethiopia providing HIV/AIDS prevention, care,
and support. For example, the Ethiopian Orthodox Church, Ethiopian Evangelical Church, and
Ethiopian Islamic Affairs Supreme Council have received funding from USAID and are working
with Pathfinder International to raise HIV awareness and extend care and support services. 386
Influential religious leaders appear to be publicly supporting action against HIV/AIDS (though
not condom promotion and use). In 1999, the patriarch of the Ethiopian Orthodox Church
launched a major HIV prevention campaign. 387 In August 2002, a conference entitled "Sex,
Stigma and HIV/AIDS: African Women Challenging Religion, Culture and Social Practices"
was held in Addis Ababa and hosted by The Circle, a network of African women theologians.
The conference was opened by Ethiopia's President Girma Wolde Giorgis and attended by highranking
church leaders (though not by Muslim officials). 388

HIV/AIDS in Ethiopia 85
In November 2002, Negatu Mereke, head of HAPCO, stated that:
Orphans
The issue of condoms is quite sensitive in Ethiopia. We are not forcing anyone,
particularly those religious organizations. It is up to the religious organizations. We just
tell them about the use of condoms. We leave them to tell their followers to use condoms.
We have to be careful in using the faith-based organizations. The secular approach is
working on condoms; the religious organizations are working against HIV/AIDS in their
own way. We want them to complement [our efforts]. It is difficult for a religious
organization to advocate condoms, because one of the Ten Commandments says 'Do not
commit adultery.' If they advocate condoms they are directly violating that
commandment. So they should do it their own way. 389
Numerous NGOs and CBOs are providing support to AIDS orphans and other vulnerable
children (see the Links section). In 1998, UNICEF launched a program for street children in six
towns; it now operates the program in 14 towns, providing health education, vaccinations, and
educational support. As of April 2002, about 1,800 children in the program had been enrolled in
school. 390
Traditional Medicine
Dr. Hareya Fassil of Oxford notes that about 80 percent of Ethiopians rely on traditional, plantderived
medicines for their basic health care needs. (Given the state of the health system
discussed earlier, this figure is not surprising.) However, professional traditional health
practitioners play a much less pronounced role in rural communities than has generally been
presumed. Most ailments are diagnosed and treated at the household level. Very few informants
report seeking professional traditional help on a regular basis. When professionals are consulted,
it is often for their specialized traditional knowledge and skills pertaining to a relatively limited
range of health problems. 391
Given the above, however, one might infer that many Ethiopians with AIDS will use traditional
medicine to alleviate symptoms of OIs. The MOH has encouraged the involvement of traditional
healers in AIDS care and a national committee comprising scientists and traditional healers has
been formed. The Department of Drug Research at the Ethiopian Health and Nutrition Research
Institute is now working with traditional healers who claim to have cures for AIDS and some
OIs. 392 , 393
Blood
(Also see the Epidemiology section.) The MOH has recently published a national blood service
strategy that mandates the Ethiopian Red Cross Society (ERCS) to operate blood transfusion services
throughout the country. GFATM funding will be used to increase the number of blood banks and
initiate other improvements. 394

HIV/AIDS in Ethiopia 86
Universal Precautions
The MOH has prepared draft national guidelines on UP. GFATM funding will be used to
implement it (e.g., training, supplies, and equipment).
Post Exposure Prophylaxis
The MOH has created a policy on PEP. This involves establishing an exposure surveillance
system. Again, GFATM funding is expected to finance implementation of the strategy. 395
PMTCT
According to WHO, only 50 clients received PMTCT services in Ethiopia during 2001 (i.e.,
basic counseling, testing, and AZT or NVP treatment). There were three public/NGO sites
providing basic PMTCT services in 2001, with no such services in the commercial sector. 396
In January 2002, national guidelines on PMTCT were released. In addition, the national policy
on ART promotes improving the coverage of PMTCT in all parts of the country. With support
from UNICEF and NVP donated by Boehringer-Ingelheim, the MOH has initiated a pilot
PMTCT program. The MOH envisions using GFATM financing to scale up PMTCT to 50 sites
spanning all regions. It is also planning to implement PMTCT+ services. Addis Ababa
University's Medical Faculty is currently conducting a research project on the efficacy of a
longer course of NVP among breastfeeding mothers in three sites. 397
VCT
According to the 2000 EDHS, only 2.2 percent of Ethiopian men had been tested for HIV. A
much higher percentage of men living in Addis Ababa (16.5 percent) have been tested for HIV,
as have urban men (9.3 percent) and men with at least secondary education (8.4 percent), than
their counterparts. However, 64.8 percent of all men who have not been tested for AIDS want to
be tested. Men under age 40, those never-married, those residing in urban areas and in Oromiya
and Harari regions, and highly educated men are more likely to desire an HIV test. (The 2000
EDHS did not ask these questions of women.)
According to WHO, during 2001, only 2,400 to 3,500 clients were seen at Ethiopia's 20 publicly
funded/NGO VCT centers. (Twenty percent of VCT services were offered in the commercial
sector.) 398
The 2002 GFATM proposal stated that in 2002, the country had 23 VCT centers, of which 3
were government, 12 private, and 8 NGO. It estimated that 10,000 clients were seen at these
facilities in 2002. With GAFTM financing, this figure is projected to rise to 500,000 by year
five. 399
Almost all of the country's VCT services are located in Addis. Family Health International's
IMPACT project, funded by USAID, has assisted the Addis Ababa Health Bureau to integrate
VCT into the standard package of services in all public health centers in the city. 400

HIV/AIDS in Ethiopia 87
There is a severe lack of trained HIV/AIDS counselors in the country. According to anecdotal
evidence from Shinn, counseling done under the auspices of a church appears to
be more effective, reportedly because infected individuals put greater trust in medical personnel
associated with a church than with a governmental organization. 401
Care and Support
The Ethiopian MOH and Addis Ababa University have developed national guidelines on
HIV/AIDS care and support for adults and children. There are multiple care and support
activities occurring in Ethiopia. However, there is great disparity with regard to resources for
HIV/AIDS care and support between Addis and other regions of the country. Another constraint
is that although there are numerous care and support training activities, they are not coordinated
nor are their curricula standardized. There is a major lack of resources to coordinate the multiple
training activities conducted by Ethiopian public health institutions and international partners. As
such, there is no systematic process whereby health care providers can take advantage of these
training opportunities to ensure that their knowledge and skills keep pace with emerging best
practices. The MOH is working with CDC and HRSA through the International Training and
Education Center on HIV (I-TECH) to strengthen care and support through the establishment of
a national training center. 402
Some NGOs have been providing home-based care since 1992. National guidelines on HBC
were developed in 2001. Ethiopia's 2002 GFATM proposal outlines the need to disseminate
these guidelines throughout the country, requiring substantial investment in translating the
guidelines and related manuals into local languages and training several levels of trainers so as to
reach most kebeles. 403
ART
According to the 2002 GFATM, although national guidelines on clinical management of HIV
infection in adults and children have been in use for two years, they require updating. 404 The
World Bank loan mentioned above includes financing to help strengthen the health infrastructure
in anticipation of ART. 405 Ethiopia also plans to use GFATM funding to undertake preparatory
work for large-scale introduction of ART. 406
According to WHO, no adults with HIV/AIDS received isoniazid prophylaxis during 2001. (Data
on cotrimoxazole prophylaxis in Ethiopia were not included in the WHO report.) 407 Access to
HIV/AIDS-related care and support services in Addis, other urban areas, and rural areas is
deemed minimal. WHO reported that there were no public/NGO nor private sites providing ART
during 2001. 408
In 2001, Shinn noted that:
During the delegation’s visit, limited amounts of antiretroviral drugs were available on
the black market or purchased illegally in Ethiopian pharmacies. Within the past month,
the government has legalized the importation of these drugs. A small number of wealthy

HIV/AIDS in Ethiopia 88
individuals are taking them on an unsupervised or inadequately supervised basis. There is
virtually no capacity now to monitor the use of these drugs and few individuals can
afford them in any event. The drugs are unavailable in most of Ethiopia. 409
Some researchers are exploring alternatives to the biologic markers used to determine initiation
of ART in wealthy countries. For example, the Ethio-Netherlands AIDS Research Project has
identified simple markers to replace CD4 counts and viral load. It notes, however, that the
validity of these markers for monitoring patients' improvement following therapy remains to be
evaluated. 410
Military
The Ethiopian National Defense Force (ENDF) has approximately 100,000 personnel, rendering
it one of the largest military forces in Africa (though the number is significantly smaller than the
250,000 plus troops that existed during the Derg regime). Since the early 1990s, the ENDF has
been in transition from a rebel force to a professional military organization with the aid of the
U.S. and other countries. Training in demining, humanitarian and peacekeeping operations,
professional military education, and military justice are among the major programs sponsored by
the U.S. 411 Shinn notes that Ethiopian defense forces are often cited as being at the forefront of
HIV prevention. The Ethiopian military has developed an extensive HIV/AIDS workplan that
includes training at all levels, widespread distribution of condoms, information dissemination,
surveillance, and research. 412 A major initiative under way is deploying demobilized soldiers as
HBC providers; a database has already been established to facilitate easy access to this group. 413
In March 2003, CDC and the ENDF announced a joint HIV/AIDS project. CDC is providing
about 2.8 million Ethiopian birr (about US$325,000) for the five-year project, which will focus
on peer education. The project will also focus on the Ethio-Djibouti transportation corridor. 414
Family Health International, the Civil-Military Alliance to Combat HIV & AIDS, the POLICY
Project of The Futures Group International, the U.S. Naval Health Research Center, Population
Services International, the U.S. Department of Defense, USAID, and UNAIDS are also
participating in this project. 415
The U.N. peacekeeping mission in Ethiopia and Eritrea (UNMEE) is training troops from both
countries, as well as its own peacekeepers, to instruct fellow soldiers and civilians on HIV
prevention. Troops that have graduated from the HIV training program have been trained to help
educate their communities when they return home. 416
Other Mobile Populations
The World Food Program is working with local NGOs and transport companies to train over
2,000 WFP-employed truck drivers and their assistants in HIV/AIDS awareness and prevention.
After a rapid baseline assessment of the truck drivers' needs, 12 trainers along with regional
health officers offered three, two-hour daily sessions for 60 consecutive days. Sessions dealt with
a range of risk-reducing behaviors and included time for participants to share personal
experiences. T-shirts, cassette tapes of prevention songs, educational materials to share along
their routes, and condom "starter kits" were offered to drivers at the end of the training. All

HIV/AIDS in Ethiopia 89
participants received a card certifying their attendance. The project also involves follow-up
support through the use of peer educators. 417
The International Organization for Migration is deploying mobile units along the Ethio-Djibouti
trucking route and in a gold mining area in Ethiopia. These units are seeking to address the needs
of mobile populations such as truck drivers, merchants, gold miners, and sex workers. Each unit
has four staff, two counselors and two nurses. The units provide free services and easy access to
VCT and syndromic treatment of STIs. 418
Private Sector
According to the 2000 EDHS, only 4.2 percent of men and 1.1 percent of women had heard
about HIV/AIDS at their workplace. Note, however, that of "employed" women, 56.3 percent
work in the agriculture sector, and of these women, 93.6 percent work on their own land. Among
employed men, 83.9 percent work in agriculture (comparable data on landholding were not
available from the 2000 EDHS). 419 Thus, reaching those in rural areas is crucial.
Some workplace interventions are beginning to occur. For example, the Confederation of
Ethiopian Trade Unions and the Addis Ababa Chamber of Commerce have received funding
from USAID to implement HIV prevention programs in the workplace. 420 Some of the projects
mentioned in this paper that work with transport workers have also included transport company
owners as key stakeholders. However, to what degree these companies are themselves initiating
projects is unclear.

HIV/AIDS in Ethiopia 90
Links
Government
Ministry of Health
National HIV/AIDS Prevention and Control Office (HAPCO)
Regional AIDS Council Secretariats
AIDS Resource Center Addis Ababa. Ethiopia's premier source of
AIDS information. Searchable databases of organizations, funders, and materials. Can also
subscribe to newsletter . Managed by HAPCO
with funding from CDC and technical assistance from the Johns Hopkins University Center
for Communication Programs and Analytical Sciences, Inc.
Central Statistical Authority
Academic and Research Institutes
Addis Ababa University
Gondar College of Medical Sciences
Jimma Institute of Health Sciences
Black-Lion Teaching Hospital Addis Ababa
Zewditu Hospital Addis Ababa
Balcha Hospital Addis Ababa
Tikur Anbesa Hospital
Ramo Institute Addis Ababa
Armed Forces Hospital Addis Ababa
Miz-Hasab Research Center Addis Ababa
Ethio-Netherlands AIDS Research Project (ENARP)
Ethio-Swedish Children's Hospital Addis Ababa
Tekle-Haymanot Health Center Addis Ababa
Ethiopian Health and Nutrition Research Institute (EHNRI)
Ethiopian Medical Association
Ethiopian Public Health Association
Ethiopian Economic Association
Ethiopian Economic Policy Research Institute (EEPRI)
VCT Centers in Addis Ababa
1. Bethezata Higher Clinic
2. Blue Nile Higher Clinic
3. Arsho Electronic Laboratory
4. Tirat Higher Clinic
5. St. Gabriel Hospital
6. D’ Afrique Higher Clinic
7. Addis Ababa Poly Clinic

HIV/AIDS in Ethiopia 91
8. Medical Missionary of St. Marry
9. Menaharia Higher Clinic
10. Global Medium Clinic
11. Tekle Haimanot Higher Clinic
12. Hayat Hospital
13. Haya hulet Mazoria Higher Clinic
14. Prime Higher Clinic
15. Tikur Anbesa Hospital
16. Balcha Hospital
17. Zewditu Hospital
18. CARE Ethiopia Kazanchis Health Center
19. OSSA
20. Rabie Higher Clinic
International Partners
University of Amsterdam
Division of Public Health and Environment, Municipal Health Service, Amsterdam
Department of Public Health, Erasmus University, Rotterdam
AIDS Center, Department of Clinical Microbiology and Infectious Diseases, The Hebrew
University-Hadassah Medical School, Jerusalem
Rambam Medical Center, Haifa, Israel
Haifa District Health Office, Ministry of Health, Israel
Clalit Health Services, Haifa & West Galilee District, Haifa, Israel
Karolinska Institute, Stockholm
Department of International Health, Institute of General Practice and Community Medicine,
University of Oslo
University of Nottingham
Emerging Diseases Epidemiology Unit, Pasteur Institute Paris.
Institute of Development Studies, University of Sussex
Oxford University
McGill University AIDS Center
Harvard AIDS Institute
Johns Hopkins University Bloomberg School of Public Health
Boston University School of Public Health
Columbia University
Keck School of Medicine, University of Southern California
Ipas Sexual and reproductive health research. Based in Chapel Hill.
Population Council
International Center for Research on Women
National NGOs and CBOs
Abyssinian Health
Addis Ababa Chamber of Commerce

HIV/AIDS in Ethiopia 92
Amhara Development Association Bahir Dah.
Bahir Dar Michael Orphanage Affiliated with the Ethiopian Orthodox Church.
Beza Lewegen
Consortium of Family Planning NGOs in Ethiopia (COFAP)
Dawn of Hope Association of PWHA. Provides pre- and posttest counseling and testing
services; home-based care services; assistance to families; and education and training on
HIV/AIDS prevention and management. P.O. Box 24378, Code 1000 Addis Ababa, Ethiopia;
tel: (251) 1 560154; fax: (251) 1 560245.
Development Aid for Youth
Ethiopian Aid
Ethiopia AIDS Prevention Society
Ethiopian Trade Unions
Ethiopian Evangelical Church Mekane Yesus
Ethiopian Gemini Trust - Youth & Creative Arts
http://www.developmentgateway.org/pop/dg-contribute/itemdetail?item_id=292112&version_id=171091&from=alert
an unusual NGO which was set up
in 1983 in response to the very high death rate among twin babies in Ethiopia. It is run by
an Ethiopian staff under a Board of Trustees, and currently supports over 1,100 destitute
families for whom ...
Ethiopian Islamic Affairs Supreme Council
Ethiopian Orthodox Church
Ethiopian Red Cross Society- Blood Transfusion Service
Family Guidance Association of Ethiopia Offices in Addis Ababa, Awassa, Bahirdar,
Dessie, Nazareth
Fatumatu Zahara Aid Organization (FZAO) Offers a care and
support program for AIDS orphans, primarily in urban areas of Amhara Region.
Fifty Lemons Works through partnership-based programming,
including anti-AIDS club support, sponsorship and care of orphans, youth prevention
education, and youth behavior research.
GOAL Works with street children.
Good Shepherd Family Care Services
Hope For Children Addis Ababa
Integrated Holistic Approach Urban Development Project
Integrated Service for AIDS Prevention and Support Organization (ISAPSO) Prevention
and education, workplace programs (Ethio-Djibouti truck route, other transportation sites,
factories, construction workers), orphan care, and vocational training.
Jerusalem Association Children's Home Found in 1985 as
response to children orphaned by civil war, drought, and famine.
Love to Human Being
Mary Joy AIDS through Development Prevention and care. Outreach to street children,
capacity building for CBOs, skills training, and microcredit programs.
Medical Missionaries of Mary Counseling & Social Services Center Addis. Support to
PWHA, their families, and orphans and OVC.
Mekdim Ethiopia HIV Positive Persons and AIDS Orphans National Association
HIV awareness raising for public at large; psychological

HIV/AIDS in Ethiopia 93
support (counseling) and social support for HIV patients and AIDS orphans; home-based
care services for critically ill AIDS patients and AIDS orphans.
Nazareth Children’s Center for Integrated Development
Organization for Integrated Services for AIDS Prevention and Support (ISAPSO)
Organization for Social Services for AIDS in Ethiopia (OSSA) Addis Ababa. National
scope. Home-based care, orphan and OVC care and support. Services iplemented through
memeber organizations such as churches, mosques, other NGOs.
Save Your Generation
Tigray Development Association
YWCA of Ethiopia
International NGOs
See InterAction for comprehensive list of (primarily U.S.-based) international NGOs
working in Ethiopia: http://www.interaction.org/members
ActionAid
Adoption Advocates This is an international adoption
agency site focusing on children from Ethiopia and several other countries. Most of the
children up for adoption, though not HIV-positive themselves, have lost their mother or both
parents to HIV/AIDS.
African Humanitarian Action Funded by USAID (through Pathfinder
International) to manage a small-scale, community-level HIV prevention program.
African Partnership for Sexual and Reproductive Health and Rights of Women and Girls
(Amanitare) Partnership to consolidate the skills,
knowledge, and institutional resources of groups and individuals active in the field of sexual
and reproductive health, gender equality, and women's rights. Coordinated by RAINBO
(see below).
American Red Cross
Amnesty International
Association François-Xavier Bagnoud
Canadian Public Health Association
CARE International U.K.
CARE International U.S.
More CARE International affiliates
Catholic Agency for Overseas Development
Catholic Relief Services
Center for Reproductive Rights
Christian Aid U.K.
Christian Children’s Fund
Christian Relief and Development Association (CRDA)
Civil-Military Alliance to Combat HIV & AIDS, Rolle, Switzerland
CONCERN–Ethiopia Irish-based NGO. Funds Mekdim Ethiopia HIV Positive Persons
and AIDS Orphans National Association.
Concern Worldwide
Dan Church Aid
DKT International
Family Care International

HIV/AIDS in Ethiopia 94
German Foundation for World Population
A Glimmer of Hope
International HIV/AIDS Alliance
International Committee of the Red Cross
International Family Health
International Federation of Red Cross and Red Crescent Societies
International Food Policy Research Institute
International Organization for Migration
Marie Stopes International Reproductive
health.
Médecins Sans Frontières (MSF) Belgium
Norwegian Church Aid
Oxfam Australia
Oxfam UK
Oxfam US
PACT
People to People, Inc.
PharmAccess International
Plan International
Population Communications International
Reseach Action and Information Network for the Bodily Integrity of Women (RAINBO)
Promotes women's sexual and reproductive health and rights; focus
on female circumcision/female genital mutilation and other forms of gender-based violence.
Rotary International
Save the Children Norway
Save the Children UK
Transparency International
Uniting Churches of the Netherlands
World Council of Churches
World Vision
UN Agencies
UNAIDS
Global Fund to Fight AIDS, Tuberculosis & Malaria
WHO
Roll Back Malaria Initiative
UNDP
World Food Program
UNFPA
UNICEF
United Nations High Commissioner for Refugees (UNHCR)
UNIFEM
UNDCP

HIV/AIDS in Ethiopia 95
ILO
U.N. Office for the Coordination of Humanitarian Affairs
FAO
International Fund for Agricultural Development (IFAD)
World Bank
International Finance Corporation (IFC)
IMF
African Development Bank (AFDB)
Bilateral Donors
Canadian International Development Agency (CIDA)
Commonwealth
U.K. Department for International Development (DFID)
The British Council
European Commission
EC Food Security Network (RESAL)
Gesellschaft für technische Zusammenarbeit (GTZ)
GTZ Backup Initiative Supports countries in
obtaining funds for HIV/AIDS, TB, and malaria.
Ireland Aid
Japan International Cooperation Agency (JICA)
Norwegian Agency for Development Cooperation (NORAD)
Royal Norwegian Embassy
SNV Netherlands Development Organization
Royal Netherlands Embassy
Swedish Agency for International Development (SIDA)
USAID and
Funds projects of:
Academy for Educational Development http://www.aed.org/
Advance Africa Seeks to improve family planning and
reproductive health services reaching underserved groups.
Center for Development and Population Activities (CEDPA) www.cedpa.org
Development Alternatives http://www.ecouncil.ac.cr/devalt

HIV/AIDS in Ethiopia 96
Engender Health http://www.engenderhealth.org
Family Health International/IMPACT
Works to increase the
capacity of Ethiopian government and NGOs to implement HIV/AIDS prevention, care,
and support interventions among vulnerable populations.
Famine Early Warning Systems Network (FEWS Net)
The Futures Group International/POLICY Project
Supports the MOH in
sentinel surveillance data analysis.
INTRAH
John Snow, Inc. http://www.jsi.com or http://www.mothercare.jsi.com
Macro International http://www.macroint.com/
NGO Networks for Health
PACT
Supports organizations working with street children and children affected by AIDS. Also
addresses democracy and governance, including the rights of people living with
HIV/AIDS and the rights of children orphaned due to AIDS.
Pathfinder International
Faithbased
and workplace initiatives.
Population Council/Horizons
Population Services International/ DKT/AIDSMark
Program for Appropriate Technology in Health (PATH)
Ethiopia is one of the countries identified for increased HIV/AIDS funding under the
proposal laid out by President Bush in his January 2003 State of the Union address. As of
March 2003, the actual amount of funding was still unclear. Major concerns have also been
raised about the "gag rule" that will apply to any HIV/AIDS funding under this bill.
U.S. Centers for Disease Control and Prevention (CDC) Global AIDS Program
Priorities include VCT;
surveillance; information management; and care, support, and treatment. In December 2002,
CDC and the Ethiopian MOH signed an agreement to formalize cooperation on improving
HIV/AIDS prevention, care, and support, and strengthening capacity to address the national
HIV/AIDS epidemic through financial and technical assistance in partnership with
communities, government, and national and international organizations. 421
U.S. Centers for Disease Control and Prevention (CDC) National Prevention Information
Network Works with ARC in Addis.
U.S. Naval Health Research Center San Diego.
Working with Ethiopian military on HIV prevention and education.

HIV/AIDS in Ethiopia 97
U.S. Health Resources and Services Administration (HRSA), International Training and
Education Center on HIV/AIDS (I-TECH)
U.S. National Alliance of State and Territorial AIDS Directors (NASTAD)
Working in Addis Ababa to build capacity
of government, civil society, and the private sector to respond to HIV/AIDS through
exchange of information, resources, and experience.
Foundations
Ford Foundation
Gates Foundation
Packard Foundation
Subregional Organizations
InterAfrica Group (IAG) NGO that seeks to represent the
voices of citizens in the Greater Horn of Africa.
Nile Basin Initiative
Electronic Discussion Fora
HealthNet Ethiopia
Partnership between Satellife and Addis
Ababa University's School of Medicine. Provides access to a wide range of information
services critical to health care delivery.
AF-AIDS
Launched by the Fondation du Présent; moderated by Health & Development Networks, and
hosted by Health Systems Trust, Durban, South Africa.
African Networks for Health Research & Development (AFRO-NETS)
Hosted by SatelLife; includes links of partner organizations.
Other Information Sources
Integrated Regional Information Networks (IRIN)
News service of the UN Office for the
Coordination of Humanitarian Affairs, in partnership with ReliefWeb. Reports on political,
economic, and social issues affecting humanitarian efforts in Africa. Daily news organized
by subregion and country. Includes PlusNews, an HIV/AIDS news service.
Abbyssinia Cyber Gateway
Extensive links to Ethiopian websites.

HIV/AIDS in Ethiopia 98
AllAfrica.com: Ethiopia Compilation of daily news articles
from a variety of media outlets.
Development Information Network on Ethiopia
University of Pennsylvania: Ethiopia Resources
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HIV/AIDS in Ethiopia 99
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HIV/AIDS in Ethiopia 100
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HIV/AIDS in Ethiopia 101
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.
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HIV/AIDS in Ethiopia 102
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101 U.S. Department of State. Background Note: Ethiopia. Washington, DC: November 2001
102 U.S. Department of State. Background Note: Ethiopia. Washington, DC: November 2001
103 U.S. Department of State. Background Note: Ethiopia. Washington, DC: November 2001
104 U.S. Department of State. Background Note: Ethiopia. Washington, DC: November 2001
105 U.S. Department of State. Background Note: Ethiopia. Washington, DC: November 2001
106 U.S. Department of State. Background Note: Ethiopia. Washington, DC: November 2001
107 World Bank. Ethiopia: Country Brief. Washington, DC: February 2003
108 IRIN/UN Office for the Coordination of Humanitarian Affairs. "Eritrea-Ethiopia: Peace ''unravelling'', says
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109 International Food Policy Research Institute. Ending the Cycle of Famine in Ethiopia. February 28, 2003
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368 Global Fund Coordinating Committee of the Federal Democratic Republic of Ethiopia. The Global Fund
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394 Global Fund Coordinating Committee of the Federal Democratic Republic of Ethiopia. The Global Fund
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