Damen Haile Mariam

Economic costs of endemic non-filarial elephantiasis in Wolaita Zone, Ethiopia

Background  Endemic non‐filarial elephantiasis or podoconiosis is a chronic and debilitating geochemical disease occurring in individuals exposed to red clay soil derived from alkalic volcanic rock. It is a major public health problem in countries in tropical Africa, Central America and North India.

Toward universal access to HIV counseling and testing and antiretroviral treatment in Ethiopia: looking beyond HIV testing and ART initiation.

Expanding access to HIV counseling and testing (HCT) and antiretroviral treatment (ART) has reduced morbidity and mortality in people living with HIV/AIDS. As a result, many countries are scaling up HIV/AIDS services. In this paper we discuss challenges experienced during the move toward universal access to HCT and ART services in Ethiopia. We reviewed routine reports from the Ministry of Health and implementing partners. We also had interviews, about linkage to and retention in care of patients, with 10 HIV/AIDS program managers, as well as 2 to 7 health care providers and 5 to 15 patients in each of 23 health centers and 32 hospitals in all regions of the country. We found that the number of people tested for HIV increased 10-fold from 435,854 in 2005 to 4,559,954 in 2008. Only 61% of the HIV-positive patients were linked to chronic care immediately after tested for HIV. The number of patients initiated on ART annually increased from 26,021 in 2005 to 53,696 in 2008. Attrition of patients increased from 18% in 2005 to 26% in 2008. Our interviews indicated that fear of stigma, transport cost, feeling healthy and opting for traditional medicines were the main reasons for poor linkage to and retention in care. Lack of nutrition and feeling better were also reasons for poor retention. In conclusion, in spite of the rapid scale-up of HCT and ART services in Ethiopia, linkage and retention were not adequate. Therefore, strategies should be developed and implemented to improve linkage and retention.

The Iddir in Ethiopia: Historical Development, Social Function, and Potential Role in HIV/AIDS Prevention and Control

Problem Statement: Mortality from AIDS has been increasing at an alarming rate in Ethiopia, especially in urban centers, to the great detriment of households and communities. The epidemic causes stress or even collapse of social institutions performing valued community functions. One such institution threatened by the HIV/AIDS epidemic is the iddir, a form of indigenous social insurance whose main function is to help members during bereavement. Results: The historical review suggests that iddirs were developed by migrants to Addis Ababa in the early part of the twentieth century and spread rapidly from the time of the Italian occupation, with increasing use of currency, formalization, diffusion, and transformation from mono- to polyethnic voluntary organizations. The review considers the relationships of iddirs with the state during three successive regimes, noting that despite considerable potential for partnership, iddirs have tended not to become involved with development activities such as education and healthcare services or community development, fearing state interference. The surveys showed that while none of the iddir leaders had heard of an iddir going bankrupt due to increased mortality and payment overload, all the study iddirs reported decreases in their deposits in recent years. Mortality increase in the younger population was the perceived reason for these financial constraints. Strategies used to cope with the increased mortality problem include increasing membership contributions and premiums and renting out equipment.

Outcomes of antiretroviral treatment program in Ethiopia: Retention of patients in care is a major challenge and varies across health facilities

BackgroundMany resource-limited countries are scaling up antiretroviral treatment (ART) towards universal access. However, there are few studies which evaluated outcomes of ART programs in these countries. In addition, these studies generally include a limited number of facilities and patients creating a clear need for studies with a wide range of facilities and large numbers of patients. In this study, we intended to evaluate the outcomes of the ART services in 55 health facilities in Ethiopia.MethodsA retrospective longitudinal study was conducted to determine levels of patient retention in care, CD4 count and shift to second-line ART regimen in 30 hospitals and 25 health centers selected as sentinel sites for monitoring the outcomes of ART program in the country. The outcomes were determined at baseline, after 6, 12 and 24 months on ART. Data was collected from routine patient registers and charts, and entered and analyzed using EPI-Info statistical software.ResultsHealth facilities were able to retain 29,893 (80%), 20,079 (74%) and 5,069 (68%) of their patients after 6, 12 and 24 months on ART, respectively. Retention rates vary across health facilities, ranging from 51% to 85% after 24 months on ART. Mortality was 5%, 6% and 8% after 6, 12 and 24 months on ART. More than 79% of patients with available CD4-cell counts had a baseline CD4-cell counts less than 200 cells per micro-liter of blood. The median CD4-cell counts (based on patients who were retained after 24 months on ART) increased from 125 (inter-quartile (IQ), 68-189) at baseline to 242 (IQ, 161-343), 269 (IQ, 185-380) and 316 (IQ, 226-445) cells per micro-liter after 6, 12, and 24 months on ART, respectively. The transition to second-line ART remained very low, 0.33%, 0.58% and 2.13% after 6, 12 and 24 months on ART.ConclusionThe outcomes of the ART services in the 55 health facilities in Ethiopia are similar to those in other countries. Retention of patients in care is a major challenge and varies across health facilities with high, medium and low retention rates. We therefore recommend further studies to understand the organization of care in health facilities with high, medium and low retention rates. It is also imperative that early initiation of patients on ART is taken seriously as more than 79% of the patients had baseline CD4-cell counts less than 200 cells per micro-liter of blood. Finally, we recommend that the shift to second-line ART might be too low and warrants close monitoring.

Indigenous social insurance as an alternative financing mechanism for health care in Ethiopia (the case of eders).

With increasing demand for services further propagated by population growth and by peoples response to newly emerging pathologies, nations in sub-Saharan Africa are faced with insurmountable problems in sustaining their health systems. Realizing the inadequacy of solely relying on the public sector, these countries are seeking alternative mechanisms for health financing. Among the alternatives suggested are risk-sharing mechanisms that include community-based schemes that tap the potential of indigenous social arrangements. In Ethiopia, eders are major forms of indigenous arrangements utilized mainly for assisting victims in bereavement and executing funeral-related activities. These associations are also called upon in various self-help activities and sometimes provide health insurance, even though mostly in an informal manner. Therefore, they have the potential to serve as social financing mechanisms. Since these are already functioning groups, the administrative cost for the extra health-related activity will not be as high as in the case of forming a new insurance entity. In addition, the fact that eders are based on mutual understanding among members minimizes the possibility of adverse selection. Based on the above background, an exploratory study was conducted in 40 villages distributed in various parts of Ethiopia to assess the possible roles eders might play in providing insurance for health financing. Both qualitative and quantitative (household and health facility exit interview surveys) methods of data collection were utilized. The study concludes that eder-based schemes are, indeed, options for experimentation as mechanisms for financing health care in rural Ethiopia. It was also found that 21.5% of respondents in the household and 16% of those in the exit surveys were already utilizing eders to finance part of their health expenditure. In addition, 86% of the respondents in the household and 90% of those in the exit survey were willing to participate in eder-based health insurance schemes.

Effectiveness and Acceptability of Delivery of Antiretroviral Treatment in Health Centres by Health Officers and Nurses in Ethiopia

Objective The World Health Organization (WHO) recommends shifting tasks from physicians to lower cadres for the delivery of antiretroviral treatment (ART) for countries short of physicians. Our objective was to evaluate the effectiveness and acceptability of ART delivery by health officers and nurses in Ethiopia. Methods A retrospective cohort study to evaluate outcomes of ART services in 25 health centresstaffed with health officers and/or nurses and 30 hospitals staffed with physicians in 2009. Median CD4-cell counts, mortality, loss to follow-up and retention were the primary outcomes. Interviews and focus group discussions were conducted with people living with HIV/AIDS, AIDS programme managers and health care providers to identify the types and acceptability of the tasks conducted by the health officers, nurses and community health workers. Results Health officers and nurses were providing ART, including ART prescription, for non-severe cases. The management of severe cases was exclusively the task of physicians. Community health workers were involved in adherence counselling and defaulter tracing. The baseline median CD4-cell counts per micro-liter of blood were 117 (interquartiles [IQ] 64,188) and 119 (IQ 67,190) at health centres and hospitals respectively. After 24 months on ART, the median CD4-cell counts per micro-literof blood increased to 321 (IQ 242, 414) and 301 (IQ 217, 411) at health centres and hospitals respectively. Retention in care was higher in health centres (76%, 95% confidence interval [CI] [73%-79%]) than hospitals (67%, 95% CI [66%-68%]). This difference is mainly due to the higher loss to follow-up rate in hospitals (25% versus 13%). Mortality was higher in health centres than hospitals (11% versus 8%), but the difference is not statistically significant. Service delivery by non-physicians was accepted by patients, health care providers and programme managers. However, the absence of a regulatory framework for task shifting, the lack of extra remuneration for the additional roles assumed by nurses and health officers, and the high cost for training and mentorship were identified as weaknesses. Conclusion ART delivery in health centres, based on health officers and nurses is feasible, effective and acceptable in Ethiopia. However, issues related to regulation, remuneration and cost need to be addressed for the sustainable implementation of these delivery models.

Utilization of antiretroviral treatment in Ethiopia between February and December 2006: spatial, temporal, and demographic patterns

BackgroundIn 2003, the Ethiopian Ministry of Health (MOH) started to implement a national antiretroviral treatment (ART) program. Using data in the monthly HIV/AIDS Updates issued by the MOH, this paper examines the spatial and temporal distribution of ART on a population basis for Ethiopian towns and administrative zones and regions for the period February to December 2006.ResultsThe 101 public ART hospitals treated 44,446 patients and the 91 ART health centers treated 1,599 patients in December 2006. The number of patients currently receiving ART doubled between February and December 2006 and the number of female patients aged 15 years and older surpassed male patients, apparently due to increased awareness and provision of free ART. Of 58,405 patients who ever started ART in December 2006, 46,045 (78.8%) were adhering to treatment during that month. Population coverage of ART was highest in the three urban administrative regions of Addis Ababa, Harari and Dire Dawa, in regional centers with referral hospitals, and in several small road side towns that had former mission or other NGO-operated hospitals. Hospitals in Addis Ababa had the largest patient loads (on average 850 patients) and those in SNNPR (Southern Nations and Nationalities Peoples Republic) (212 patients) and Somali (130 patients) regions the fewest patients. In bivariate tests, number of patients receiving treatment was significantly correlated with population size of towns, urban population per zone, number of hospitals per zone, and duration of ART services in 2006 (all p < 0.001). The stronger relationship with urban than total zonal populations (p < 0.001 versus p = 0.014) and the positive correlation between distance from 44 health centers to the nearest ART hospital and patients receiving treatment at these health centers may be due to a combination of differential accessibility of ART sites, patient knowledge and health-seeking behavior.ConclusionThe sharp increase in ART uptake in 2006 is largely due to the rapid increase in the provision of free treatment at more sites. The marked variation in ART utilization patterns between urban and rural communities and among zones and regions requires further studies. Recommendations are made for further expansion and sustainability of the ART scale-up.

Patterns of knowledge and condom use among population groups: results from the 2005 Ethiopian behavioral surveillance surveys on HIV.

BackgroundBehavioral surveys help interpret the magnitude of HIV/AIDS. We analyzed indicators of knowledge on HIV/AIDS and condom use among sub populations selected for behavioral surveillance in Ethiopia.MethodsWe used 2005 HIV/AIDS behavioral data from ten target groups. These were female sex workers, defense forces, police force, pastoralists, truck drivers, intercity bus drivers, road construction workers, teachers, factory workers and people in ANC catchment areas.ResultsData from 14,524 individuals were analyzed. The majority were males (63.6%). Overall, knowledge of the three preventive methods, misconceptions and comprehensive knowledge was 57%, 75% and 18.5%, respectively. Female sex workers and the defense force showed some behavioral change in using a condom during the most recent sexual encounter and consistently used a condom with non-regular sexual partners and paying partners. Women, pastoralists and the illiterate were less likely to use condom.ConclusionMisconceptions about the transmission of HIV were high and comprehensive knowledge about HIV & AIDS was low, particularly among pastoralists. Consistent condom use and condom use during the last sexual encounter were high among both female sex workers and defense force employees, both with paying and non-regular sexual partners. This might be a positive sign, though a considerable proportion in each target group did not report using a condom during sex with non-regular partners.

HIV / AIDS in Ethiopia: an overview.

Problem Statement: The rapidly growing literature on HIV/AIDS in Ethiopia has failed to examine the epidemic, its impacts, and the national prevention and control program in their socioeconomic, cultural, and political contexts. Objectives: This paper reviews the epidemiology, driving forces, and impacts of the epidemic at the societal level and evaluates prospects for prevention and control. Methods: The literature was reviewed through online searches of PubMed/ National Institute of Health, Medscape, and PAHA (Partners Against HIV/AIDS in Ethiopia) databases; unpublished sources were obtained from the Ministry of Health and other Ethiopian institutions, United Nations organizations, as well as the Centers for Disease Control and Prevention (CDC) and nongovernment organizations. Results: Since the rapid spread of HIV infection in the 1980s and 1990s—primarily by commercial sex workers, truck drivers, and soldiers along major transportation routes—children, adolescents, and the general population have increasingly become infected. While the epidemic has spread rapidly in the slowly in rural areas, surveillance activities remain underdeveloped. Thus, the fragmentary data on the occurrence and impact of HIV/AIDS are speculative, and planning and implementation of prevention and control programs have been hindered. Available data show that knowledge levels about HIV/AIDS and use of condoms have increased in towns, and a few populations with declining risk behavior have been identified in Addis Ababa, although a high degree of denial, discrimination, and high-risk behavior persist. Little is known about the situation in rural Ethiopia. Poverty, war, gender inequities, traditional practices, and political problems have all inhibited the effectiveness of prevention and patient care/support programs. The socio-ecnomic impacts of HIV/AIDS are severe and increasing, and a sharp decline in population growth is anticipated. The national HIV/AIDS prevention program is briefly reviewed, and prospects for decentralized, multisectoral, and community-based planning and implementation of prevention and patient support strategies are examined. Conclusion: The HIV/AIDS epidemic has become a major threat to Ethiopian society. Limited administrative capacity and persisting economic, behavioral, and attitudinal problems at all levels of society need to be improved rapidly, and the Ministry of Healths Multisectoral HIV/AIDS Strategic Plan should be implemented on schedule to reverse the epidemic. Emerging behavioral changes associated with declining HIV rates in selected urban populations similar to those reported from Uganda and other countries with successful prevention programs give rise to guarded optimism, assuming that these changes can be achieved in the broader population.

Assessment of HIV/AIDS-related risks among men having sex with men (MSM) in Addis Ababa, Ethiopia

Ethiopia has a high prevalence of HIV/AIDS. Single-point estimates show adult HIV prevalence of 2.1 per cent for 2007. The 2005 Ethiopia Demographic and Health Survey (EDHS 2005) had indicated a national-level adult prevalence rate of 1.4 per cent among adults aged between 15 and 49 years (6 and 0.7 per cent in urban and rural residents, respectively). The rate in the capital, Addis Ababa, was 5 per cent. We conducted an ethnographic study to explore the possible role of men having sex with men (MSM) in the epidemiology of HIV/AIDS in the city of Addis Ababa, Ethiopia. To collect data, we used four focus group discussions with MSM, six key informant interviews, and extended observations at different places in Addis Ababa. These data were analyzed using open code software and a ‘grounded theory’ approach. We found that contextual factors, such as sociocultural background and politicolegal situation, predisposed to HIV/AIDS-related risk behavior among members of the study subgroup. The infection might have been transmitted between the study population and heterosexual people in the community by many possible routes. The study showed that men have sex with men among a segment of Addis’ population. The portion of the population involved is non-negligible. They are exposed to HIV/AIDS risks. It is, therefore, high time that the issue be openly discussed in the context of current efforts to control the HIV pandemic.