ETHIOPIA

Monitoting and Evaluation of HIV/AIDS programs

Mengesha Yadeta, Abebe Shume

Background

Ethiopia has over 60 million inhabitants and a GNP per capita of US $100. The first AIDS case was detected in Addis Ababa in 1986. National HIV prevalence was estimated at 7.4% by the end of 1997, with urban prevalence about five times higher than rura l rates. The AIDS epidemic is thus generalized and is dominated by heterosexual transmission.

National response

In 1987 a national AIDS control programme was established and a first mid-term plan was developed. WHO/GPA and bilateral donors were the main supporters. The STD control programme was integrated with the AIDS programme in 1991. In 1994, the programme was decentralized to the region, but resources for the programme dwindled. The UNAIDS country office was created in 1996 and a five year multi-sectoral strategic plan has just been completed. Also in mid 1998 the government ratified a national HIV/ AIDS p olicy. Condom promotion was a key intervention from the beginning. Screening of donor blood was done in 65 laboratories across the country, about half of the labs have ELISA readers.

Monitoring and evaluation

Until the decentralization in 1994 the national programme had a fairly good surveillance and monitoring system. HIV surveillance included at different points in time sero-surveys among commercial sex workers (1988-91), truck drivers (1988-90), antenata l women (1991-93, 2 sites each year), STD clients (1993, 2 clinics), rural survey (1993), and scholarship winners (1993-94). National data were available on HIV prevalence among blood donors until 1994, after that only for Addis Ababa.

The responsibility for monitoring and evaluation was moved to the regions in 1994. The regional levels are understaffed and reporting is poor.

At the central level the monitoring and evaluation unit is too small to supervise and support the regions. The national HIV/AIDS/STD team is a small unit within the Department of Epidemiology and AIDS of the Ministry of Health. No monitoring and eval uation system in place in this unit.

In 1995, Ethiopia carried out an assessment of the WHO/GPA prevention indicators in four cities. It included a population-based survey, health facility survey, record review and a sero-survey among antenatal care attenders. The population-based survey was intended to provide baseline data for evaluating the effectiveness of the AIDS control programme. In addition, a cross-sectional unlinked anonymous survey of HIV and syphilis (RPR test) was carried out among women 15-24 years in 16 randomly selected c linics in Addis Ababa in 1995. Detailed and recent HIV trend data based on antenatal data and a population-based survey are available from a longitudinal study in Addis Ababa since 1996, but no monitoring is ongoing in the regions.

STD monitoring is based on the health information system but data are inadequate to assess the prevalence and trends of STD. Smaller studies are carried out on an ad hoc basis to assess syphilis prevalence among antenatal clients or antibiotic sensitiv ity of the gonoccoccus.

Input, output and context

Records of the distribution of free condoms by the Ministry of Health are available up to 1994 and in the most recent years no more condoms have been distributed. But even before 1994, numbers of condoms distributed never exceeded 1.2 million in a year . The condom social marketing programme started in 1990 and provides data on numbers of condoms imported and distributed. The numbers of condoms distributed peaked at 28 million in 1997. The WHO/GPA survey of four cities in 1995 estimated that over 25 mil lion condoms were available in Ethiopia in the 12 months preceding the survey, corresponding with 1.3 condoms per person per year.

Condoms were available for 80% of the population in at least one outlet during the last 12 months. A survey by the condom social marketing programme in 1998 provided recent data on knowledge about AIDS and condoms.

It is believed that more than 95% of blood donated in the country is screened through for HIV. Voluntary blood donation exists only in a number of towns.

An evaluation of the quality of STD services in 20 government health facilities in 4 cities in 1995 found that 42% of patients were treated ineffectively, 17% of patients were advised on condoms and 35% on partner notification. The knowledge levels we re found to be fairly high in the four-city prevention indicator survey in 1995.

Proximate determinants

The WHO/GPA prevention indicator surveys in 1995 provided data on sexual behaviour. The overall prevalence of non-regular sexual relationships (PI 4) was 18% among men and 5% among women in the four cities, with Addis Ababa having higher rates than the other locations. 48% of men and 47% of women reported use of condoms in their most recent intercourse with a non-regular partner (PI 5).

HIV and STD

There are very few data on HIV prevalence with few exceptions, all from Addis Ababa. In 1995 HIV prevalence was 13.6% among 2,400 pregnant women attending antenatal clinics. In 1996, a study in 1996 reported 17.8% sero-prevalence in antenatal clinics. Prevalence in a population-based survey was much lower: 6.0 and 6.9% among adult men and women respectively. Because of the lack of HIV prevalence data from more than five years ago (and from Addis Ababa only) the 1995 data are often used in planning and policy making.

There are insufficient data to give a good picture of STD prevalence. The main sources of data are the outpatient clinic data and a study on the prevalence of syphilis among antenatal clients (showing 14% and 4% prevalence in urban and rural areas resp ectively).

AIDS impact mitigation

AIDS case reporting is poor and estimated at 15% of the true number of cases. There are no monitoring data on care and support of people living with HIV/AIDS.

Conclusion

Until 1994-95 the monitoring and evaluation component of Ethiopia's AIDS programme was functioning relatively well, focusing on HIV monitoring and a baseline survey for interventions in 1995. The decentralization of the programme in 1994 and the lack o f resources at central and regional levels have seriously affected monitoring and evaluation of the epidemic and the programme. Data are only generated by the blood transfusion programme, the condom social marketing programme, and a cohort study in Addis Ababa that includes antenatal clinic surveillance. A new multi-sectoral plan for the HIV/AIDS programme has been developed and this includes strengthening of the monitoring and evaluation component.