HIV Prevention Activities in Gambella

This is a continuing activity from FY07 reprogrammed funding. In FY08, funds for this activity will be split

evenly across AB ($125,000) and OP ($125,000).

Gambella is the westernmost region of Ethiopia, bordering Sudan. The region is sparsely populated with the

Ethiopian Central Statistics Agency estimating a regional 2005 population of only 247,000, 80% of whom

live in rural areas. Pastoralism and agriculture are the major economic activities for the people of Gambella.

One of the major ethnic groups in Gambella is the Anuak people, who comprise about 30% of the region's

population. The Anuak are considered to be ethnically, culturally, linguistically, historically and religiously

different from most other Ethiopians, and there have been ethnic conflicts in recent years in the region with

significant tensions persisting.

The 2005 Demographic and Health Survey (DHS) revealed a surprisingly high HIV prevalence of 6.0% in

Gambella region. Gambella has the highest regional prevalence recorded by the DHS and is nearly three

times higher that the national prevalence of 2.1%. Behavioral data also reveals high levels of risk behavior.

Compared to other regions and the national average, men in Gambella reported high rates of multiple

partners, high-risk sex, life-time sex partners, and having paid for sex. Women in Gambella reported higher

than average risky sexual behavior. The draft Epidemiological Synthesis of HIV/AIDS in Ethiopia,

commissioned by HIVAIDS Prevention and Control Office (HAPCO) and the World Bank, identifies

Gambella as a "hotspot." Gambella's circumcision rate is the lowest in the country, with only 47% of men

circumcised, compared to a national rate of 93% for circumcision coverage. Furthermore, there are very few

civil society groups working on HIV in Gambella, and USG-supported prevention efforts in Gambella prior to

FY07 reprogramming have been largely limited to work in the refugee camps on the Sudanese border. Pact

is one notable exception with its Track 1 Abstinence and Being Faithful youth program Y-CHOICES which

has been active in four districts in Gambella since FY06.

Through reprogrammed FY07 funds, Pact will expand HIV-prevention interventions focused on behavior

change to address the prevention needs of adults in Gambella. Building off of a similar approach to that of Y

-CHOICES, Pact will provide technical assistance and organizational capacity development support to a

select number of local organizations that will carry out the prevention interventions in Gambella. However,

there is very limited civil society activity in Gambella and depending on the presence and capacity of local

organizations to target adults, Pact may also engage in some direct implementation of prevention services.

Because the region is quite different from many other parts of Ethiopia and there is little civil society

experience to draw from, a rapid assessment of prevention needs and local partners to work with will be

conducted in 2007. Some adaptation of Pact's established approaches in other regions of the country may

be necessary in order to be relevant to the populations in Gambella. Though largely rural, due to the

disparate population, initial prevention efforts will focus on the capital city, Gambella town, as well as other

districts where Y-CHOICES activities are already in place. Assessments for feasible means of outreach to

rural populations will be conducted.

The needs assessments already conducted by the health network partner in Gambella, Johns Hopkins

University, will also be considered in the program design. With so few partners in Gambella, linkages

between services will be essential, as there will be few other organizations to reach this high prevalence

population. Pact will establish a strong referral program for counseling and testing with JHU, the care and

treatment provider in Gambella who manages CT sites at health facilities. Connections with the new activity

related to male circumcision (MC) by JHPIEGO will also be established. As behavior-change messages are

a critical component of any male circumcision intervention, the assessments Pact conducts and the

information they provide will be an important link for MC activities. An ongoing Nike Foundation program for

Girls Empowerment will also be leveraged. Pact is also implementing a USAID-funded peace project in

Gambella called "Restoration of Community Stability in Gambella." Lessons learned from this project in

working in a heavily underserved region will be drawn upon for stronger program design.

Initial assessments of venues where HIV-prevention efforts may be expanded include the use of public

transport and public transport workers, as they are the hub of nearly all mobility in the region and heavily

depended upon by the public. Transport workers and systems may be used to address social norms

contributing to HIV risk, to address HIV prevention directly and heighten risk perception among those using

public transport. There will be training transport workers to engage riders in dialogue about HIV while using

the transport system, production of audio materials or radio programs with HIV-prevention information and

behavior change messages. Training and support to help those engaged in transactional or commercial sex

to enter the high-demand market of public transport may also be explored as an alternative means of

income for some high-risk and economically vulnerable individuals. Other platforms for prevention activities

in addition to public transport will also be assessed.

Although the results of the rapid assessment will be critical to program design, based on the DHS data,

some likely priorities are evident. Focusing on adult men and women, with a particular emphasis on men, in

order to raise risk perceptions related to multiple/concurrent sexual partners as well as transactional and

commercial sex appear to be key needs. Condom skills building and distribution in order to promote correct

and consistent condom use, particularly with non-marital or cohabitating partners, will be emphasized

(funded in OP). Peer education approaches will likely be used to raise individual risk perception among

adults. Beyond individual risk perception and skills building, community organizations will be challenged to

find forums to address community norms that heighten HIV risk. This may take place in the form of

community conversations, identifying and training community leaders, or targeted use of media (e.g., radio,

community drama, church sermons, etc.) for consistent messages that address harmful norms.

By addressing with new activities, Pact will also establish linkages between Y-CHOICES efforts and new

activities aimed at higher risk populations and adults. Public forums to raise awareness and challenge social

norms, community conversations, etc. will be implemented in concert with Y-CHOICES so that community

groups working to address particular populations have an opportunity to come together to develop

strategies to support one another and assure that the prevention needs of both youth and adults are

addressed.

As Pact will be providing comprehensive prevention activities, the targets for this adult-focused program will

Activity Narrative: be counted in the HVOP section. Interventions and trainings will include A, B, and C approaches. The

program will aim to train 50 people and reach about 3,000 people with HIV-prevention messages and

education. Pact will also establish a consistent definition of person "reached" as having received some

intensive dose of the intervention designed (e.g. Completing a curriculum, multiple sessions with a peer

educator, etc) to assure that the focus of the intervention is on quality, leading to greater plausibility for

behavior change. As needs are assessed and approaches are tested in FY08, targets will be relatively

modest with the expectation that capacity to reach larger segments of the population will increase with time.

Expanding prevention activities into high-prevalence areas is a critical strategy for addressing HIV

transmission where new infections are occurring. A focus on high-prevalence urban populations with a an

emphasis on adults and high-risk populations represents a response to recommendations made through

two technical assistance visits by members of the Office of the Global AIDS Coordinator's general

population and most-at-risk populations working groups. As the highest prevalence region in Ethiopia with

almost no current prevention efforts ongoing, this activity addresses a critical gap in Ethiopia's prevention

needs.

Muslim Agencies Recharging Capacity for AIDS

PACT Ethiopia conducts HIV prevention and capacity building through three indigenous Muslim faith-based

organizations. With PEPFAR/Ethiopia funding, in FY06 PACT collaborated with the Ethiopian Muslim

Development Agency (EMDA) to implement abstinence, be faithful (AB) prevention activities in and around

Jimma (Oromiya region), Dire Dawa and Harari. Based on the successes achieved with EMDA, two

additional local partners were engaged: Ogaden Welfare and Development Association (OWDA) based in

Somali region and Rohi Weddu Pastoral Women's Development Organization based in Afar. In total the

project covers several zones where a large percentage of Muslims reside in Oromiya, Harari, Dire Dawa,

Afar, Somali, Amhara, and Tigray.

HIV/AIDS is still a major health crisis in Ethiopia. Adult HIV prevalence within the program's geographic

coverage, based on the Ethiopian Demographic and Health Survey (EDHS) 2005 and newer single-point

estimated (SPE) 2007 data, is summarized below:

Dire Dawa: ANC/2005: urban 8.0%, rural 0.9%; EDHS/2005: 3.2%; SPE/2007: 4.2%

Jimma (Oromiya): ANC/2005: urban 8.0%, rural 1.3%; EDHS/2005: 1.4%; SPE/2007: not available

Harari: ANC/2005: urban 6.9%, rural 0.5%; EDHS/2005: 3.5%; SPE/2007: 3.2%

Somali: ANC/2005: urban 3.5%, rural 0.7%; EDHS/2005: 0.7%; SPE/2007: 0.8%

Afar: ANC/2005: urban 13.7%, rural 1.7%; EDHS/2005: 2.9%; SPE/2007: 1.9%

According to the EDHS 2005, polygamy accounts for 16% in Jimma and 5.5% in Harari. These are cash

crop areas known for coffee or khat (catha edulis, a stimulant) production. During the harvest season, there

is an influx of migrant workers to rural areas and commercial sex workers to urban areas.

PACT provides technical assistance to institutionally strengthen local partners to effectively plan, manage

and implement HIV/AIDS prevention projects. The project reached 1.2 million people in its first year

(FY05/06) with AB messages. In FY06/07 Pact Ethiopia's local partners reached an additional 707,068

adults and youth. Working through local imams, youth groups and interested community members, EMDA

facilitated weekly interactive congregational sessions at the mosques, youth groups and community

gatherings to discuss AB prevention, stigma and existing care and treatment services.

In FY08, Pact and its partners will continue to implement capacity building and HIV-prevention activities.

Using activity grants through PACT, local partners will implement AB messaging through Mosques to reach

men, community clubs to reach women, youth anti-AIDS clubs to distribute information and education

materials, use volunteers to organize public gatherings and support radio broadcast of AB messages.

The geographic scope will be expanded to cover Mekele (Tigray), Bahir Dar and Dessie (Amhara),

Nazareth (Oromiya) and additional urban towns in Afar using the existing Islamic Council and community-

based structures.

Basic HIV transmission, AB and gender training of imams and community leaders supported a greater

consistency of messaging from Muslim leaders and succeeded in challenging taboos and attitudes and

behaviors of religious leaders and their followers. Voluntary counseling and testing (VCT) has also

increased. Some areas went as far as introducing new by-laws to prevent marriages without certificates

from a VCT center.

Pact and its partner organizations promote awareness about and the use of existing public health services

such as VCT, sexually transmitted infections treatment, ART, childhood immunization, family planning, and

other primary healthcare through provision of technical assistance to clubs and community educators. Pact

collaborates with Johns Hopkins University/Health Communications Program (JHU/HCP) to provide training

and technical assistance to the three local partners on using the Youth Action Kit developed by JHU/HCP.

Pact will foster linkages between local partners and other PEPFAR funded HIV prevention, care, and

treatment activities. In addition, Pact will create opportunities for club members to share their Y-CHOICES

experiences (abstinence and be faithful for youth (ABY)) and promote joint out-of-school and local faith-

based association efforts in all project locations of the M-ARCH/EMDA program.

The target population in this program is a) youth between the ages of 10 and 24 reached through clubs and

b) adults of ages between 25 and 49 reached in mosques and through community educators. Individuals

are reached through mosques, community groups and youth anti-AIDS clubs.

This activity addresses male norms and behaviors through the use of training for Imams throughout several

areas of the country. The imams directly address AB messages to Muslims in the area. The majority of

those addressed in mosque are males, offering a structured environment for behavior change messages

and education. PACT has made an effort to increase the number of females included in HIV-prevention

programming under this program through girls clubs and married women venues.

PACT builds the organizational and technical capacity of three local subpartners. The Ethiopian Muslim

Development Agency is a national partner operating in all regions of Ethiopia, although the M-ARCH activity

focuses on Amhara, Harari, Oromiya, and Tigray in and around major urban centers. The Rohi Weddu

Pastoral Women Development Organization operates in Afar region. The Ogaden Welfare and

Development Association operates in Somali region.

Prevention Activities in Gambella

This activity is a continuation of FY07 reprogrammed funds. In FY08, funds for this activity will be split

evenly across AB ($125,000) and Other Prevention (OP—$125,000).

Gambella is the westernmost region of Ethiopia, bordering Sudan. The region is sparsely populated; in

2005, the Ethiopian Central Statistics Agency estimated a regional population of only 247,000—80% of

whom live in rural areas. Pastoralism and agriculture are the major economic activities for the people of

Gambella. One of the major ethnic groups in Gambella is the Anuak people, who comprise approximately

30% of the region's population. The Anuak are considered to be ethnically, culturally, linguistically,

historically, and religiously different from most other Ethiopians, and there have been ethnic conflicts in

recent years in the region, with significant tensions persisting.

The 2005 Ethiopian Demographic and Health Survey (EDHS) revealed surprisingly high HIV prevalence of

6.0% in Gambella region. Gambella's was the highest regional prevalence recorded by the EDHS, and is

nearly three times the Government of Ethiopia's (GOE) national single-point prevalence of 2.1%. Behavioral

data also reveals high levels of risk behavior. Compared to other regions and the national average, men in

Gambella reported high rates of multiple partners, high-risk sex, lifetime sex partners, and having paid for

sex. Women in Gambella reported higher than average high-risk sex. The draft Epidemiological Synthesis

of HIV/AIDS in Ethiopia, commissioned by the HIV/AIDS Prevention and Control Office (HAPCO) and the

World Bank, identify Gambella as a "hotspot." Gambella's circumcision rate is the lowest in the country, with

only 47% of men circumcised, compared to a national rate of 93% for circumcision coverage. Furthermore,

there are very few civil society groups working on HIV in Gambella, and USG-supported prevention efforts

in Gambella prior to FY07 reprogramming have been largely limited to work in the refugee camps on the

Sudanese border. Pact is one notable exception, as its Track 1 ABY program has been active in four

districts in Gambella since FY06.

Through reprogramming funds, Pact will expand HIV-prevention interventions focused on behavior change

to address the prevention needs of adults in Gambella. Building off of a similar approach to that of Y-

CHOICES, Pact will provide technical assistance and support for organizational-capacity development to a

selected number of local organizations that will carry out the prevention interventions in Gambella.

However, there is very limited civil society activity in Gambella, and depending on the presence and

capacity of local organizations to focus on adults, Pact may also engage in some direct implementation of

prevention services.

Because the region is quite different from many other parts of Ethiopia and there is little civil society

experience to draw from, a rapid assessment of prevention needs and local partners to work with will be

conducted. Some adaptation of Pact's established approaches in other regions of the country may be

necessary in order to be relevant to the populations in Gambella. Though largely rural, due to the disparate

population, initial prevention efforts will focus on the capital city, Gambella town, as well as other districts

where Y-CHOICES activities are already in place. Assessments for feasible means of outreach to rural

populations will be conducted. Needs assessments already conducted by the health network partner in

Gambella, Johns Hopkins University (JHU), will also be considered in program design.

Initial assessments of venues where HIV-prevention efforts may be expanded include the use of public

transport and public transport workers, as they are the hub of nearly all mobility in the region and the public

depends heavily on them. Transport workers and systems may be used to address social norms

contributing to HIV risk, to address HIV prevention directly and heighten risk perception among those using

public transport. Training transport workers to engage riders in dialogue about HIV while using the transport

system, and production of audio materials or radio programs with HIV-prevention information and behavior-

change messages are possible methods of addressing prevention in this widely used venue. Training and

support to help those engaged in transactional or commercial sex to enter the high-demand market of public

transport may also be explored as an alternative means of income for some high-risk and economically

vulnerable individuals. Additional platforms for prevention activities in addition to public transport will also be

assessed.

Although the results of the rapid assessment will be critical to program design, based on the EDHS data,

some likely priorities are evident. Focusing on adult men and women, with a particular emphasis on men, in

order to raise risk perceptions related to multiple/concurrent sexual partners, as well as transactional and

commercial sex appear to be key needs. Condom skills building and distribution in order to promote correct

and consistent condom use, particularly with nonmarital or cohabitating partners, will be emphasized

(funded in OP). Peer education approaches will likely be used to raise individual risk-perception among

adults. Beyond individual risk-perception and skills building, community organizations will be challenged to

find forums to address community norms that heighten HIV risk. This may take place in the form of

community conversations, identifying and training community leaders, or targeted use of media (e.g., radio,

community drama, church sermons, etc.) for consistent messages that address harmful norms.

By addressing with new activities, Pact will also establish linkages between Y-CHOICES efforts and new

activities aimed at higher risk populations and adults. Public forums to raise awareness and challenge social

norms, community conversations, etc. will be implemented in concert with Y-CHOICES so that community

groups working to address particular populations have an opportunity to come together to develop

strategies to support one another and assure that the prevention needs of both youth and adults are

addressed.

As Pact will be addressing prevention comprehensively, targets for the adult populations reached will be

counted in OP, though there will be a significant emphasis on raising risk perceptions around multiple and

concurrent partners. Interventions and trainings including A, B, and C approaches, 50 people trained, and

3,000 people reached. Pact will also establish a consistent definition of person "reached" as having received

some intensive dose of the intervention designed (e.g., completing a curriculum, multiple sessions with a

peer educator) to assure that the focus of the intervention is on quality, leading to greater plausibility for

behavior change. As needs are assessed and approaches are tested in FY08, targets will be relatively

modest, with the expectation that capacity to reach larger segments of the population will increase with

time.

Activity Narrative: The overall strategy will address prevention where new infections are occurring. A focus on high-prevalence

urban populations, with a an emphasis on adults and high-risk populations, represents a response to two

recommendations made through two technical assistance visits by members of the Office of the Global

AIDS Coordinator's working groups on general population and most-at-risk populations. As Gambella is the

highest prevalence region in Ethiopia, with almost no current prevention efforts ongoing, this activity

addresses a critical gap in Ethiopia's prevention needs.

With so few partners in Gambella, linkages between services will be essential, as there will be few other

organizations to reach this high prevalence population. Pact will establish a strong referral program for

counseling and testing with Johns Hopkins University, the care and treatment provider in Gambella

managing counseling and testing sites at health facilities. Connections with the new activity related to male

circumcision by JHPIEGO will also be established. As behavior change messages are a critical component

of any male circumcision intervention, the assessments Pact conducts and the information it provides will be

an important link for MC activities. An ongoing Nike Foundation program for Girls Empowerment will also be

leveraged. Pact is also implementing a USAID-funded peace project in Gambella called "Restoration of

Community Stability in Gambella." Lessons learned from this project in working in a heavily underserved

region will be drawn upon for stronger program design.

Although the assessment will reveal more specific populations to be targeted, the focus will be on sexually

active adults with multiple sexual partners. Other high-risk populations, such as commercial sex workers

and those engaging in transactional sex, may also be addressed, depending on the results of the initial

assessment.