Global Health Technical Assistance Project

The High Risk Corridor Initiative - HIV/AIDS Prevention for Ethiopia and Dijibouti (HRCI) in Ethopia was an effort to strengthen prevention strategies for effective behaviour change, strengthen and expand accessibility to and availability of voluntary counselling and testing (VCT) and sexually transmitted infection (STI) services, and increase access to care and support services for persons living with HIV/AIDS (PLWHA). The United States Agency for International Development (USAID) Ethiopia (USAID/E) and Save the Children USA (SC/USA) together launched HRCI in 2001 as a prevention programme to address the high transmission rates of HIV among transport workers and commercial sex workers (CSWs) in 21 towns along a busy transportation corridor originating in Addis Ababa that has two separate routes to the border with Djibouti. Over its course, the HRCI programme expanded to link prevention efforts with strategies for care and support for PLWHA, and to broaden its prevention programme to additional intended audiences, especially in- and out-of-school youth who engage in high-risk activities.

As detailed here, HRCI incorporated information dissemination (HIV/AIDS information centres), peer education activities, school- and community-based prevention outreach for young people, VCT service strengthening, community home-based care for PLWHA, and interactive drama. In describing one of the core programme strategies - increase prevention practices and demand for services - the evaluation teams observed the following:

• well-attended community gatherings, such as coffee ceremonies, with HIV-positive and HIV-negative educators working together
• large-group and home-to-home education by spiritual leaders
• development of information, education, and communication (IEC) and behaviour change communication (BCC) materials [e.g., billboards that promote faithfulness for married people, condom use for truck drivers, VCT, and care for orphans and vulnerable children (OVC), as well as leaflets, brochures, youth passports, serial drama audio cassettes, the "Addis Ta'em" cassette tape, and a pictorial document about the project]
• information centres (IC) that broadcast messages; distributed cassette tapes, posters, leaflets, and youth passports; and promoted and distributed condoms to CSWs, out-of-school youth, truck drivers, bars, and hotels
• anti-AIDS clubs (AACs) for both in- and out-of-school youth
• a youth action kit (YAK) school-based peer education programme that educates adolescent/secondary school students in a variety of ways using multiple materials and that includes condom education
• primary and secondary prevention education for PLWHA, families, and neighbours through home-based care (HBC) and social gatherings.

To detail one component of this strategy, the evaluators note that the oral tradition is embedded in Ethiopian coffee ceremonies, which offer an environment for discussion and sharing of information and experience. They "have been cited as especially useful as a forum for transfer of knowledge about HIV. An effective venue for community education and problem-solving, they are held regularly at different venues in all the communities where the project is active, and they reach the community as a whole, including high-risk individuals who live there....The success of these oral teaching methods is evidenced by the demand for VCT and condoms and the uptake of testing. It was not evident, however, that the messages disseminated adequately conveyed the risks with having multiple or concurrent sex partners."

Briefly, other core strategies detailed and evaluated in the document include:

• increase availability of and access to prevention and treatment services - the evaluation teams observed: VCT promotion through banners, leaflets, message cards, and billboards; health facility VCT, provider-initiated counselling and testing (PICT), and prevention of mother-to-child transmission (PMTCT) counselling; mobile VCT in both urban and rural communities; training of health providers in VCT and PICT; referrals to STI services; and referrals for opportunistic infection (OI) treatment and provision of OI meds to health centres and hospitals.
• provide care and support services, including food support - the teams observed: referrals for antiretroviral therapy (ART) by VCT counsellors and HBC volunteers (HBCV); HBC by volunteers and nurse supervisors; spiritual counselling by Muslim, Orthodox Christian, and Protestant spiritual leaders working in teams; HBCV support for ART adherence; formation of PLWHA associations for advocacy and legal support and cooperatives for income-generating activities (IGAs); trainings for HBCVs, nurse supervisors, spiritual counsellors, and family caregivers; school materials and food support for OVC and follow-up on their progress and stability; and food support for PLWHA (e.g., training for beneficiaries on how to cook high-protein food supplements).
• enhance livelihoods - the teams observed: support for and training in establishing PLWHA cooperatives; support for and training in establishing IGAs; linkages with microfinance organisations to maximise resources for PLWHA; and individual arrangements with business owners and private citizens to provide employment to PLWHA or resources to assist new IGAs.

Evaluators note that the project's primary implementing structures are HIV/AIDS committess, whose members strategically includes leaders from kebeles (urban dwellers' associations), woredas (administrative divisions), health bureaus, health centres, hospitals, town administrations, churches and mosques, schools, local non-governmental organisations (NGOs), iddirs and other community-based organisations (CBOs), PLWHA, and members of at-risk populations. Each committee has 4 subcommittees: Youth and Prevention, Care and Support, Fundraising, and OVC. The evaluation found that the committees "are demonstrably effective structures for parternships, linkages, referrals, community engagement, and transparent record-keeping."

Major overall findings:

• Knowledge and practice: HRCI exceeded its objective of increasing preventive knowledge and practice by reaching community members in general, as well as intended groups.
• VCT: "The project provided solid support for health facilities-based VCT and provider-initiated counseling and testing (PICT). Partially due to the success of the information, education, and communication (IEC) campaign and increased uptake of VCT services, the project has seen an unprecented rise in demand for VCT and treatment services that staff in health facilities do not have the capacity to meet, which compromises quality assurance (QA)."
• ART: Many PLWHA access antiretroviral therapy (ART) through VCT and home-based care (HBC) referrals to ART services. PLWHA describe ART as easy to access and freely available.
• STI: Referrals to and support from STI clinics were not as integrated as other services.
• OI: There has been increased access to treatment for OI at health centres and hospitals for adult and paediatric patients.
• Care and support: PLWHA reported significant benefits from the care and support provided by the HBC programme. However, evaluators noted some concern about volunteer competence in counselling, especially around emotional issues, even though commitment and compassion were always evident. Supervision structures have been put in place by identifying nurse supervisor focal persons at local health facilities; however, supervision skills varied by site and individual.
• OVC: Material support for OVC has been meaningful, with the project providing: school uniforms, fees, and supplies; food through a partnership with the World Food Programme (WFP); and additional family support through partnership with the Positive Change: Children, Communities, and Care (PC3) project.
• Palliative care: is just now emerging as a health specialty in Ethiopia, so evaluators concluded that achievement of this component was an unrealistic expectation.
• Food support: "is recognized as crucial in helping PLWHA and OVC regain health, respond optimally to ART, and return to productive lifestyles".
• Livelihood security: The project was able to lay the foundation for sustainable livelihood security for a limited number of PLWHA along the corridor. Despite reaping only small profits, some IGA appeared to have already achieved a measure of sustainability. Replicating these activities, however, may require more seed money and more intensive business training.
• Cross-cutting issues (gender, stigma reduction, and community strengthening): More females were beneficiaries because more women are HIV-positive, and the project had a successful focus on CSWs. There was little evidence that gender awareness was raised among HRCI staff, however. Both males and females were recruited as HBCVs. 

"Stigma reduction is probably the single most successful outcome of the project....Stigma has been reduced through a combination of awareness campaigns, distribution of prevention materials, broad community representation on HIV/AIDS committees, HBCVs providing care and support to families affected by HIV/AIDS, access to ART enabling PLWHA to reintegrate into normal community life, Community Conversations, and widespread community testing. The integration of PLWHA and HIV-negative people as educators is also considered key. Community strategies focused on capacity-building training for HIV/AIDS committees and other HRCI project implementers. The project is credited with increasing volunteerism along the corridor and for modeling compassionate care in communities previously characterized by HIV/AIDS phobia and discrimination. It has built up community capacity through training in IGA management and entrepreneurship and seed money grants for IGA start-up."

"The evaluators are grateful to have had the opportunity to witness the community spirit that has grown as a result of the HRCI project. We have witnessed extraordinary levels of compassion and commitment."

Recommendations for future planning include:

1. explore partnerships with larger private industries in Ethiopia (e.g., in the pharmaceutical industry) to mobilise more resources for responding to HIV.
2. explore partnerships with businesses along the corridor (e.g., tire manufacturers and spare parts businesses).
3. expand local partnerships (e.g., with hotels that give food to PLWHA) along the corridor.
4. build the palliative care knowledge and skills of HBCVs and nurse supervisors by linking with University of California San Diego (UCSD) and I-Tech.
5. add "care for the caregiver" trainings for HBCVs, family caregivers, nurse supervisors, and spiritual counsellors.
6. provide regular skilled support for volunteers who make home visits to sick clients.
7. include at-risk populations in the design of strategies and messages intended to change the risky behaviours.
8. ask community and religious organisations to fund lower-cost activities, such as coffee ceremonies and Community Conversations, which have proven successful in educating communities about HIV.

Development Experience Clearinghouse (DEC) Express, June 26 2009.