Gender, Early Marriage and HIV Infection in Amhara Region and Addis

Evidence suggests that girls who marry early have increased risk of HIV infection, even compared to their

unmarried sexually active peers. A study in Kenya and Zambia revealed that married adolescent girls have

50% higher HIV rates compared with unmarried sexually active girls. Married girls' high infection rates are

related to more frequent intercourse, almost no condom use, and husbands who are significantly older,

more experienced, and more likely to be HIV-positive compared with boyfriends of unmarried girls.

Amhara region has the lowest age at marriage in the country, with 46% of girls marrying by 15 years. Most

of these girls have not had sex before marriage and, in this population, the earlier a girl marries, the earlier

she has sex. In addition, Amhara region has one of the highest rates of divorce in the world, with early

marriage being a predictor of divorce (Tilson and Larsen, 2000). Demographic and Health Survey (DHS)

data from Ethiopia highlights that the HIV epidemic is concentrated among ever-married women, including

young women. Ethiopian women who are divorced are a population highly affected by HIV, with 8.1% of

divorced women HIV-positive, nationally.

The HIV epidemic in Ethiopia is concentrated in urban areas of the country; however, it disproportionately

affects migrants to urban areas, rather than natives. Many young women migrate to urban areas following

divorce, to pursue educational or livelihoods goals, or to escape early marriage. A study by Population

Council in low-income areas of Addis Ababa found that 45% of adolescent girls had migrated from rural

areas; among the most common reasons given for migration were education, work, and to escape early

marriage (Erulkar et. al. 2006). Though migrants hope for a better future in urban centers, many end up

highly vulnerable, often in low-paid and exploitive domestic work or in sex work. Being economically

vulnerable and socially isolated, such girls and young women are highly vulnerable to forced or coerced

sex, transactional sex for daily or periodic support, and negative reproductive health outcomes, including

HIV infection. Indeed, among young urban women below the age of 30, 6.8% of migrants to the urban

center are HIV-positive compared to 2.8% of young women who are native to the urban area; likewise 16%

of urban women who are divorced and migrated to the area are HIV-positive (PC tabulations of 2005

Ethiopian Demographic and Health Survey (EDHS)).

This gender, early marriage and HIV infection activity addresses the HIV risks associated with early

marriage as well as associated divorce, and migration. 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 beforehand may help delay marriage, prevent transmission and/or foster

long-term faithfulness. Delaying marriage may result in lower rates of divorce and related migration

following divorce. Few programs have addressed the HIV risk of pre-married and married adolescent girls,

including the risk of migration, either escaping marriage or following divorce. This activity implements

community awareness and premarital voluntary counseling and testing (VCT) interventions in Amhara to

promote later, safer, chosen marriage and marital fidelity. In view of unequal marital relationships, this

activity develops interventions encouraging married men to remain faithful. Key faith and community leaders

will reinforce these messages.

This expansion of a continuing activity will be undertaken in urban and peri-urban areas of Bahir Dar,

Gondar, Debre Markos, Dessie, and Addis Ababa, with the latter three being new sites during the current

year. All districts are contiguous with the urban centers and along truck routes, where many girls migrate in

the event of divorce and where many husbands go on market days, often representing an opportunity for

drinking and/or engaging in extramarital relations. Strategies include: 1) educating communities on the risks

associated with early marriage, marital HIV transmission and promoting faithfulness, 2) promoting

premarital VCT for engaged couples and VCT for married couples, and 3) supporting and educating married

adolescent girls and their husbands through clubs.

Religion is a powerful force in Ethiopia and for many communities the church may be their only sustained

institutional contact. An additional 1000 religious leaders will be trained through ‘Days of Dialogue,' to reach

congregations and community members with prevention messages, tailored to the nature of HIV risk in

Amhara. Over 1,000,000 individuals will be reached with prevention messages related to HIV, delaying

marriage, male norms and behaviors, faithfulness, and premarital VCT. During the current year, core

messages will integrate information on linkage between early marriage, divorce, migration, and vulnerability,

as well as male norms and risks associated with market days and other types of short term movements.

Two hundred selected religious and community leaders from the new project sites will be trained as VCT

promoters to promote premarital VCT and refer couples to VCT sites. Clients testing positive will be

provided ongoing support and referral to existing care and support services.

This activity will establish married girls' clubs to reach over 15,000 married adolescent girls, providing

venues through which girls can receive information, advice, and social support, including in instances where

they feel their husbands pose HIV risk or when they are contemplating migration. The clubs will include

livelihoods and mentoring opportunities, as well as non-formal education and HIV information and referral.

In collaboration with EngenderHealth's Male Norms Initiative, the activity will establish married men's clubs,

reaching 12,000 men, as a venue through which to discuss male roles and gender norms, gender based

violence, and faithfulness, among others.

This activity will be closely linked to Engender Health's Male Norms Initiative in establishing men's clubs to

promote faithfulness in marriage and creating a positive male role in gender norms and gender based

violence; contributing to reduction of violence. It will also be linked to counseling and testing programs

through referrals for pre-marital VCT. The focus of the program will be young girls (married and unmarried)

thereby addressing gender equity in HIV programming. It will also increase the girls' access to income and

productive resources through the non-formal education and livelihood skills training that they receive

through their clubs. The faith-based organizations, Amhara Regional Youth & Sports Bureau, and other

local organizations partnering with Population Council will have their capacity built in through trainings

directed at addressing the problem at the community level.

The program conforms to the PEPFAR Ethiopia Prevention Strategy of targeting high-risk groups; and uses

existing faith and community structures to reach the young women (especially those at risk of migration),

(prospective) husbands, their families and communities that support early marriage.

Preventing Early Marriage in Amhara Region

Evidence suggests that girls who marry early have increased risk of HIV infection, even compared to their

unmarried, sexually active peers. A study in Kenya and Zambia revealed that married adolescent girls have

50% higher HIV rates compared with unmarried, sexually active girls. Married girls' high infection rates are

related to more frequent intercourse, almost no condom use, and husbands who are significantly older,

more experienced, and more likely to be HIV-positive compared with boyfriends of unmarried girls.

Amhara region has the lowest age at marriage in the country, with 46% of girls marrying by 15 years. Most

of these girls have not had sex before marriage and, in this population, the earlier a girl marries, the earlier

she has sex. In addition, Amhara region has one of the highest rates of divorce in the world, with early

marriage being a predictor of divorce (Tilson and Larsen, 2000). Data from the 2005 Ethiopian Demographic

and Health Survey (EDHS) highlights that the HIV epidemic is concentrated among ever-married women,

including young women. Ethiopian women who are divorced are a population highly affected by HIV, with

8.1% of divorced women HIV-positive, nationally.

The HIV epidemic in Ethiopia is concentrated in urban areas of the country; however, it disproportionately

affects migrants to urban areas, rather than natives. Many young women migrate to urban areas following

divorce, to pursue educational or livelihoods goals, or to escape early marriage. A study by Population

Council (PC) in low-income areas of Addis Ababa found that 45% of adolescent girls had migrated from

rural areas; among the most common reasons given for migration were education, work, and to escape

early marriage (Erulkar et al., 2006). Though migrants hope for a better future in urban centers, many end

up highly vulnerable, often in lowly paid and exploitive domestic work or in sex work. Being economically

vulnerable and socially isolated, such girls and young women are highly vulnerable to forced or coerced

sex, transactional sex for daily or periodic support, and negative reproductive health outcomes, including

HIV infection. Indeed, among young, urban women below the age of 30, 6.8% of migrants to the urban

center are HIV-positive compared to 2.8% of young women who are native to the urban area; likewise 16%

of urban women who are divorced and migrated to the area, are HIV-positive (PC tabulations of 2005

EDHS).

The gender, early marriage and HIV infection activity addresses the HIV risks associated with early

marriage, as well as those associated with divorce and migration. 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 beforehand may help delay marriage, prevent transmission, and/or

foster long-term faithfulness. Delaying marriage may result in lower rates of divorce and related migration

following divorce. Few programs have addressed the HIV risk of pre-married and married adolescent girls,

including the risk of migration, either escaping marriage or following divorce. This activity implements

community awareness and premarital voluntary counseling and testing (VCT) interventions in Amhara to

promote later, safer, chosen marriage and marital fidelity. In view of unequal marital relationships, this

activity develops interventions encouraging married men to remain faithful. Key faith and community leaders

will reinforce these messages.

This expansion of a continuing activity will be undertaken in urban and peri-urban areas of Bahir Dar,

Gondar, Debre Markos, Dessie, and Addis Ababa; the latter are being new sites during the current year. All

districts are contiguous with the urban centers and along truck routes, where many girls migrate in the event

of divorce and where many husbands go on market days, often representing an opportunity for drinking

and/or engaging in extramarital relations. Strategies include: 1) educating communities on the risks

associated with early marriage, marital HIV transmission, and promoting faithfulness, 2) promoting

premarital VCT for engaged couples and VCT for married couples, and 3) supporting and educating married

adolescent girls and their husbands through clubs.

Religion is a powerful force in Ethiopia, and for many communities the church may be their only sustained

institutional contact. An additional 1,000 religious leaders will be trained through ‘Days of Dialogue,' to reach

congregations and community members with prevention messages, tailored to the nature of HIV risk in

Amhara. Over 1,000,000 individuals will be reached with prevention messages related to HIV, delaying

marriage, male norms and behaviors, faithfulness, and premarital VCT. During the current year, core

messages will integrate information on linkage between early marriage, divorce, migration, and vulnerability,

as well as male norms and risks associated with market days and other types of short-term movements.

Two hundred selected religious and community leaders from the new project sites will be trained as VCT

promoters to promote premarital VCT and refer couples to VCT sites. Clients testing positive will be

provided ongoing support and referral to existing care and support services.

This activity will establish married girls' clubs to reach over 15,000 married adolescent girls, providing

venues through which girls can receive information, advice, and social support, including in instances where

they feel their husbands pose HIV risk or when they are contemplating migration. The clubs will include

livelihood and mentoring opportunities, as well as informal education and HIV information and referral. In

collaboration with EngenderHealth's Male Norms Initiative, the activity will establish married men's clubs,

reaching 12,000 men, as a venue through which to discuss male roles and gender norms, gender-based

violence, and faithfulness, among others.

This activity will be part of the HVAB 10521 activity, but with more focus on the male behavior change and

will include condom promotion. This activity will be closely linked to Engender Health's Male Norms Initiative

in establishing men's clubs to promote faithfulness in marriage and creating a positive male role in gender

norms and gender-based violence; this will contribute to reduction of violence. The activity will also be

linked to counseling and testing programs through referrals for pre-marital VCT. The focus of the program

will be young girls (married and unmarried,) thereby addressing gender equity in HIV programming. It will

also increase the girls' access to income and productive resources through the informal education and

livelihood skills training that they receive through their clubs. The faith-based organizations, Amhara

Regional Youth & Sports Bureau, and other local organizations partnering with Population Council will have

their capacity built in through trainings directed at addressing the problem at the community level.

The program conforms to the PEPFAR Ethiopia Prevention Strategy of targeting high-risk groups; and uses

existing faith and community structures to reach the young women (especially those at risk of migration),

husbands or prospective husbands, their families, and communities that support early marriage.

Activity Narrative: Preventing Early Marriage in Amhara Region

Adolescent Girls, Early Marriage and Migration

Amhara Region has the lowest age at marriage in the country, with 46% of girls marrying by 15 years. Most

of these vulnerable girls have not had sex before marriage and, in this population, the earlier a girl marries,

the earlier she has sex. Orphan girls are more likely to experience early marriage than non-orphans. In

addition, Amhara region has one of the highest rates of divorce in the world, with early marriage being a

predictor of divorce (Tilson and Larsen, 2000). A study by Population Council (PC) in low income areas of

Addis Ababa found that 45% of adolescent girls had migrated from rural areas; among the most common

reasons given for migration were education, work, and to escape early marriage (Erulkar et. al. 2006).

Though migrants hope for a better future in urban centers, many end up highly vulnerable, often in lowly

paid and exploitive domestic work or in sex work. Being economically vulnerable and socially isolated, such

girls and young women are highly vulnerable to forced or coerced sex, transactional sex for daily or periodic

support, and negative reproductive health outcomes, including HIV infection. Evidence suggests that girls

who marry early have increased risk of HIV infection, even compared to their unmarried sexually active

peers. A study in Kenya and Zambia revealed that married adolescent girls have 50% higher HIV rates

compared with unmarried sexually active girls. Married girls' high infection rates are related to more

frequent intercourse, almost no condom use, and husbands who are significantly older, more experienced,

and more likely to be HIV-positive compared with boyfriends of unmarried girls.

Few programs, especially OVC programs, have addressed the specific needs of married adolescent girls,

including the risk of migration, either escaping marriage or following divorce. Due to social and cultural

definitions of childhood, once a girl is married she is no longer considered a child regardless of her age or

stage of development. OVC programs working with communities to identify OVC need to take this issue into

consideration. This activity will assist OVC programs with meeting the specific needs of adolescent girls

who have migrated without adult supervision to urban centers most often to escape early marriage.

This activity will complement the continuing Population Council AB activity and will be undertaken in urban

and peri-urban areas of Bahir Dar, Gondar, Debre Markos, Dessie, and Addis Ababa with the latter three

being new sites during the current year. All districts are contiguous with the urban centers and along truck

routes, where many girls migrate. The objectives of this activity are 1) developing tools and training for OVC

programs on meeting the needs of adolescent girls experiencing or escaping from early marriage 2)

providing services and referrals to female OVC who have migrated to low income urban centers. Services

to be provided include emotional and social support from adult female mentors, non-formal education, HIV-

prevention information, livelihoods training including financial literacy and entrepreneurship, and referrals to

post-rape counseling, health services, VCT, PMTCT, and ART. Population Council will partner with

economic growth programs specializing in livelihoods for vulnerable populations to provide guidance on

entrepreneurship training and employment strategies and resources. Linkages with programs addressing

exploitive child labor will be made to leverage experience and capacity.

In four urban areas of Amhara Region (Bahir Dar, Gondar, Debre Markos and Dessie) and Addis Ababa,

the activity will establish girls' groups for the most vulnerable, out-of-school, migrant girls, including

domestic workers. The groups, led by adult female mentors, will provide a safe space for girls to discuss

their problems, obtain peer support, and engage with supportive adults. Providing non-formal education to

girls in these groups will allow them to catch up with their interrupted or missed education. Different types of

livelihood skills training will be given to enable them to work and support themselves and therefore prevent

engaging in risky behavior for sustaining themselves.

Over 7500 of the most vulnerable migrant girls will be reached in COP08 through 100 trained female

mentors. Groups will be managed by the local ward administrations as well as local NGOs, to be identified.

Site selection will be done in collaboration with OVC programs to ensure maximum use of resources and

avoid duplication. Female mentors will serve a pivotal role in identifying needs, providing support, and

making and following up on referrals. The activity will build on lessons learned from the pilot project "Biruh

Tesfa" (Amharic for ‘Bright Future') program for vulnerable adolescent girls in the Mercato, area of Addis

Ababa. Through this pilot project, the most vulnerable urban girls are recruited house to house by female

mentors, who negotiate directly for the girls' participation with gatekeepers, including employers of domestic

workers.

Assistance to OVC programs will include provision of technical input on how to improve reach and depth of

services to adolescent girls who have migrated to urban and peri-urban areas. South-to-south exchanges

will be facilitated between OVC program and activities in Kenya that are addressing the impacts of early

marriage and migration of girls.

The activity will focus on vulnerable adolescent girls and therefore increase gender equity in HIV/AIDS

programs. The Population Council, through lessons learned from this program, will continue to lead

PEPFAR partners in enhancing programming directed to address the needs of vulnerable girls and young

women. The program will also include capacity building to partnering ward administration offices and local

NGOs to help them recognize the impacts of girls experiencing early marriage and how to address their

needs.

The activity will apply the recently drafted Standards of Services for OVC in Ethiopia and conform to the

PEPFAR Ethiopia Prevention Strategy of targeting high risk groups. Faith and community structures will be

engaged in identifying and providing support to adolescent girls their prospective husbands, their families

and communities that support early marriage. The program will link closely with Population Council's Safer

Marriage activity in the Amhara Region since that activity will focus on prevention of early marriage and

prevention of marital transmission of HIV through messages for the community, use of faith based

structures at the community level and promoting faithfulness in marriage.