40653 HIV/AIDS in Africa- Getting Results These reports describe activities, challenges and lessons learned during the World Bank Global HIV/AIDS World Bank's HI/AIDS work with countries and other partners. Program and ACTafrica Ethiopia Multi-Sector AIDS Project ­ changing lives, giving hope Five examples of some of the ways in which the sense of self-worth to 15 people living with, affected by, or Emergency AIDS Fund for community level interventions at risk of HIV. in the IDA-funded Ethiopia Multi-Sector AIDS Project (the Ethiopia MAP) have saved and changed lives, and given health, care, and new hope to people infected or affected by HIV across Ethiopia. Community grants for HIV interventions In 2000 Ethiopia committed to developing a participatory, decentralized and community-driven response to HIV and AIDS. This included establishing AIDS Councils and HIV/AIDS Prevention and Control Offices (HAPCOs) at federal, regional and woreda levels. The IDA -funded Ethiopia Multi-Sector AIDS Project (Ethiopia MAP) provided support from 2001-2005. Nearly half of the $60 million project funding was allocated to the Emergency AIDS Fund (EAF) for community level interventions, focused mainly on awareness, prevention, care and support. EAF funded NGOs and private sector organizations, and communities and organizations operating at the woreda and kebele levels (the two lowest administrative levels). The regional and woreda- level HAPCOs and their related multi-sectoral review boards provide technical support to the kebeles and Productive employment can help young women like this communities, to help them in their own efforts to respond one avoid exposure to HIV to the epidemic. These workers ­ among them a few professional This decentralized system of support has greatly carpenters and metalworkers ­ are organized by the expanded care for orphans and people bedridden by Nazareth branch of Dawn of Hope, a local NGO that AIDS, community awareness and direct responses, and supports people who are infected or affected by HIV. With provided drugs for opportunistic infections. People livi ng funds from the Ethiopia Multi-Sectoral AIDS Project with HIV report a reduction in the stigma and (Ethiopia MAP), the NGO provides space, equipment and discrimination they face in society. materials to enable these members to earn a living. The group includes 12 people living with the virus and two affected by it. There is also a young woman of 20 who is Providing life-enhancing and life-saving learning skills that will give her an economic alternative to support to people living with HIV ­ commercial sex work, and thus allow her to avoid the risk of HIV. Dawn of Hope, Nazareth Regional Branch The products made in the workshop are sold at a The metalwork and carpentry workshop in the middle of showroom up the street, which is one in a long row of Nazareth in Ethiopia looks like any other in the town ­ commercial spaces that were constructed by Dawn of though it produces far more than furniture. More Hope with funding from the MAP. The organization uses importantly, it provides an occupation, an income and a two of the other spaces for income generating activities ­ one is a bulk grain shop, and the other sells a variety of the organization earns income through renting out the rest local spices. All three businesses are run by groups of of the commercial spaces. about 10 -12 Dawn of Hope members, who share the work and the profits. The smiles on their faces reflect The Nazareth branch of Dawn of Hope has 2,500 their pride in being better able to care for themselves members, including 380 orphans, all of whom are HIV and their families, as a result of their work (though many positive. The organization offers free drugs for minor remain very poor). opportunistic infections and coverage of hospital charges. For the orphans, most of whom live with relatives or neighbors, it provides 50 birr (about US$6) a month. The NGO also operates a Recovery Center, where lifesaving care is provided to people on whom the local hospital has given up. The patients are extremely poor, previously having worked mainly as bar servers, petty traders or casual laborers. While many of them are on anti- retroviral treatment (ART), they are not able to regain their health due to serious under-nourishment. Since it opened a year ago, the center has cared for 190 patients, many arriving with CD4 counts as low as 5 ­ literally on the verge of death. And yet, despite statements from referring doctors such as "this patient has only a few hours left to live", all but ten of the Center's 190 patients have recovered. This has been due to the care, counseling, and nutritious diet that patients receive at the Center. The Center is staffed by a trained nurse/counselor, a manager, and 15 HIV+ volunteers, many of whom are recovered patients. One staff member is a young woman who arrived at the Grain seller showing his receipt book with pride Recovery Center several months ago in a pre-comatose state ­ today she is the center's bread baker. Dawn of Hope/Nazareth has received some financial and in-kind support from the local Orthodox Church, and in- kind support from the Nazareth Association of Taxi Drivers, but its main financial backing has come from the MAP, through the project's regional-level grant window. But the gap in funding between the end of Ethiopia's MAP in December 2006 and a planned follow-on project some time in 2007 is problematic, as it will leave this NGO (like so many others) unable to pay staff or rent, or continue its support for orphans. The organization's work has been enhanced by the contributions of seven professional staff, but it has been constrained by the lack of transport to travel around its catchment area. And so far the income-generating activities initiated by members have not always produced the profits necessary to ensure the group members have access to sufficient nutrition. Spice seller now able to earn an income and live Nonetheless, the group's Project Coordinator, Meslin positively with HIV Feyisa, notes with deserved pride the positive change in the members' attitudes: In addition to the 34 members in these three income "While in the beginning they came to beg for five or ten generating activity (IGA) groups, another 116 people birr (around $1), today they come asking for business have been helped to start up independent business start-up funds. All this is due to having been given an initiatives. Beyond these individual economic benefits, opportunity to improve their own lives." 2 AIDS, TB and Malaria). The group briefed Piot and Feacham on their struggle for survival without free ART and the urgent need to start a treatment program in their country. The two international AIDS leaders took the message to the Ethiopian Prime Minister, and in 2004 Ethiopia's ART program was launched, with funding from the Global Fund. After 18 months on ART, Sileshi's CD4 count improved to 185 and he felt sufficiently strong and encouraged about his future to start a second university degree in management, and to start a family. Today, Sileshi's CD4 count is 550, and he is a leader in the Ethiopian AIDS community, representing people living with HIV on the National AIDS Council and the National AIDS Committee Management Board. He is also the proud father of an eighteen month old son. (His son does not have HIV, Dawn of Hope Recovery Center staff with children whose mothers are patients at the Center thanks to treatment to prevent transmission from mother- to-child.) While it is access to free anti-retroviral drugs that is Story of Sileshi Betelei, Executive Director of keeping him and his wife healthy today, Sileshi says Dawn of Hope, Addis Ababa clearly that it was the free OI drugs financed by EMSAP that allowed him and "many, many other Ethiopians" to have lived long enough to finally benefit from ART. In 2000, while finishing a university degree in plant sciences and then working as an agronomist, Sileshi "The MAP made a big difference in people's lives ­ Betelei suffered two serious bouts of illness and was without it we couldn't even talk about ART, since before found to be HIV-positive. Counseling helped him find the ART people were dying of OIs. The MAP enabled us to courage to speak to his family about his HIV status, and arrive at the era of ART." he received their full support. He believes their positive Sileshi also notes that the counseling and home-based reaction was due to their understanding that anyone can care provided through the MAP were essential ­ "without get HIV, even a hard-working, serious-minded counseling there is no positive living, there is no hope." professional like Sileshi. Sileshi returned to work and continued to live normally, until 2001 when his CD4 count dropped to 52 and he became extremely weak. Though Sileshi wanted to start on ART, he could not afford the drugs then available in the country. He refers to this period of his life as `the disaster time'. However, in 2002 he saw on television the founders of Dawn of Hope ­ a local NGO of people living with HIV ­ and decided to join them, and work on the advocacy campaign for public provision of free anti-retroviral treatment (ART). During this period he received drugs for opportunistic infections (OIs) through Dawn of Hope ­ financed by the Ethiopia Multi-Sector AIDS Project (Ethiopia MAP) ­ which enabled him to manage his health well enough to keep going, and to marry. His wife is also HIV-positive. As an activist, Sileshi attended the 15th International AIDS Conference in Bangkok, where he and other Ethiopians living with HIV met with Dr. Peter Piot Sileshi beaming at a photo of his son celebrating his first (Executive Director of UNAIDS) and Prof. Richard birthday Feacham (then Executive Director of the Global Fund for 3 An AIDS orphan who wants to make a difference with his life ­ the story of Zerihun Gashaw The slow smile and quiet manner of Zerihun Gashaw give little hint of the traumas he has endured as an AIDS orphan, the weight of responsibility he shoulders in raising his younger siblings, and the success that he has achieved so far in his young life. As members of Dawn of Hope, a local NGO in Ethiopia that supports people infected and affected by HIV, Zerihun's parents received financial assistance to cover rent, grain, drugs for opportunistic infections, soap and other basic essentials during the final period of their lives. They were also given funds to cover school fees for their children. Zerihun, the eldest of four, was thus Zerihun Gashaw (left), with his friend Sileshi Beteli, at the able to continue his education and enter university even office of Dawn of Hope in Addis Ababa, Ethiopia. as he lost first his father, and then his mother, to AIDS. The assistance provided through Dawn of Hope was funded by the Ethiopia Multi-Sector AIDS Project (MAP). Having just completed his university degree with a double major in political science and international relations, After their parents' deaths, the children became Zerihun is a role model not only for AIDS orphans, but for members of Dawn of Hope in their own right, as AIDS all youth. Indeed, he says that most young people in his orphans. Zerihun's siblings were 9, 7 and 5 at that time place "end up on the street". He is invited to youth forums, and he, at age 17, became the head of household. contributes to local newspapers, and is now working to Dawn of Hope continued to provide support to the family, start an organization of and for AIDS orphans so that their and this was supplemented by income Zerihun earned voice can become "louder and louder". by tutoring school children and loading and unloading goods whenever possible. To work, however, he needed The combination of this young man's sense of to drop out of university. responsibility for himself and his siblings, his intelligence and personal drive ­ along with the financial backing After a year, with support from Dawn of Hope, another provided to his family by the Ethiopia MAP and others ­ organization and the Ministry of Education, he was able has led Zerihun Gashaw to where he is today. In his own to restart his studies at Addis Ababa University. His words, he is preparing for "the next chapter" of his life, family manages to survive with the continued support of "standing for the rights of this segment of society". 150 birr ($18) a month from Dawn of Hope, the payment of rent by a friend who believes in Zerihun's potential to make something of his life, and gifts of food provided by community members during religious ceremonies. A faith-based HIV/AIDS initiative offers services and hope ­ The support from those in the village where the family the Ethiopian Orthodox Tewahido Church now lives reflects what Zerihun describes as "a national attitude change about HIV/AIDS" due to the fact that Sunday School Project "people have come to know that the problem is their problem." Previously, however, the family lived in a Aba (Father) Serekebrhan and his dedicated team of village where the children were labeled and suffered young colleagues from the Ethiopian Orthodox Tewahido social rejection because of their parents' HIV status. Church Sunday School HIV/AIDS Prevention and Control Project exemplify the important role played by the many Once back at university, Zerihun became an AIDS faith-based organizations that have been funded by the activist. He has shared his experience with fellow Ethiopia Multi-Sectoral AIDS Project. students through anti-AIDS clubs and with communities through outreach efforts (both funded by the Ethiopia The Church's project began with the objective of educating MAP), and at workshops and conferences. His thesis their own young members (up to age 30), but soon was entitled "The Challenge and Prospects of the expanded, and now reaches out to needy people in 12 Millennium Development Goals, with Particular communities through the Church's branch offices. Emphasis on Combating HIV/AIDS in Ethiopia", and prior to graduation he published an article in a university review called "The Politics of AIDS in Ethiopia". 4 · Home-based care for those bedridden with AIDS. This critical community service is offered directly by volunteers from the Church's Sunday School HIV/AIDS Program, who receive funds for transport. In addition to the personal love and care they bring into the homes of people in need, these volunteers help with bathing, washing clothes, house cleaning, and cooking. During their daily visits they also ensure that drugs are taken correctly and on time. · In addition, the project offers counseling and spiritual support to those living with or affected by the virus. With encouragement from the Archbishop ­ who chairs the project's board of directors ­ Aba Serekebrhan believes that the very difficult situation faced by Ethiopian communities is better today than before the MAP, in spite Aba Serekebrhan and two youth leaders of the Orthodox of the ongoing challenges of poverty and stigma and Tewahido Church Sunday School HIV/AIDS program discrimination. Looking to the future, he says "We have to (left), along with a young man and his family participating work harder than before, as we haven't achieved our goal in the Church's income generation project. yet." But he notes with his characteristic enthusiasm that the Ethiopian Orthodox Tewahido Church Sunday School HIV/AIDS Project "plans to do better if we can get The project team believes that through the Church's continued wide geographical coverage, and the respect and trust support". accorded to them by their communities, they are well- placed to contribute to the national response to HIV in Ethiopia. Over the past three years, with financial Selling spices support exclusively from the MAP, the project has on the street provided the following services, all of which are offered with support irrespective of religion: from the Church's · Training and initial start-up funds for youth (up to Income age 30) living with HIV. Beneficiaries receive 1,000 Generating birr ($120) to help them get off the ground, and most Activities have used the money to start micro-business activities initiative makes such as petty trading and small-scale wooden furniture it possible for making. To date the project has assisted 240 people this young woman to with HIV in each of its 12 branches (720 in total), all support herself. now supporting themselves. However, due to the low Her dream is to levels of income they are able to earn, some still do expand her not have enough money to eat as well as they need to, small business especially if they are on ART. inside covered · Support for AIDS orphans, whose growing numbers premises. are over-taxing the ability of communities to respond on their own. The children face a range of problems Caring for Ethiopia's AIDS Orphans and from lack of family love and care, to labeling and Vulnerable Children ­ unkind treatment from the community, to lack of The Abebech Gobana Children's Care and financial resources. The project has responded by Development Organization (AGCCDO) providing psychosocial counseling; community sensitization; and school uniforms and instructional materials to make it possible for them to stay in school It was 27 years ago that Abebech Gobana was traveling in and off the streets. It has also provided 100 birr ($12) the north of her country when her life was changed by a a month for each orphan, to assist the neighbors, chance meeting with two little girls in a camp for famine- friends and extended family members who care for affected Ethiopians. Seeing that they were destitute and them. A total of 900 orphans (75 per branch) have alone, she took them back with her to Addis Ababa, and been supported. shortly thereafter took in 19 impoverished street children. At that point she left her old life and ever since has 5 dedicated herself to providing care and support for though to a small extent in the organization's own vulnerable children. dormitories), nutritious food to eat, and an education. For orphans who are HIV-negative, this is an investment in a future free of HIV, by keeping them off the streets, where they could be put at risk of infection. The organization also offers skills training for people living with or affected by the virus, and provides home-based care to those who are bedridden due to AIDS. A child in The impact of these activities is reflected in the increased the care of number of orphans able to stay in school, extension of the AGCCDO lives of parents so that children can remain under the care and protection of their families, less social harassment of people living with HIV and a greater sense of self-worth among them as they learn new skills and manage to support themselves. The reduction in stigma and discrimination and provision of anonymous voluntary counseling and testing has enabled many more people in these communities to know their HIV status, an important aspect of HIV prevention. In addition, with increased community awareness, demand for condoms has grown from 56,000 in 2005 to 241,000 in 2006. Finally, the iddirs have expanded their traditional role in the community from In the beginning Abebech Gobana survived and collection of funds and facilitation of funerals to fundraising supported herself and the children by selling local foods, and awareness-raising for orphans and vulnerable but eventually found public and private financial support children. that enabled her association to become one of the country's major providers of care for orphans and other From the perspective of this key player in the national needy children. Today the organization named for her ­ response to AIDS in Ethiopia, these impacts ­ and the known by its acronym AGCCDO ­ has 226 staff, works continued, healthy lives of many orphans and vulnerable in two regions of the country, supports nearly 12,000 children ­ could not have been realized without the orphans, and offers an impressive array of services. financial support provided by the Ethiopia MAP. Over the past several years a focus on HIV has been added to the long-standing support for orphans and vulnerable children. With support from the Ethiopia Multi-Sector AIDS Project (Ethiopia MAP), the organization has been able to provide the communities they serve with funds and food to help extended families care for AIDS orphans, offer voluntary counseling and testing, provide drugs for minor opportunistic infections, develop nutrition and hygiene materials, support income generating activities, provide psychosocial support and undertake capacity building. In order to increase awareness and change behavior, through the MAP, Abebech Gobana has provided HIV prevention information and worked to reduce stigma at community level by: training peer educators, anti-AIDS club members and their teachers; training women community leaders to provoke discussion of orphans and vulnerable children at `coffee ceremonies' and get local `iddir' (neighborhood organization) leaders to do the same with their members; and producing IEC materials. In an effort to provide care and support, the organization AGCCDO enables this woman to care for her six used MAP funds to ensure that AIDS orphans have a grandchildren who were orphaned by AIDS, of whom two roof over their heads (mainly in extended families, are living with HIV 6 About the MAP and Ethiopia Multi-Sector AIDS Project: The Africa Multi-Country AIDS Program (MAP) was designed to help countries intensify and expand their multi-sectoral national responses to the HIV epidemic, to dramatically increase access to HIV prevention, care, and treatment. To qualify for MAP funding, countries were asked to: (i) develop HIV-AIDS prevention, care, treatment and mitigation strategies and implementation plans through a participatory process; (ii) have a national multi-sector coordinating authority with broad stakeholder representation from public and private sector and civil society, with access to high levels of decision-making; (iii) empower and mobilize stakeholders from village to national level with funds and decision-making authority within a multi-sectoral framework; and (iv) agree to use exceptional implementation arrangements such as channeling money directly to communities and civil society organizations, and contracting services for administrative functions like financial management, procurement, monitoring and evaluation, IEC etc as needed. The Ethiopia Multi-Sector AIDS Project (Ethiopia MAP) was one of the first of 39 projects approved under the MAP. The Ethiopia MAP provided an IDA Credit of US$59.70 million to the Government of Ethiopia. It was approved on September 12, 2000, and closed on December 30, 2006. Nearly half of the project funds were channeled directly to approximately 6,000 community and NGO initiatives, including those described in this note. The Ethiopia MAP has provided the only systematic support to civil society organizations working on AIDS in Ethiopia and helped to establish the decentralized local response system that is in place today. The project has funded local activities that have had a positive impact on attitudes about people living with HIV and about the importance of knowing one's status. It has financed home-based care, care of AIDS orphans, treatment for minor opportunistic infections, food for needy people with HIV, and income-generating activities. Without the project's support for life-saving drugs for opportunistic infections, many HIV-positive Ethiopians would have died before anti-retroviral treatment (ART) became available in 2004. One of the lessons learned is that food is an overarching basic need for many HIV-positive people in Ethiopia, since most Ethiopians living with HIV are very poor and undernourished. Especially for those on ART, lack of sufficient and nutritious food makes it impossible to regain or maintain their health. More information on the project can be found on the World Bank website, www.worldbank.org, search within projects, using the project number: P0696886. A follow-on Ethiopia MAP II project will be used to consolidate the gains achieved, help to spread the program into rural areas, strengthen and simplify sub-project operating procedures, address the issue of nutrition, and give additional support to the regional bodies that play a key role in the local response. Acknowledgments: We sincerely thank all the people who shared their stories, and gave us permission to publish their stories and photographs. About the author: Janet Leno works with the World Bank Global HIV/AIDS Program and ACTafrica. From 2001 to mid-2002 she was National HIV/AIDS Coordinator for ActionAID/Ghana, and then until mid-2006 worked as UNAIDS Country Coordinator for Sri Lanka and Maldives, under World Bank secondments. Janet met the people whose stories are told in this note during December 2006, while visiting Ethiopia to assess the local response component of the MAP, as part of a broader assessment of community support initiatives being undertaken by ACTafrica. For further information, or feed-back, please contact: Elizabeth Lule, ACTafrica (for more on the World Bank Multi-Country AIDS Program -- MAP), elule@worldbank.org Gebreselassie Okubagzhi (for more information on the Ethiopia Multi-Sector AIDS Project) Gokubagzhi@worldbank.org Joy de Beyer, Global HIV/AIDS Program (for additional copies of this note), jdebeyer@worldbank.org January 2007 7