Gender, Early Marriage and HIV Infection in Amhara Region

This is a continuing activity. The partner received 100% of FY06 funding in June 2006 and began start-up activities during August 2006. This activity will specifically focus on addressing social norms that lead to the sexual transmission of HIV among young girls with older men. Recent research has contributed to emerging evidence that girls who marry early may be at an increased risk of HIV infection, even compared to their unmarried sexually active counterparts. A study in Kenya and Zambia, using biomarker and survey data revealed that married adolescent girls aged 15 to 19 had 50% higher rates of HIV compared to unmarried sexually active girls. Analysis revealed that married girls' rates of HIV infection were related to increased sexual frequency, almost total lack of condom use, and husbands who were significantly older, more experienced, and more likely to be HIV infected compared to boyfriends of unmarried girls. Data from Malawi suggests that while only two percent of girls enter marriage HIV+, 20% of grooms are HIV+ at the time of marriage. Ethiopia's Amhara region has the highest rates of HIV prevalence and the lowest age at marriage in Ethiopia with 42% of girls marrying by age 15. The vast majority of these girls have not had sex at the time of marriage. The fact that early marriage and high HIV infection co-exist in Amhara may suggest that early marriage is fueling the spread of the disease. Communities often erroneously assume that marrying girls off will prevent premarital sex and HIV infection. Understanding the HIV risks of marriage and knowing each other's HIV status before marriage may help delay marriage, prevent transmission and/or foster long-term faithfulness.

Few, if any, programs in Ethiopia have addressed the HIV risk of pre-married and married adolescent girls, a sizeable, high-risk population. This activity will implement interventions in Amhara region to support later, safer, and chosen marriage and forge faithfulness within marriage through community awareness and premarital VCT. Recognizing the unequal power relations within marriage, this activity will also develop interventions encouraging married men to remain faithful. Key faith and community leaders will be used to reinforce these messages. This activity will take place in six woredas in Amhara region in West Gojjam and North Gondar zones, reaching a population of over 1,200,000. Religion is a powerful force in Ethiopia and for many remote rural communities the faith structures may be their only sustained institutional contact. This activity will coordinate activities with the ongoing IOCC-DICAC and Pact-EMDA programs to undertake "Days of Dialogue' involving 800 faith leaders from the 400 faith institutions in the project area. The result will be core messages to educate communities on the HIV risks associated with early marriage, and promote later, safer marriage and premarital VCT. One community or faith leader from each of the 200 Peasant's Associations will be trained as VCT advocates. Community VCT advocates will promote premarital VCT and refer couples to premarital VCT sites. Given that VCT services may be at some distance from rural locations, the cost of transportation for couples will be subsidized using a coupon referral system, allowing the tracking of referrals. Clients testing positive will be provided ongoing support and referral to existing care and support services. This activity will establish 200 married girls' clubs to give girls a venue through which they can receive information, advice, and social support, including in instances where they feel their husbands pose HIV risk. The clubs will be managed by a local FBO and include livelihoods and mentoring opportunities with adult married women and periodic assembly of larger extended family groups, including husbands and in-laws. The program conforms to the PEPFAR Ethiopia Prevention Strategy of targeting high risk groups. The program utilizes the existing faith and community structures to reach the young girls, (prospective) husbands, their families and communities that support early marriage in rural hotspots with high HIV prevalence rates. The specific project objectives are: (1) To provide technical assistance to the local partners on gender issues, specifically related to early marriage, coercive sex and the vulnerability of young girls; (2) To delay sexual initiation among unmarried adolescent girls in Amhara region by promoting social change and awareness of the RH and HIV transmission risks for married adolescents. (3) To promote premarital VCT for couples before marriage to foster long-term behavior change and faithfulness. (4) To improve HIV knowledge of married adolescent girls and their husbands through HIV prevention information, education and referrals through married girls' clubs and related couples' activities. (5) To increase the information related to the risks and vulnerabilities of married and pre-married girls in Amhara region in order to contribute to programming that responds to their circumstances (year one).

To achieve these goals and objectives, four strategies will be undertaken, namely: (1) Working with religious and community leaders as advocates to promote dialogue on HIV/RH risks and child marriage at the community level. (2) Creating demand for expanding premarital VCT "pre-counseling" and referral, through religious leaders and other community leaders. (3) Creating clubs for married adolescent girls and related activities for couples through which married girls and their husbands will receive HIV prevention education, information related to reproductive health, and referrals for VCT, PMTCT, ART and other reproductive health services, particularly safe motherhood services. (4) Working with religious and community leaders to create an environment supportive of faithfulness for young married men.

Added July 2007 Reprogramming: In addition to activities around mitigating risks of HIV infection due to early marriage, the partner will initiate urban-focused programs with females migrating to urban areas where no coping structures exist. Programs will improve risk perception and awareness well networking these girls to existing community services and the public health system.

Population Council was funded in FY06 and FY07 for HIV prevention activities. After analysis of the Population Council program for HIV prevention and early marriage, FY07 OVC funds were reprogrammed to the Population Council mechanism to support comprehensive HIV prevention programming for older adolescent girls who migrate to urban areas where HIV prevalence rates are high. This funding request represents utilizing HIV prevention and OVC funding streams to address this target population. OVC funds will be utilized within the existing program to identify highly vulnerable adolescent girls (OVC) in Bahir Dar and Addis Ababa and provide information, address factors placing them at high risk for HIV infection including unwanted pregnancy, social isolation, family living arrangements, support systems and safety nets. This is an urban-based activity that will strengthen access to information and OVC services including referral to medical services for girls migrated to urban areas and are highly vulnerable to engaging in transactional sexual relationships for survival.

Migrants are socially isolated and highly vulnerable girls who are typically without coping structures (family and adult supervision, housing, income) to mitigate the risk of HIV infection through transactional sex. This can be done through a local organization working with migrant girls in areas where they congregate.