BACKGROUND

While being one of the world's oldest civilizations, Ethiopia is also one of the world's least developed countries. Ethiopia is a land-locked country bordering Sudan, Eritrea, Djibouti, Somalia and Kenya. The population reached an estimated 73 million in 2005 and is continuing to grow at a rate of 2.4% annually. The life expectancy at birth in Ethiopia is 48 years, and 44% of the population is under the age of 15. The infant mortality rate is 95 deaths per 1,000 live births. Eighty-five percent of the people live in rural areas, and about 16% of the population faces starvation. The health system in Ethiopia is extremely underdeveloped, even in comparison to other African countries.

Ethiopia is one of the countries more severely affected by HIV/AIDS and the number of people currently living with HIV/AIDS in Ethiopia is estimated to be 1.5 million. The HIV prevalence in rural areas is 2.3%, as opposed to a prevalence of 13.2% in urban areas. The impoverished condition of Ethiopia makes it difficult for the country to cope with this huge burden of disease, while the devastation already suffered and the magnitude of the population make it unlikely that a decline in the prevalence will be seen in the near future.

The Ethiopian government and its many partners are incessantly putting forth every effort to face the odds and contain the AIDS epidemic. The HIV/AIDS policy, the revised strategic framework, institutional arrangements for leadership, monitoring of activities, and the mobilization of resources are among the steps made by the government towards fighting the spread of this disease. However, these efforts need to be continued and maintained in order to be effective.

THE HIV / AIDS EPIDEMIC IN ETHIOPIA

Evidence suggests that the AIDS epidemic in Ethiopia started in the early 1980s, even though the first cases were not officially reported until 1986 from Addis Ababa. While the HIV epidemic began in urban areas in the mid 80s, and seemed to plateau in the mid 90s, the epidemic did not begin in the rural areas until the 90s and might still be in its beginning stages.

HIV/AIDS cases continued to rise rapidly during the 1990s, even though the vast majority of cases remained unreported and a large number of people died unnoticed. The estimated prevalence of 2.1 percent in 1989 drastically increased to 7.1 percent in 1997 and 7.3 percent in 2000. The prevalence dropped slightly in 2001 to 6.6 percent, though the Ministry of Health believes that this drop does not represent a decline in the epidemic, but rather is a result of the reclassification of a sentinel site. By September 2003, the number of reported cases in Ethiopia had escalated to 147,000.

TRENDS IN HIV / AIDS PREVALENCE IN ETHIOPIA

Heterosexual contact and mother-to-child transmission (MTCT) account for almost all HIV infections in Ethiopia. HIV transmission due to unsafe injections appears to be very low, though recreational drug use is increasing, especially among street children. The highest burden of disease is among the age group of 15 to 24 years, followed by 25 to 34 year-olds. Therefore, the most productive age groups are the ones primarily affected by the disease. Gender-specific rates show that females tend to be infected at a younger age than males. The group with the highest prevalence in Ethiopia is women between the ages of 15 to 24. In 1990, the prevalence of HIV among sex workers in five urban areas was found to range from 36.4 to 55 percent, though there has been very little data since then to indicate the progression of the infection among these sex workers.

While knowledge of HIV/AIDS is high among Ethiopians, women are less likely to have heard of the disease or be aware of the important ways to avoid contracting HIV. In addition, poverty, ignorance, gender inequality, cultural barriers (such as stigma, discrimination, denial, abduction, rape, and female genital mutilation), war and displacement also facilitate the spread of HIV.

SURVEILLANCE

Surveillance data in Ethiopia has been obtained from the National Sentinel Surveillance (NSS) in antenatal care attendees, Voluntary Counseling and Testing (VCT) Clients, voluntary blood donors, foreign migration visa applicants, and hospital based reports of suspected AIDS cases. Among the 23,861 NSS samples obtained in 2003, 8.2% were found to be positive; however, the HIV seroprevalence differed between samples from rural areas (4.1%) when compared to those from urban areas (12%). HIV prevalence among adults was estimated to be 4.4%, (rural = 2.6%, urban = 12.6%). Of the 15,580 blood donors tested, 4.7% were positive for HIV. Also, 3.6% of the visa applicants were HIV positive and 16.7% of the VCT clients were reported as HIV-infected.

Out of the estimated 1.5 million people living with AIDS in Ethiopia, 96,000 are children under the age of 15. The estimated number of new adult cases in 2003 was 98,000, while in children it was 25,000. .

Trend analysis has indicated that the rising urban epidemic has plateau over the past seven years. The data obtained from NSS also shows that the national HIV prevalence and the absolute numbers in 2003 are lower than the ones from 2001. However, rather than being a result of an actual decrease in the prevalence of HIV/AIDS, the lower numbers might actually due to the use of more robust analytical techniques. The prevalence rates from previous years are believed to have been overestimated due the use of less refined methods.

PREVENTION EFFORTS

The National HIV/AIDS taskforce was established in 1985, before the first AIDS case had been officially diagnosed. In 1987 the National AIDS Control Program (NACP) was established at the Ministry of Health (MOH). Though the MOH had developed many short-term plans in the late 80s and 90s, the interventions were inadequate in scale and eventually failed. The Ministry of Health established an HIV surveillance system in 1988, and in 1989, the Health Bureau of the Addis Ababa City Administration began sentinel surveillance. Ethiopia was one of the first countries to draft an HIV/AIDS policy, but the process took nine years to complete, and the national policy was not approved until 1998.

A great number of donors currently fund HIV/AIDS activities in Ethiopia. For example, Ethiopia has received grants totaling $139.4 million dollars from The Global Fund to Fight AIDS, TB, and Malaria and $64.3 million dollars from the World Bank to address HIV/AIDS.

In 2000, the National AIDS Prevention and Control Council was established, which is chaired by the President of Ethiopia and is comprised of members from government, NGOs, religious bodies, and civil society. This council declared HIV/AIDS a national emergency. The HIV/AIDS Prevention and Control Office (HAPCO) was established in 2002, and is headed by the Prime Minister. HAPCO is responsible for resource mobilization, advocacy, and for the coordination of sectoral responses.

NGOs are mostly concentrated in large cities, but have been providing home-based care since 1992. Though there are national guidelines on the care and support of HIV patients, access to HIV/AIDS care in both urban and rural areas is thought to be minimal.

CHALLENGES

The Ethiopian health care system is woefully unequipped to handle the burden of HIV/AIDS in the country. The country's size and poor transportation systems also serve as major obstacles. Although more funding is required, improving coordination, building manpower in the health sector, and especially using the available money efficiently are also essential. In addition, since most of the funding currently comes from external donors the sustainability of the program also raises concern.

In conclusion, HIV/AIDS has already caused a tremendous amount of devastation in Ethiopia and is expected to continue doing so for the foreseeable future. A sense of urgency, political commitment and the increasing funding from international donors will undoubtedly help mitigate the impact of the epidemic in a country where the response has been constrained until now by poverty and limited resources.

Updated, 2/2006 by Sameera Tanveer Warsi