A presentation by Workneh Yadete, Nicola Jones, Elizabeth Presler-Marshall and Kiya Gezehagn to the 15th Annual Conference of the Ethiopian Society of Sociologists, Social Workers and Anthropologists (ESSSWA), March 2019

1. 21/07/2020
Workneh Yadete, Nicola Jones, Elizabeth Presler-Marshall, Kiya Gezehagn
March 2019
Accelerating progress on eliminating HIV by
focusing on adolescent lives

2. HIV/AIDS in Ethiopia
 It is estimated that nearly 720,000 Ethiopians are HIV+ (FHAPCO).
 Of young people aged 15–24, girls are 5 times more likely to be HIV + than boys (2012
EDHS).
 Ethiopia is not on track to meet its 2020 goals of 90% know their status/90% in
treatment/90% have viral suppression, nor the 95/95/95 targets by 2030.
• UNAIDS (2017) reports that new infections are only down 5% since 2010.
• Girum et al. (2018) estimate that rates of infection are actually increasing since 2008.
• Testing, not ARV uptake, is preventing progress:
 Less than 60% of people over the age of 15 have ever been tested (2016 EDHS).
 It is estimated that only 2/3 of those living with HIV know that they are HIV+ (Girum et
al., 2018).
 Stopping the backslide and accelerating progress requires focusing on adolescents’ age- and
gender-related risk factors.

3. What is GAGE?
© Natalie Bertrams / GAGE 2019

4. Gender and Adolescence: Global Evidence (GAGE):
A longitudinal research programme (2015-2024)
By finding out ‘what works,’ for whom, where
and why, we can better support adolescent girls
and boys to maximise their capabilities now and
in the future.
We are following the largest cohort of adolescents in the Global South

5. GAGE research sample
Baseline (2017-2018)
ETHIOPIA: 6700 total
Rural: 4700, Urban: 2000,
Pastoralist: 500, Disability: 360
Baseline (2017-2018)
ETHIOPIA: 220
girls/boys
Annual cohort (2018-2019)
ETHIOPIA: 200 adolescents

6. GAGE Ethiopia Research Sites
 3 regions (Afar, Amhara, Oromia) + Dire
Dawa City Administration
 Research site selection based on:
• Districts with among highest rates of
child marriage as proxy for
conservative gender norms (MOWCA,
UNICEF and ODI, 2015)
• Urban and rural sites
• Food insecure and pastoralist sites as a
proxy for economic poverty
• Woreda based mapping of all kebeles
based on infrastructure and service
availability (vulnerable/ less
vulnerable)
• Programming capacities of NGO
implementing partners

7. Adolescent risk
factors
© Natalie Bertrams / GAGE 2019

8. Urbanisation and migration are central drivers
 Key informants report that HIV rates in urban areas are high – with rural-to-
urban migrants at elevated risk.
‘Girls who have come from the rural areas (are at risk of HIV) because they have
little awareness about the disease.’ (Preparatory student, Dire Dawa)
 Work-related migration is spreading HIV from towns and cities to more rural
areas.
‘Migration is the main reason for HIV prevalence, when people migrate they
bring back the disease that they pick from there and spread the infection here.’
(Woman, Community C)
‘The main problem for young people (when they migrate) is disease. Some
people are caught with HIV/AIDS.’ (Woman, Community D)

9. Young males spread HIV between communities
‘The men are the ones bringing the disease most of the time.’
(Woman, Community C)
 Boys’ and men’s sexual practices spread STI’s, including HIV. They visit
CSWs and keep concubines in town.
‘I try to tell the girls that the current generation of boys have sexual
experiences with women when they go to Metema. I am sure we can’t find
a young man who didn’t go to Metema in the name of work.’
(Women’s Affairs KI, Community G)
‘In this particular area, having “qimit” or “gulit” [a mistress] is considered
as prestigious and sense of pride, even it is practiced among kebele
officials.’ (Religious leader, Community E)

10. Boys have age-related risk factors
 Adolescent boys and young men feel invincible.
‘The youth have not worried about HIV.’ (Justice KI, Community G)
‘He tells me I am too worried and no one can trick him’ (Mother, Debre Tabor)
‘They (youths) also said “there is no AIDS after 6:00pm (at the night time).” As a result
the youths and adults have become patients.’ (Adult, Community F)
 Substance use increases risk.
‘After youths have taken alcoholic drinks they have sexual relationships without using
condoms.’ (Adult, Community F)
‘It is being highly transmitted because of many night clubs. When adolescents go to the
night clubs, they will get drunk and exposed to unprotected sex.’
(preparatory student, Dire Dawa)

11. Girls are most at risk of infection
 Females are more biologically susceptible to HIV infection.
 Adolescent girls are socially more at risk – they are the most desirable partners in terms of
marriage and extra-martial sex.
‘Most of the males wanted to made sexual relationships with adolescent girls at their lower
age.’ (Justice KI, Community G)
 They are at risk of sexual violence in rural and urban settings.
‘The majority of the girls raped were those attending school. In addition, girls have also been
raped when they collect fuel wood in the forest area and fetch water.’
(Justice KI, Community G)
‘There is a tablet that makes you feel sleepy. After they go there the boy will add it to Coca-
Cola or any other soft drinks when she goes to toilet. She drinks it. Then he does whatever he
wants.’ (Young adolescent girl, Dire Dawa)

12. Child marriage increases girls’ risk
 Nationally, the age of marriage is increasing – but the proportion of girls who are
married before the age of 18 is relatively static: about 40%.
 In some areas, girls now have more input into who and when they will marry.
 Ethiopian wives are generally 5–7 years younger than their husbands.
 Gender norms mean women have little ability to refuse sex or insist on safe sex.
 Due to their age, adolescent girls have the least voice and the fewest exits.
‘I was 17 years old. My mother told me to get married to a man. We lived together for
less than 1 year. The man is from Metema, he knows as he is HIV positive. When I
tested HIV, my husband left the area, he went back to his place.’
(19-year-old HIV+ divorced girl, Community D)
‘They could not divorce with their husbands easily.’ (Mother, Community D)

13. Changing sexual practices increase girls’ risk
 In Amhara, pre-marital sex is increasing girls’ exposure – especially given that stigma and
silence preclude disclosure.
‘If they are above 15 years, they are not a virgin.’ (Older boy, Community C)
‘They live in secret. Because around here even if you have another disease people say it's HIV.’
(Older girl, Community D)
 In Oromia and Afar, shifts in cultural dances may be increasing the risk of HIV. In East
Haraghe, shegoye dances are increasingly lasting all night long and providing opportunities
for young people and possibly providing opportunities to engage in sex.
‘In the previous time, people did not allow them to spend the night.’ (Father, Community K)
 In Zone 5, Sadah dances expose even quite young adolescents to sex.
‘Those who need each other would come closer for dancing… I give a sign to a girl whom I
love most and persuade her to go to somewhere nearby.’ (Older boy, Community A)

14. Limited options increase girls’ risk
 Poverty and school failure are pushing some girls into risky sexual behaviours.
‘Out-of-school girls from poor families and school girls who did not pass grade 10 or
dropped out from primary school are now becoming prostitutes and concubines,
especially in small rural towns in [Community D]. These girls are exposed to HIV/AIDs’
(Justice KI, Community G)
 ‘Failed’ child marriages push girls into commercial sex work.
‘The majority of them come from other areas after divorcing with their marriage
partner.’ (Older girl, Community D)
 Many girls understand the risk they are taking – but do not have viable income-
generating alternatives.
‘We also fear dying due to HIV/AIDS but it better than dying with hunger.’
(16-year-old CSW, Community D)

15. Summary and policy
and programming
implications

16. Strengthen knowledge, especially in rural areas
 Messages about HIV are generally available in schools, clinics, radio, markets, and religious
institutions.
‘Our office closely works with the health office in creating awareness among vulnerable social groups
and adolescent school boys and girls about the spread of HIV/AIDs and how to protect themselves from
the disease and how to prevent its spread. Adolescent girls and boys in all primary schools are our target
groups in creating awareness about reproductive health and HIV/AID through school health clubs.’
(BOWCA KI, Amhara)
 In urban areas, even young adolescents sometimes have very good information.
‘We learn in the school that HIV/AIDS has been expanding in Ethiopia. The causes for HIV/AIDS include
unprotected sexual relationships, use of sharp things, etc. Most of the time, young people are exposed to
HIV/AIDS.’ (11-year-old boy, Dire Dawa)
 Implication for action: In rural areas, expand awareness raising efforts to address knowledge
barriers. ‘Many people don’t know what a condom is. If you ask one women, how she use a
condom, she will ask you back what a condom is?’ (Kebele chair, Community D)

17. Promote testing for all
 Testing increasingly happens prior to marriage in urban areas and in study communities in Amhara.
‘The couples take HIV/AIDS test when they get marry. If a girl or a boy is caught with HIV/AIDS, they stops
the marriage.’ (Plder girl, Community D)
 Adolescent friendly services – including testing – is available in some urban areas.
‘They got any reproductive health service in night time to make them free from any kind of shame.…We
give advice to use the service freely.’ (Health KI, Dire Dawa)
 Many young people do not want to be tested.
‘Though we provide advocacy service to have a medical test they are not willing to attend and didn’t get
medical examination.’ (Religious leader, Community E)
 Married couples do not test regularly, despite evidence of extra-marital sexual relationships.
‘The problem is that they made the blood text only once and there is no people checking their blood after
married.’ (HEW, Community F)
 Implication for action: testing needs to be made routinely available in a variety of settings (e.g. clinics,
markets, youth centres) and be provided in confidential and non-stigmatising ways.

18. Ensure condoms are widely accessible –
physically and socially
 There is evidence that some adolescents have – and use – condoms.
‘All of them (unmarried adolescent boys) use condoms.’ (HEW, Community L)
‘I give 3 boxes of condom for one adolescent. I did that to make them close and open to me.’ (Women
Association KI, Batu)
 Condom supply is limited—especially in rural areas and for boys and young men.
‘There is a shortage of condoms in Debre Tabor town in particular and at the national level in general.’ (HEW,
Debre Tabor)
‘Boys can get condoms in any drug store, but they are not free.’ (Preparatory students, Dire Dawa)
 Demand for condoms is also limited.
‘Men are not willing to use condom.’ (Religious leader, Community E)
‘Men want to have unprotected sex.’ (Adolescent CSW, Batu)
 Implication for action: urgent measures need to be taken to make condoms widely available and free of
charge in clinics, workplaces, youth centres, university campuses, secondary schools and media-based
behavioural change communication campaigns launched to shift perceptions of condom use.

19. Expand access to ARVs
 Even in rural areas, most of those who know that they are HIV+ take ARVs.
 Transportation to reach medical centres that dispense ARVs is expensive.
‘The cost of transport is very expensive for me. I spend 200 birr every month to collect our
medicine.’ (HIV+ mother, Community D)
 Nutrition needs are higher and add to associated costs.
‘I am ok when I eat well and take the medicine. I start to experience symptom after I lack food to
eat.’ (HIV+ mother, Community D)
 Younger people who are HIV+ have limited access to social protection to offset costs.
‘We are not safety net beneficiaries, I asked to get support from safety net but they said since you
are young you should work.’ (19-year-old HIV+ divorced girl, Community D)
 Implication for action: Ensure that people understand viral suppression prevents both illness
and spread; expand availability of ARVs to local clinics; and consider linking financial and
nutritional support to PSNP direct support programme.

20. Focus on adolescents’ age- and gender-related risks
CSW63
To tackle risks of HIV for young people prioritise the following:
 Step up efforts to prevent child marriage.
 Expand substance abuse education and directly link messages to
risky sex.
 Improve access to secondary school and decent employment to
encourage longer-term thinking.
 Grow girls’ voices through empowerment programming.
 Provide positive masculinities programming for boys.

21. Contact us
WEBSITE:
www.gage.odi.org
TWITTER:
@GAGE_programme
FACEBOOK:
GenderandAdolescence
About GAGE:
• Gender and Adolescence: Global Evidence (GAGE) is
a nine-year (2015-2024) mixed-methods longitudinal
research programme focused on what works to
support adolescent girls’ and boys’ capabilities in the
second decade of life and beyond.
• We are following the lives of 18,000 adolescents in
six focal countries in Africa, Asia and the Middle East.