DRAFT

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Contents
Contents ..................................................................................................................................... 1
Acknowledgements ................................................................................................................... 5
Acronyms ................................................................................................................................... 6
Executive Summary ................................................................................................................. 10
The Epidemic in Perspective ......................................................................................... 10
What is New in this Plan ............................................................................................... 10
Strategic Framework Vision, Goal, and Guiding Principles ............................................ 11
Prioritization in the NSP ............................................................................................... 11
Strategic Objectives ..................................................................................................... 13
Social and Programmatic Enablers to Maximize the Reach and Impact of Ethiopia’s
HIV/AIDS Response ...................................................................................................... 16
1. Introduction .................................................................................................................. 17
1.1. Country context ................................................................................................. 17
1.1.1. Health Sector Financing....................................................................................... 18
1.1.2 Health Indices ...................................................................................................... 18
1.1.3 The Health Care System ................................................................................. 19
1.1.4. Gender ................................................................................................................ 22
1.2. Aligning with National and Global Strategies ...................................................... 23
1.3 NSP development process .................................................................................. 24
1.4 Planning within the context of the COVID-19 pandemic and potential effects
on implementation ...................................................................................................... 25
1.5 What is new in this Plan ..................................................................................... 25
2. HIV/AIDS Epidemiology and response analysis ........................................................ 26
2.1. HIV burden and characterization of the epidemic .............................................. 26
2.2. HIV Epidemic Trends in the General Population (Prevalence) ............................. 28
2.3. Spatial (geographical) trends in prevalence and incidence ................................. 30
2.4. HIV Epidemic Trends in the general population (Incidence) ................................ 31
2.5 Mother to child transmission ............................................................................. 32
2.6 AIDS mortality in the general population ........................................................... 33
2.7 HIV in Key and Priority Populations (KPPs) ......................................................... 34
2.8 The Response to HIV/AIDS Epidemic in Ethiopia ................................................. 37
2.8.1 Combination HIV Prevention .......................................................................... 37

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 2.8.2 Prevention in Key and Priority populations .................................................... 37
2.8.3 HIV Case Finding and Testing Strategies ......................................................... 40
2.8.4 HIV Care and Treatment................................................................................. 45
2.8.5 TB/HIV co-infection treatment ....................................................................... 49
2.8.6 HIV and Cervical Cancer ................................................................................. 50
2.8.7 HIV and Hepatitis: .......................................................................................... 50
2.9. Cross-Cutting Issues for the HIV/AIDS Response................................................. 50
2.9.1. Information Systems and Data Management Investments ............................. 50
2.9.2 Supply Chain System ...................................................................................... 51
2.9.3 Laboratory ..................................................................................................... 53
2.9.4 Resources for HIV........................................................................................... 53
2.9.5 Multi-sectoral aspects of the HIV response .................................................... 56
2.9.6 Strategic Planning .......................................................................................... 58
2.9.7 HIV policy and laws ........................................................................................ 58
2.9.8 Stigma and Discrimination ............................................................................. 58
2.9.9 Gender-based violence .................................................................................. 59
2.9.10 Stakeholder Analysis of the HIV Response ...................................................... 60
3. Sustained HIV Epidemic Control Framework ............................................................. 64
4. The Investment Case Analysis...................................................................................... 66
Interventions that demonstrated evidence to be most cost effective, using the Goals
model and other available evidence, were prioritized for scale up. These interventions
included female sex workers, PrEP, condoms, VMMC, SBCC and differentiated ART. ...... 66
5. Strategic Framework Vision, Goal and Guiding Principles ......................................... 71
6. Strategic Objectives ...................................................................................................... 74
6.1 Strategic Objective 1: Reach 90% of Key and Priority populations with targeted
combination HIV prevention interventions by 2025 ..................................................... 74
6.1.1 Context .......................................................................................................... 74
6.1.2 Population and Geographic Prioritization ....................................................... 74
6.1.3 Strategic interventions ................................................................................... 78
1. ............................................................................................................................. 83
6.1.4. KPPs Service Delivery Models .............................................................................. 86
6.1.5 General Population Prevention Interventions and service delivery models .... 90
1. ....................................................................................................................................... 91

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6.2 Strategic Objective 2: Enhance HIV case finding to attain 95% of PLHIV
knowing their HIV status and linked to care by 2025 .................................................... 91
6.2.1 Context .......................................................................................................... 91
6.2.2 Population and Geographic Priorities ............................................................. 91
1. .......................................................................................................................... 92
6.2.3 Case finding strategic interventions and service delivery models ................... 92
6.2.4 Linkage to Care and Treatment ...................................................................... 94
6.3 Strategic Objective 3: Attain virtual elimination of MTCT of HIV and Syphilis by
2025 94
6.3.1 Context .......................................................................................................... 94
6.3.2 Strategic Interventions and Service delivery models ...................................... 95
6.4 Strategic Objective 4: Enroll 95% of PLHIV who know their status into HIV care
and treatment and attain viral suppression to at least 95% for those on antiretroviral
treatment .................................................................................................................... 96
6.4.1 Context .......................................................................................................... 96
6.4.2 Viral Load Coverage and Suppression ............................................................. 98
6.4.3 Children and adolescents lagging behind ....................................................... 98
6.4.4 Management of co-morbidities .................................................................... 101
6.4.5 Tuberculosis Co-infection ............................................................................. 102
6.4.6 HIV and Hepatitis B and C Co-infection......................................................... 103
6.4.7 Models of service delivery............................................................................ 104
6.5 Strategic Objective 5: Mobilize resources and maximize efficiencies in
allocation and utilization ............................................................................................ 105
6.5.1 Context ........................................................................................................ 105
6.5.2 Investment trends for the HIV program ....................................................... 106
6.5.3 Available funding for the HIV programs........................................................ 106
6.5.2 Resource needs to implement the NSP ........................................................ 108
6.5.3 Sustainable financing of the response .......................................................... 110
6.5.4 Co-ordinating strategic investments with external partners ......................... 117
6.5.5 Investing in financial systems and capacity .................................................. 117
6.6 Strategic Objective 6: Enhance generation and utilization of Strategic
Information for an accelerated evidence-based response .......................................... 119
6.6.1 Context ........................................................................................................ 119
6.6.2 Strategic Interventions ................................................................................. 121

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7. Social and programmatic enablers to maximize the reach and impact of Ethiopia’s
HIV/AIDS response.............................................................................................................. 125
7.1 Gender and Gender based Violence ................................................................. 125
7.2 Stigma and discrimination ................................................................................ 126
7.3 The role of civil society, communities, PLHIVs and the private sector ............... 127
7.4 Embracing a Human rights approach to the HIV response ................................ 129
7.5 Health Systems ................................................................................................ 131
7.5.1 Supply Chain System .................................................................................... 131
7.5.2 Laboratory System ....................................................................................... 135
7.6 Human resources for health/ HIV response ...................................................... 137
7.6.1 Context ........................................................................................................ 137
7.6.2 Strategic interventions ................................................................................. 137
7.7 Governance, leadership, coordination and accountability ................................ 137
7.8 Policy ............................................................................................................... 139
7.8.1 Context ........................................................................................................ 139
7.8.2 Strategic Interventions ................................................................................. 140
7.9 Partnership, Multisectoral Collaboration, Civil society and the Private Sector .. 140
7.9.1 Multisectoral Collaboration.......................................................................... 140
7.9.2 CSOs, FBOs and CBOs ................................................................................... 142
7.9.3 Strategic interventions ................................................................................. 142
7.9.4 Community-Led Monitoring (CLM) ............................................................... 143
7.10 Private for Profit Sector Strategic Interventions ............................................... 145
8. Monitoring and Evaluation Framework ............................................................................ 146
Annexes.................................................................................................................................. 147
Annex 1: Results Matrix: Indicators and annual targets .............................................. 148
Annex 2: Resource Needs Estimation Model .............................................................. 161
Summary.................................................................................................................... 172
Annex 3: References .................................................................................................. 173

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Acknowledgements
Federal HIV/AIDS Prevention and Control Office (FHAPCO) would like to acknowledge the
support and inputs provided by the Ministry of Health, other government sectors, regional
health bureaus, development partners, civil society and especially People Living with HIV.
FHAPCO also acknowledges the expertise and contributions provided by technical working
group members and other experts. Special appreciation goes to UNAIDS for financial and
technical support through the overall process of development of the strategic plan. FHAPCO
would also thank UN Agencies, PEPFAR and other development partners for the technical
assistance and support at various stages in the process, as well as the consultant team who
played important role in providing technical support to the country’s effort in the
development of the HIV/AIDS National Strategic Plan.

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Acronyms

AGYW Adolescent girls and young women

AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
ART Anti-Retroviral Therapy
ARV Anti-Retroviral
BCC Behavioral Change Communication
BSS Behavioral Surveillance Survey
CBOs Community-Based Organizations
CCM Country Coordination Mechanism
CCRDA Consortium of Christian Relief and Development Association
CDC Centers for Disease Control
CSOs Civil Society Organizations
DBS Dried Blood Spot
DHS Demographic and Health Survey
DHIS2 District Health Information System
DIC Drop in center
DTG Dolutegravir
EDHS Ethiopian Demographic and Health Survey
EFY Ethiopian Fiscal Year
EVF Efavirenz
EID Early Infant Diagnosis
EmONC Emergency Obstetric and Newborn Care
e-MTCT Elimination of Mother-To-Child Transmission of HIV
EPHI Ethiopian Public Health Institute
EPHIA Ethiopia Population HIV Impact Assessment
EPP Estimations and projections Package
EHSP Essential Health Service Package
ETORRS Electronic test ordering & result reporting system
FBOs Faith-Based Organizations
FGM Female Genital Mutilation

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FHAPCO Federal HIV/AIS Prevention & Control Office
MOH Federal Ministry of Health
FSW Female Sex Workers
GBV Gender based violence
GNI Gross National Income
GTP Growth and Transformation Plan
HAPCO HIV/AIDS Prevention and Control Office
HCD Human Centered Design
HCT HIV Counseling and Testing
HDA Health Development Army
HEI HIV exposed infants
HEWs Health Extension Workers
HDI Human Development Index
HIV Human Immunodeficiency Virus
HIVST HIV self-testing
HMIS Health Management Information System
HRD Human resource development
HSDP Health Sector Development Program
HSTP Health Sector Transformation Plan
ICT Index case testing
IEC Information Education Communication
IGAs Income Generating Activities
IPLS Integrated Pharmaceutical Logistic System
KPP Key and Priority Population
LIS Laboratory information system
LWHIV Living with HIV
MARPs Most At Risk Populations
MDGs Millennium Development Goals
M&E Monitoring and Evaluation
MIS Management Information System
MMD Multi-month distribution
MNCH Maternal, Neonatal, and Child Health

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MOE Ministry Of Education
MOH Ministry Of Health
MOLSA Ministry of Labor and Social Affairs
MRIS Multi-sectoral information system
MSG Mother Support Group
MTCT Mother-To-Child Transmission of HIV
MWCYA Ministry of Women, Children and Youth Affairs
NAC National AIDS Council
NASA National AIDS Spending Assessment
NEP+ Network of Networks of HIV Positive in Ethiopia
NHA National Health Account
NGOs Nongovernmental Organizations
NNPWE National Network of Positive Women Ethiopians
NSP National Strategic Plan
OI Opportunistic Infections
OOP Out of pocket
OVC Orphan and Vulnerable Children
PBFW Pregnant and breast feeding women
PEP Post-Exposure Prophylaxis
PEPFAR President Emergency Plan for AIDS Relief
PFSA Pharmaceuticals Fund and Supply Agency
PHC Primary Health Care
PHEM Public Health Emergency Management
PITC Provider-Initiated Testing and Counseling
PLHIV People Living With HIV/AIDS
PMTCT Prevention of Mother-To-Child Transmission of HIV
PNS Partner notification service
PSI Population Service International
PSM Procurement and Supply Management
PWID People wiho inject drugs
RAT Risk screening tool
RHB Regional Health Bureau

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RRF Requisition and Report Forms
RTK Rapid Test Kit
SBCC Social behavioral change communication
SPM Strategic Plan Management
SRH Sexual and Reproductive Health
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
THE Total Health Expenditure
TB Tuberculosis
TPT Tuberculosis Preventive Therapy
TWG Technical Working Group
UN United Nations
UNAIDS Joint United Nations Program on AIDS
VCT Voluntary Counseling and Testing
VfM Value for Money
WHO World Health Organization

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Executive Summary
This HIV/AIDS National Strategic Plan (NSP) for Ethiopia 2021-2025 provides a unique
opportunity to consolidate the steady decline in the HIV burden over the past decade and
refocus interventions for maximum public health impact. Enormous gains that Ethiopia has
achieved in addressing the HIV epidemic mean that epidemic control lies within reach.

The Epidemic in Perspective

The Ethiopian HIV/AIDS epidemic is characterized as mixed, with wide regional variations
and concentrations in urban areas, including some distinct hotspot areas driven by key and
priority populations. The National adult (15-49) HIV prevalence is 0.93% in 2019; prevalence
in women constitutes 61% of infections (women 1.22%, men 0.64%). There are wide
regional variations ranging from a high in Gambella at 4.5%, Addis Ababa at 3.42% with the
lowest in Somali region at 0.01%. In 2019, the national HIV incidence rate in the adult
population is estimated at 0.02% (0.03% in females and 0.02% in males) with an estimated
15,000 (9,000 females and 6,000 males) new infections, the majority (67%) of these
occurring in the age group below 30 years. About 265 out of more than 1000 Woredas
(districts) in the country constitute nearly two thirds of all new infections annually. With an
estimated 669,000 People living with HIV (PLHIV) of which 39,792 are <15 years of age, HIV
remains a heavy burden on the country.
Since the rapid expansion of the ART program in Ethiopia, the number of AIDS deaths has
shown dramatic decline from 117.7/100,000 in 2001, to 11.73/100,000 in 2019. At the peak
of the death curve, an estimated 70,173 AIDS deaths occurred within one year. Compared
to the 2010 level, there is a 52% reduction in AIDS deaths in 2019. With declining mortality
rate the number of orphans due to AIDS has also decreased by more than half, from
628,000 in 2010 to 309,000 in 2019. As of December 2019, a total of the 79% of estimated
PLHIVs who know their status, 90% were on ART while 91% were virally suppressed.

What is New in this Plan

The thinking and rational behind the prioritized elements of this National Strategic Plan
represents a new way of doing business to achieve maximum public health impact within a
resource constrained setting:
 It addresses the key drivers of the epidemic in a differentiated manner with
evidence-based rationales and geographic prioritization
 It demonstrates a shift from an intervention-focus to a people-centered response
 It identifies the key drivers of the epidemic and prioritizes interventions with the
maximum impact, specifically prevention among key and priority populations (KPPs)
 It is optimized to achieve maximum possible impact within a constrained funding
environment, and rigorously applies the investment case approach and value for
money principles (economy, efficiency, effectiveness, equity and sustainability).
 It sets a clear path to reach HIV epidemic control in all parts of the country by 2030
 Lastly, but not least it engages country leadership at the highest levels and multiple
stakeholders

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Strategic Framework Vision, Goal, and Guiding Principles

Vision: An AIDS-Free Ethiopia

Goal: The goal of the Ethiopia National Strategic Plan for HIV 2021-2025 (NSP) is to attain
HIV epidemic control nationally by 2025, by reducing new HIV infections and AIDS mortality
to less than 1 per 10,000 population.

The NSP has set the following impact targets to be achieved by the end of the 5-year period:

 Number of new HIV infections reduced to less than 1 per 10,000 population
(Disaggregated by sex, age, region and population group)
 HIV related deaths reduced to less than 1 per 10,000 population
 Incidence Mortality Ratio reduced to minus 1 (Target: From 1.08 to 0.9)
 Percentage of child HIV infections from HIV- positive women delivering in the past 12
months reduced from 13.39% to less than 5% by 2025; and less than 2% by 2030.

The Strategic Objectives, packages of interventions, and coverage levels in the NSP have
been designed and modelled to ensure that the above goals can be realistically achieved
with the right enablers and levels of funding, whilst leaving no marginalized groups behind.

Guiding Principles: The NSP will be implemented with adherence to the following guiding
principles:

a. Multisectoral: A multisectoral approach and partnership that builds on HIV being the
responsibility of all sectors and constituencies.
b. Inclusiveness: An inclusive and people-centered approach that recognizes different
prevention options that individual may choose at different stages of their lives.
c. Gender Responsiveness:- A gender-sensitive approach that caters for the different
needs of women, girls, men and boys in accessing HIV information and related
services.
d. Value for Money (VfM): All planning for and execution of activities in this NSP will
address the multiple dimensions of VfM, including equity, economy, efficiency,
effectiveness and sustainability

Prioritization in the NSP

The NSP was informed by Investment Case modelling produced by Spectrum Goals to
prioritize the most cost-effective interventions (those that promise the highest impact at
least cost) whilst investing in critical social and program enablers, including rights-based
programming to achieve this.

Therefore, the NSP is a rights-based plan that was developed through considering the 5
dimensions of the Value for Money (VfM) lens, that defines how to maximize and sustain
equitable and quality health outcomes and impacts in a constrained economic and financial

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environment. Progress towards achieving VfM will be tracked against VfM indicators
included in the NSP Results Framework.

Geographic Prioritization: While HIV testing and treatment programs are needed
everywhere there are PLHIV, the investment case modelling demonstrates that prevention
programs will be more cost-effective in the high incidence woredas defined as an incidence
>0.03%. These 265 woredas account for about two-thirds of all new infections and thus
constitute a geographic core where prevention interventions will be scaled up first to
achieve maximum cost-effectiveness. The country has about 1076 woredas. Based on HIV
incidence woredas are categorized into three geographic priority areas:

1. High (265): Woredas with HIV incidence of ≥0.03% of people aged 15-49;
2. Medium (326): Woredas with HIV incidence of 0.01- 0.029% of people aged 15-49;
3. Low (485): Woredas with HIV incidence of < 0.01% of people aged 15-49

1. Population Prioritization: The following population

groups are defined as Key and Priority Populations KEY POPULATIONS:
taking into consideration local epidemiology, HIV
 Female Sex Workers (FSW) and
prevalence, high risk behaviors increased morbidity
their clients
and mortality or higher vulnerabilities.
 Prisoners
The NSP has targeted achieving 90% coverage of  People with injecting drug use
combination prevention interventions for the Key and (PWID)
Priority Populations in high priority Woredas.
PRIORITY POPULATIONS:
2. Prioritization of Interventions Based on Cost-  Widowed and divorced men
Effectiveness: Interventions that demonstrated and women Long distance
evidence to be most cost effective, using the drivers
Spectrum Goals model and other available evidence  Workers in hot spot areas
are prioritized for scale up. These interventions
 High risk adolescent girls and
include female sex workers, PrEP, condoms, VMMC,
young women
SBCC and differentiated ART. These core programs are
 PLHIV and their partners
shown in the investment case modelling for Ethiopia
to avert substantial numbers of new infections and
AIDS deaths if an appropriate enabling environment is in place. Modelling of the impact of
implementing the NSP 2021-2025 as part of the Ethiopia Investment Case for HIV (2020)
demonstrated that it could avert 30,000 new infections (compared to the current baseline
interventions and coverage) during the period at a cost per infection averted (undiscounted)
of approximately $11,000.

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Cost-Effectiveness of Prevention

New HIV infections averted through implementing the NSP 2021-2025

20 000

15 000

10 000

5 000

0
2019 2020 2021 2022 2023 2024 2025

Base NSP Targets

Testing and treatment are the most cost-effective interventions since they are together cost
saving over the period 2021-2025. As described above, prevention programs will be more
cost-effective in the high incidence woredas defined as an incidence >0.03%.

Strategic Objectives
Result 1: Comprehensive knowledge
There are six Strategic Objectives underpinned by about HIV and AIDS reached 90% by
critical social and programmatic enablers 2025 for key and priority
populations
Strategic Objective 1: Reach 90% of Key and Priority
populations with targeted combination HIV prevention Result 2: Condom use among key
interventions by 2025 and priority populations engaged in
risky sexual behavior reached 90%
During the strategic plan period (2021-2025) 90% of by 2025
the estimated 3.75 million key and priority populations
will be reached with combination prevention Result 3: 90% for key populations
(behavioral, bio-medical and structural) interventions. will know their HIV status by 2025

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The prevention program will be built on principle of population and geographic prioritization
for maximum impact. Client centered, integrated and sustainable service delivery models
will be used to deliver combination prevention services and interventions. While the focus
of the program is on key and priority populations in 265 high incidence woredas, general
population and KPPs in intermediate and low incidence woredas will be reached through
integrated and sustainable prevention interventions within strategic sectors and community
initiatives. ANC level services will be offered in all geographical areas.

Strategic Objective 2: Enhance HIV case finding to attain 95% of PLHIV knowing their HIV
status and linked to care by 2025

Targeted case finding will enable 95% of PLHIV to know their status. High yield case finding
modalities include index case testing and partner notification, social network services and
PITC using an HIV risk screening tool at both public and private health facilities. HIV self-
testing (HIVST) will be expanded through social marketing outlets. Ninety-five per cent of
those newly diagnosed with HIV will be linked to care and treatment.

Strategic Objective 3: Attain virtual elimination of Mother to Child Transmission (MTCT) of

HIV and Syphilis by 2025

The virtual elimination of mother to child Expected result 1 : Mother-to-child

transmission (MTCT) presents significant transmission of HIV during pregnancy,
challenges which will be addressed in this childbirth and breastfeeding reduced to
NSP. Strengthened primary prevention, less than 5% by 2025
optimized ART regimens, sustained support
Expected Result 2: Percentage of pregnant
from mothers support groups, strengthened
women who know their HIV status
and scaled up Point of Care testing for HIV increased from 84% to 95% by 2025
exposed infants with enhanced prophylaxis,
supported by strengthened health worker Expected result 3: At least 98% of
capacities are among the interventions to expectant mothers living with HIV are
reach expected results. virally suppressed at labor and delivery

Strategic Objective 4: Enroll 95% of PLHIV Expected Result 4 : Percentage of infants

who know their status into HIV care and born to women living with HIV receiving a
treatment and attain viral suppression to at virological test for HIV within 2 months of
least 95% for those on antiretroviral birth increased from 64% to 95% by 2025
treatment.

Ethiopia has made excellent progress towards achieving the 2nd and 3rd 90s among adults.
As of December 2019, of the 79% of estimated PLHIVs who know their status, 90% were on
ART and 91% were virally suppressed although there remain large regional variations in ART
coverage. However special attention is warranted to increase access to treatment for
children as only 67% of children <15 years are receiving ART and viral suppression is also
suboptimal.

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The focus of this NSP will be to reach 95% coverage of ART and viral suppression nationally
across all age groups. Differentiated models of service delivery will be expanded.
Additionally identifying and treating co-morbidities which critically affect treatment
outcomes, especially co-infection with TB, screening and treatment of Hepatitis B and C,
cervical cancer screening and treatment are addressed.

Strategic Objective 5: Mobilize resources and maximize efficiencies in allocation and

utilization

The Spectrum Resource Needs Model was used as the primary tool to estimate the financial
costs of implementing the NSP over the 5-year period. Unit costs were computed from a mix
of sources.

The annual resource needs for the NSP increases from $267 million in 2021 to $299 million in
2025 (12% growth). reaching a total of $1.4 billion over the five years. This annual increase
is largely driven by scaling up prevention and treatment services to reach more people, so
that the NSP goals can be reached. Over the 5-year period, primary prevention interventions
will drive 15% of financial resource needs, HIV testing 11%, PMTCT 8% and care and
treatment services, 39%.

Annual Resource Needs for HIV 2021-2025 (USD)

A resource mapping exercise was undertaken to determine current sources and levels of
funding for the HIV response and to project expected funding for the upcoming period of
the NSP. Principal sources of funding for HIV in Ethiopia come from PEPFAR, the Global Fund
and domestic resource mobilization. Declining trends in donor funding and the need to
develop more sustainable financing options led to the development of a Domestic Resource
Mobilization Strategy (DRMS) for Ethiopia. The NSP outlines strategies to meet the
challenges of fully funding the NSP. The analysis shows that to achieve the goals of the NSP,
both the ambitious domestic resource mobilization targets in the Ethiopia DRMS and the

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maintenance of current funding levels from Ethiopia’s main development partners would
need to be realized during the 5-year period. The analysis also shows that further
optimization would be required if targeted funding levels are not achieved and there would
be severe disruptions to prevention services and other social and program enablers.

Strategic Objective 6: Enhance generation and utilization of Strategic Information for an

accelerated evidence-based response

This NSP will address both the lack of strategic information and gaps in the quality and use
of data to provide both an evidence base and information for improved program quality.
Interventions include health information system scale up and sustainability plan, extension
of e-MRIS and DHIS, integration of LMIS, HRIS and FMIS data into DHIS 2, granular mapping
and availing strategic information for key and priority populations, expanded data quality
assessments, integrating, individualizing and digitizing data collection tools, evidence
generation (through a number of special surveys and mapping of key and priority
populations), enhanced data analysis and use for policy and decision-making, enhanced
tracking of 95-95-95 and the PMTCT cascades.

Social and Programmatic Enablers to Maximize the Reach and Impact of

Ethiopia’s HIV/AIDS Response

The multi-sectoral and social nature of the HIV epidemic highlights underlying critical social
and programmatic situations and circumstances which, if not addressed, can diminish
efforts to maximize the reach and impacts of Ethiopia’s HIV/AIDS response. This NSP
embraces a human rights approach to the HIV response and includes analysis and
interventions addressing gender and gender-based violence and stigma and discrimination.

The successful implementation of programs to address the HIV/AIDS epidemic requires

eliciting joint responses from multiple levels of society. Communities are the best way to
reach key and priority populations, people living with and affected by HIV. They have the
trust of the people they serve, and community-led organizations are the most effective way
of reaching people living with HIV and key populations. The NSP outlines an increased role
for civil society, faith-based and community- based organizations, the private sector, key
and priority populations and PLHIV associations both in the delivery of key interventions as
well as in community led program monitoring activities.

Successful delivery of the ambitious targets outlined in this NSP will be underpinned by
strengthening key aspects of the health system: key policy reforms, strengthened and
trained health workforce, an efficient supply chain and functioning laboratory systems.

The NSP was developed through robust analysis and involved a wide array of stakeholders
at all levels. It outlines opportunities to strengthen the governance, coordination and
management of the HIV/AIDS response and galvanize strong political leadership at all levels.

This National Strategic Plan 2021-2025 provides the platform for Ethiopia to reach HIV
epidemic control.

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1. Introduction
1.1. Country context

Ethiopia is sub-Saharan Africa’s second most populous nation with a population of

1021million approximately 80 ethnic groups and languages, and a diverse geographic area
of1.127 million sq.km. About 79% of the population resides in rural areas. Approximately
65% of Ethiopia’s population is under 25 years of age; forty seven per cent are < 15 years of
age. Ethiopia hosts one of the largest refugee populations in Africa as a result of conflict and
political oppression in surrounding countries. 2020 has been marked by the growing threat
from COVID-19, the worst locust infestations in decades, resurgences of polio and guinea
worm, and on-going epidemics of cholera and measles in many parts of the country. Eastern
Ethiopia has experienced both drought and flooding, particularly in Somali region. The most
severe humanitarian threat is COVID-19, with widespread health and economic
consequences. The country’s fragile health system will likely be overwhelmed as already
strained laboratory and treatment facilities deal with those afflicted with the virus.

Although Ethiopia has made substantial economic and social progress over the last 30 years,
in 2017, the Gross Domestic Product was US$ 862 per capita, much lower than the average
for other sub-Saharan countries of US$1,553. The World Bank Poverty and Equity data
indicates that 27% of the population remains below the poverty line of $1.90/ day 2, and the
country ranked 173 out of 189 countries in the 2019 Human Development Report. However,
between 2000 and 2018, Ethiopia’s Human Development Index (HDI) value increased from
0.283 to 0.470, an increase of 65.8 percent. Between 1990 and 2018, Ethiopia’s life
expectancy at birth increased by 19.1 years to 64.5 years (62.4 for men and 66.6 for women),
mean and expected years of schooling increased by 1.3 years and 5.6 years respectively.
Ethiopia’s Gross National Income (GNI) per capita increased by about 173.7 percent between
1990 and 2018 (see Fig 1).

The country is structured in a federal system comprising 9 regional states and Addis Ababa
City and Dire Dawa Administration. This is further sub-divided to more than 1000 woredas
(districts) and 17,000 kebeles, the smallest local administrative unit. Regions receive their
budgets as block funds from the Ministry of Finance and have considerable autonomy on
allocation of their resources to the various sectors.

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Fig 1: Trends in Ethiopia’s Human Development Index (HDI) component indices 2000-20183

1.1.1. Health Sector Financing

Over the past two decades, Ethiopia has made considerable progress in improving access to
and utilization of essential health services. The period has been characterized by huge
expansion in health investment, Primary Health Care (PHC) infrastructure, and human
resources development (HRD). Potential health service coverage increased from 50% in
2000 to more than 83% in 20194. Although the government has allocated 60-70% of total
budget to pro-poor sectors to date, allocations to health fall well short of the Abuja
Declaration target or WHO’s recommended US$86 per capita spend to deliver UHC 5. Ninety
five per cent of health expenditures is generated from three major sources: government
(tax revenue), external donors, and households (out-of-pocket payments)6. Although in
absolute amounts there have been increasing investments in health, the 7th round National
Health Account (NHA), of 2016/17, estimated Ethiopia’s total health expenditure at 72
billion ETB (US$3.1 billion) accounting for 4.2% of the country’s Gross Domestic Product
(GDP) which remains lower than the expected average of 5% for low-income countries, and
well below the global average of 9.2%7. Direct household payments to health facilities
during service use still remains unacceptably high. According to NHA-7, out-of-pocket (OOP)
spending on health amounted to 31% of total health expenditure (THE) in 2016/17,
considerably higher than the global recommended target of 20%. Household OOP spending
remains a major domestic source of financing for the health sector with a significant number
of households facing the effects of catastrophic health expenditure (4.2%).8

1.1.2 Health Indices

Ethiopia has made considerable health gains since 2000. The 2019 mini-EDHS9 shows the
ANC coverage has increased from 27% in 2000 to 74% in 2019, skilled delivery from 5% to
48%; maternal mortality dropped from 676/100,000 in 2011 to 412/100,000 in 2016 EDHS 10.

18
Even though first Antenatal Care Visit (ANC1) coverage improved, only 43% of pregnant
women had four or more visits and only 20% of women attended antenatal services in a
timely manner. However, there are remaining quality of service delivery issues both at
antenatal care and labor and delivery services. Only 40% of health facilities had fully
functioning Emergency Obstetrics and Newborn Care (EmONC) facilities in 2016 and only
14% of expected deliveries took place in functioning EmONC facilities11.

There have been significant declines in neonatal, infant and under five mortality rates which
have dropped from 49 to 30 per 1000 live births, 97 to 43 per 1000 live births, and 166 to 55
per live 1000 births respectively over the period 2000 to 2019, although the change in
neonatal mortality has not been as significant. There remain large regional differences in
under five mortality from a low of 39 per 1000 live births in Addis Ababa to 125 per 1,000
live births in the predominantly pastoralist area of Afar. Although there is overall
improvement, the proportion of children receiving three doses of pentavalent vaccine and
all basic vaccines only reached 61% and 43%, respectively in 2016. Malnutrition remains a
significant problem with Ethiopia having one of the highest rates of malnutrition in Sub-
Saharan Africa but there has been considerable improvement. Between 2005 and 2019, the
prevalence of stunting decreased from 51% to 37%; underweight declined from 33% to 21%;
and wasting decreased from 12% to 7%12.

The top most causes of premature deaths in Ethiopia are Neonatal disorders, diarrheal
diseases, lower respiratory infections, Tuberculosis, and HIV AIDS 13.

1.1.3 The Health Care System

Ethiopia has a three-tiered health system (Fig 2). The primary level care is provided at
primary hospitals, health centers and health posts, while secondary and the tertiary level
care are provided at general hospitals, and specialized hospitals respectively. The health
centers in urban areas serve a catchment population of 40,000 while in rural areas they are
intended to serve a catchment population of 15,000 -25,000. In rural areas, primary health
units include one health center with five satellite health posts each serving a catchment
population of 3000-5000 whereas primary hospitals, general hospitals and specialized
hospitals serve catchment populations of 60-100,000, 1-1.5 million and 3.5-5.0 million
respectively (see figure 2).

19
Fig 2: Ethiopian Health Care Tier System

Over the past two decades, the unprecedented expansion of primary healthcare units, made
possible through joint efforts of government, donors, and community at large, has created
favorable ground for accelerated expansion of HIV prevention, care and treatment services
in the country. In 2018/19, there were a total 17,162 health posts, 3678 health centers and
314 hospitals, with a further 425 health posts, 86 HCs and 108 hospitals under
construction14.

Figure 3: Expansion of Health posts and Health centers, 1996/97-2018

20,000
18,000 17,162
16,000 14,416
14,000
12,000
10,000
8,000
6,000
3678
4,000 2,899 2,689
2,000 76 412 519
-
1996/7 2003/4 2010 2018

Health post Health center

Although there has been considerable expansion in the number of health facilities, many
lack basic amenities such as water, electricity and sanitation and internet connectivity

20
remains limited. Primary health care providers, including district hospitals, health centers
and health posts together received more than 61% of total government recurrent
expenditure. This is in line with government’s health policy, which is focused on preventive
and promotive services provided at the primary health care level. The essential health
services package (EHSP) which guided the delivery of health services particularly at the level
of Primary Health Care (PHC) was defined in 2005. The 2019 revision of the EHSP comprises
nine components as outlined in the HSTP II which the government intends to make available
at the respective service delivery levels with an adequate level of quality 15.

Fig 4: Expansion of Hospitals, 1996/97-2018

350 314
300
250
195
200
150 126

100 87

50
0
1996/7 2003/4 2010 2018

Over the past decade, there have been major inputs into training of health workers. Table 1
dePITCs the health worker/population figures 16. Of the 39, 878 health extension workers,
5,036 are deployed in urban areas. Despite the increase in absolute numbers, quality of
training, equity in deployment throughout the country, and performance remain issues in
the health system.

Table 1. Health Workforce number and population ration by category17

Category Absolute number Population ratio

Physicians 10,194 1: 10,521
Health Officers 10,953 1: 8,820
Nurses (Diploma,degree, specialist) 59,469 1: 1,624
Midwives 16,087 1:6,005
Pharmacists 10,626 1: 9,091
Lab technicians/technologists 9,468 1: 10,773
Health Extension Workers 39,87818 1:2,362

21
1.1.4. Gender

Ethiopia has put in place appropriate and effective legal and policy provisions to promote
the rights of women and girls. These rights are enshrined in the Constitution, with the
country also ratifying many of the international and continental agreements that promote
and protect women’s rights. Different sector-level policy or strategy documents have
attempted to address the issue in addition to the 1993 National Policy on Ethiopian
Women19 and the National HIV/AIDS Policy. The government developed the National Action
Plan for Gender Equality (NAP-GE) 2006-2010 which is considered as its commitment to the
Beijing Plan of Action. According to the 2000 revised family law of Ethiopia women are
entitled to spousal property rights and gives women the right to access, use and control
property, including land20.

The country has made labor law reforms to ensure the equal participation and benefit of
women in the labor force. The Labor Law recognizes special needs of women workers. It
prohibits discrimination based on sex, promotes affirmative action, and provides for
extended maternity leave. Assurance of health care for all segments of the population is one
of the top priorities in the Ethiopia’s Health Policy and it states that special attention shall
be given to the health needs of women and children among others 21 . Besides, the
promotion of women, youth, and other vulnerable segments of the population received
significant attention in Ethiopia’s Growth and Transformational Plan (GTP) which is a key
step towards achieving the state’s development goals 22.

Ethiopia has also put the obligatory institutional mechanisms in place at federal and regional
levels, such as the Ministry of Women, Children, and Youth Affairs Offices; Child and
Women Protection Units within various police units; and a Special Bench that deals with
violence against women cases within the federal criminal court 23 . In line with such
constitutional orders, the different policies and strategies of the country have adopted the
laws even down to the program level. All ministries are expected to mainstream gender in
all the policies, laws, development programs and projects they formulate. They should
benefit women, children and youth. Each sector is expected to develop its mainstream
guidelines. This is further expanded in the recent Gender Assessment.24

However, remain a number of areas where either improvement or better implementation is

required. According to the 2019 Human Development Report, Ethiopia’s gender inequality
index (GII) is among the lowest at 0.508 in 2018, ranking 123rd from 162 countries25. Women
and girls in Ethiopia are strongly disadvantaged compared to boys and men in several areas,
including literacy, employment, health, and livelihoods. The minimum legal age of marriage
in Ethiopia is 18 years (Family Law 2000). However, 65% of women and 56% of men aged
25-49 were currently in a union with the median age at first marriage of 17.1 for women
and 23.7 years for men. About 58% of women and 9% of men were married before their
18th birthday and 13% of women aged 15 to 19 have already begun childbearing. The
majority (61%) of ever married women said that their parents had made the decision for

22
them to get married for the first time, with only 35% stating that they had made the
decision to marry by themselves26.

Gender disparities in health service utilization in Ethiopia are mostly linked to the limited
decision-making power of women at the household level. Eighty one per cent of women
participated (either as primary decision maker or jointly) in decisions regarding their own
healthcare. It was also reported that getting permission to visit a health facility, getting
money for treatment, distance to a health facility, and not wanting to go to a health facility
alone were important barriers to health service utilization among women; 70% of women
reported that at least one of these factors prevented them from accessing health services at
times of illness. Financial barriers were the most commonly reported barrier to health
service utilization among women26.

The Penal Code (revised in 2005) criminalizes acts of violence against women, including child
marriage and abduction. However, child, early or forced marriages continue to be common
practices. In Ethiopia violence against women remains a major challenge. According to EDHS
2016, among women aged 15-49, 23% have ever experienced physical violence and 10%
have experienced sexual violence; thirty-four percent of ever-married women age 15-49
have experienced spousal physical, sexual, or emotional violence. Violence against women is
12 % higher among widowed or separated than those who are married or live with a
partner.

1.2. Aligning with National and Global Strategies

Ethiopia’s Growth and Transformation Plan (GTP) provides an overarching framework for
national development across all sectors. The Second Health Sector Transformational Plan
(HSTP II) provides the framework for the health sector to support Ethiopia’s overall growth
and transformation. The total estimated cost of the HSTP II for the first five years (2020/21 –
2024/25) is US$ 50.46 billion increasing from US$7.93 billion in 2020/21 to US$ 12.68 billion
in 2024/25 with a per capita expenditure in the first year of the strategic plan (2020/21) of
US$78.1 increasing yearly to US$ 114.5USD in 2024/25 and to US$100.3 USD in 2029/3027.

The goal of the HSTP II is ensuring healthy lives and promoting well-being for all at all age
groups. The five general objectives which lead to the achievement of the goal are:

i. Improved health status of the population

ii. Improve progress towards Universal Health Coverage
iii. Protect people from health emergencies
iv. Contribute towards household transformation
v. Improve health system responsiveness

To achieve these objectives, the HSTP II outlines a number of strategies. These include
progress towards improved health emergency and disaster risk management, delivery of
equitable and quality health services, community engagement and ownership, access to
pharmaceutical and medical devises, regulatory systems, human resource development and

23
management, informed decision making and innovations, digital health technology, health
financing, governance and leadership, health infrastructure, traditional medicine, health in
all policies as well as private engagement in the sector.

The HSTP II includes ambitious targets to reduce AIDS incidence and related deaths and
achieving 95-95-95 targets. It emphasizes enhancing community engagement,
empowerment and ownership. This includes activities such as the application of human
centered design (HCD) as one of the effective tools to understand communities’ values and
enhance community's acceptance of health care products and services. It also includes
expanding major public health interventions, strengthening community structures and
accountability of the health system, and generating community based resources 28.

The HIV/AIDS National Strategic Plan aligns and supports the targets outlined in the HTSP II,
including focused combination prevention, strengthening PMTCT, case finding through
targeted HIV testing, increasing antiretroviral treatment and viral suppression. It also aligns
with the UN General Assembly Political Declaration on HIV and AIDS: On the Fast Track to
Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030 29 and SDG 3 on
good health and wellbeing.

1.3 NSP development process

The development of the 2021-2025 National HIV Strategic Plan (NSP) was led by the Federal
HIV Prevention and Control Office (FHAPCO). A concept note was developed to guide the
process, outlining approaches and timeline for the development of the NSP. Various
coordination platforms were established with defined roles and responsibilities, under the
overall auspices of the Steering Committee, chaired by the State Minister of Health with
membership from development partners, technical working groups, civil society and PLHIV
networks. Under the Steering committee, a core technical team consisting of experts, from
MOH, FHAPCO, key government sectors, development partners, civil society and PLHIV
networks was formed. The technical team had six sub-teams (Prevention, PMTCT and
Treatment, Case Finding, Supply chain and Laboratory, Coordination, Leadership, and
Resource Mobilization and Strategic Information) to work on specific HIV program areas, as
well as crosscutting issues such as HIV related health systems, social and critical enablers.
International and local consultants were also recruited. A Core Technical Team, chaired by
FHAPCO, comprising the Chairs of all TWGs as well as the team of national and international
consultants, consolidated inputs from the six sub-teams. The overall process was built on a
review of the performance of the last strategic plan 2015-2020, an analysis of the available
epidemiological data and characteristics of the HIV epidemic in Ethiopia, extensive field
assessments, focus groups discussions with key and priority populations, young people and
PLHIV, key informant interviews with other sectors, donors and civil society, and national
multi stakeholder consultations. The process also included development of investment case
scenarios to determine the most cost effective public health interventions within available
resources as well as to engage political leadership at the highest level.

24
1.4 Planning within the context of the COVID-19 pandemic and
potential effects on implementation
The unprecedented situation presented by the COVID-29 pandemic affected the planning
process on this NSP. Initial stakeholder meetings with a wide group of stakeholders occurred
prior to limitations imposed on face to face meetings. Subsequent stakeholder consultations
continued in a virtual manner ensuring participation of regional health bureaus, other
government sectors, donors, civil society including representation from associations of
PLHIVs.

The trajectory of the COVID 19 pandemic within the African context remains unknown.
However, it remains essential that prevention activities and HIV testing by scaling up
innovative approaches like self-testing and offering HIV testing at COVID19 quarantine and
isolation sites need to continue and that there be no interruptions in the delivery of
antiretroviral treatment, identification and treatment of co-morbidities as well as
maintaining high levels of viral suppression. As such differentiated delivery models and
multi-month dispensing of ARVs will be promoted as a priority. Peer-led community support
groups will have an even more important role in maintaining the gains that Ethiopia has
achieved in addressing the HIV epidemic.

1.5 What is new in this Plan

The thinking and rational behind the prioritized elements of this National Strategic Plan
represents a new way of doing business to achieve maximum public health impact within a
resource constrained setting:

 It addresses the key drivers of the epidemic in a differentiated manner with

evidence-based rationales and geographic prioritization

 It demonstrates a shift from an intervention-focus to a people-centred response

 It identifies the key drivers of the epidemic and prioritizes interventions with the
maximum impact, specifically prevention among key and priority populations (KPPs)

 It is optimized to achieve maximum possible impact within a constrained funding

environment, and rigorously applies the investment case approach and value for
money principles (economy, efficiency, effectiveness, equity and sustainability).

 It sets a clear path to reach HIV epidemic control in all parts of the country by 2030

 Lastly, but not least it engages country leadership at the highest levels and multiple
stakeholders

25
2. HIV/AIDS Epidemiology and response analysis30
2.1. HIV burden and characterization of the epidemic
Ethiopia has made significant progress in addressing the HIV epidemic in the last 10 years.
The National adult (15-49) HIV prevalence is 0.93% 31 in 2019 32 . The epidemic is
characterized as mixed, with wide regional variations (Fig 3) and concentrations in urban
areas, including some distinct hotspot areas driven by key and priority populations.
However, with an estimated 669,000People living with HIV (PLHIV) of which 39,792 are <15
years of age, HIV is a heavy burden on the country.

Table 2: Summary table for characterizing the HIV epidemic in Ethiopia.

Epidemic
Definition Numerical proxy: HIV Prevalence in Ethiopia
Type
Concentrated HIV has spread rapidly HIV prevalence is Yes, prevalence has been
in one or more defined consistently over 5% in >5% in FSW
subpopulation but is at least one defined
not well established in subpopulation
the general population. but is less than 1% No, HIV prevalence among
among pregnant pregnant women in urban
women in urban areas. areas is 4.05%
Generalized HIV is firmly HIV prevalence No and Yes,
established in the consistently exceeding  Spectrum - Prevalence
general population. 1% among pregnant among pregnant women
Most generalized HIV women is 0.4%; though the
epidemics are mixed in prevalence for female 15-
nature, in which certain 49 is 1.15% in 2020
(key) subpopulations  ANC sentinel report,
are disproportionately 2016/17 – HIV prevalence
affected. in pregnant women is
1.5%
Mixed People are acquiring One or more Yes, there are several
HIV infection in one or concentrated subpopulations; especially in
more subpopulations epidemics within a urban areas that have HIV
and in the general generalized epidemic exceeding 1%
population.
Low-level Epidemics in which the HIV prevalence of <1% Yes, 0.93% in 2019
prevalence of HIV in the general
infection has not population nationally,
consistently exceeded or
1% in the general HIV prevalence < 5% in No, there are several
population nationally any subpopulation. subpopulations with HIV
or 5% in any prevalence exceeding 5% in
subpopulation. urban areas

Gambella has the highest adult HIV prevalence (4.45%) followed by Addis Ababa (3.42%),
while Somali (0.16%) and SNNP (0.45%) regions have the lowest prevalence (Fig.5).

26
Fig 5: HIV Prevalence among adults (15-49) regional distribution 2019

National 0.93
Gambella 4.45
Addis Ababa 3.42
Dire Dawa 3.12
Harari 2.97
Tigray 1.43
Amhara 1.28
Afar 1.04
Benishangul G 0.86
Oromia 0.65
SNNP 0.45
Somali 0.16
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

The national HIV infection among young people (15-24) is low (0.34%) as compared with
adult prevalence (0.93%). However, in those regions that have a high prevalence, it is also
higher among young people: 1.93% in Gambella and 1.79% in Addis Ababa indicating the on-
going spread of HIV in the population (Fig. 6).

Figure 6. HIV prevalence among adolescent & young people (15-24), 2019

National 0.34
Somali 0.07
SNNP 0.18
Oromia 0.26
Benishangul G 0.35
Afar 0.41
Amhara 0.46
Tigray 0.51
Harari 0.81
Dire Dawa 1.00
Addis Aababa 1.79
Gambella 1.93

0 0.5 1 1.5 2 2.5

The highest number of PLHIV (208,000) is in Amhara region followed by Oromia region
(167,000) (Fig 7). As reported in the EDHS 2016 and in the Gambella Regional HIV/AIDS Epi-
synthesis report, multiple sexual partners, paid sex and a greater mean number of lifetime
sexual partners were more common in Gambella compared to the national average 33,34.

27
Figure 7. PLHIV population by regional distribution, 2019 (in thousands)

National 669
Amhara 208
Oromia 167
Addis Aababa 116
SNNP 65
Tigray 57
Gambella 14
Afar 13
Dire Dawa 12
Benishangul G 7
Somali 6
Harari 6

0 100 200 300 400 500 600 700 800

2.2. HIV Epidemic Trends in the General Population (Prevalence)

HIV prevalence in the adult population (15-49) declined steadily over the last decade in both
women and men although prevalence in women is higher than in men (women 1.22%, men
0.64%) and constitutes 61% of the HIV population (Fig 8). This trend is also reflected among
young people aged 15-24 years. From a peak prevalence among young women of 2.66%,
prevalence is now estimated at 0.45% with a similar decline among young men from 0.83%
to 0.29% (Fig 9)35.

Fig 8: Trend of adult (15-49) HIV prevalence by sex and year 1990-2019

Both Male Female

4.00
3.76
3.50
3.16
HIV PREVALENCE (%)

3.00
2.50 2.12 2.54
2.00 1.97
1.81 1.79
1.50 1.38
1.22
1.00 0.97 0.93
0.50 0.64

0.00
1994

2008

2013
1990
1991
1992
1993

1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007

2009
2010
2011
2012

2014
2015
2016
2017
2018
2019

28
Figure 9. Trend in HIV prevalence among 15-24 age group by sex and year 1990-2019

The recent estimate of 14,842 new infections in Ethiopia in 2019 (Fig 10) indicates that
there is on-going spread of HIV infection in the population; more than 60% of the new
infections are occurring in Amhara, Oromia, SNNP, and Tigray. The burden of new infections
in absolute number in these regions is due to their relatively large population size otherwise
other regions such as Gambella and Addis Ababa have higher incidence rates.

Figure 10. New HIV infections by regional distribution, 2019

National 14,842
Amhara 4,799
Oromia 3,964
SNNP 1,832
Tigray 1,309
Addis Aababa 1,119
Afar 461
Gambella 459
Dire Dawa 306
Somali 234
Benishangul G 223
Harari 136

0 2000 4000 6000 8000 10000 12000 14000 16000

29
2.3. Spatial (geographical) trends in prevalence and incidence

A 2019 analysis of EDHS data from 2005, 2011, and 2016 concludes that it is essential to
revitalize and scale up HIV prevention interventions on the basis of geographic and
population priorities36. (Fig 11). Rapid urbanization and scale up of megaprojects have
tended to attract a mostly young workforce, which results in the emergence of new
hotspots and influences HIV transmission trends. The prevalence of HIV decreased from
2005 to 2011 in most of the regions, including Dire Dawa, Addis Ababa, Gambella, South
Nations, SNNPR, Benishangul Gumuz, and Somali; over the period 2011-2016, the
prevalence decreased in all of the administrative regions but the reduction in rural areas
was not as fast as seen in urban areas (P=0.0086).

Spatial distribution of HIV cases in all the three surveys was not random. Some parts of
Amhara regional state, a large area of Afar, a few parts of Tigray, Addis Ababa and areas
surrounding Addis Ababa continue to show the highest prevalence of HIV. The
administrative regions of Gambella and Addis Ababa have continued to have higher than
average loads of HIV cases for a long time. Gambella region has a lower coverage of male
circumcision which is one of the risk factors for HIV exposure. Addis Ababa’s high burden is
related to the urban concentration of the epidemic, where towns and cities with over
50,000 people have a higher prevalence than smaller towns and much higher than rural
areas. This in part results from the former being home to high risk groups including FSW,
long distance lorry drivers (LDTD), and the military. All geographies consistently have
women and girls remaining disproportionately affected, while a new group of men at higher
risk is emerging.

Figure 11. Trends of HIV by region; data from EDHS 2005, 2011, and 2016

30
There are common factors likely to influence exposure and transmission of HIV across the
geographic areas. These include limited knowledge and/or misconceptions about HIV,
multiple and risky sexual behaviors, untreated sexually transmitted infections, transactional
and paid sexual practices, gender-based violence and early marriage, population mobility
and displacement, rapid urbanization, and low condom utilization 37. In the age group 15-49
there are low levels of comprehensive HIV knowledge with only 20% of women and 38% of
men having comprehensive knowledge about the modes of HIV transmission and
prevention respectively; less than 1% of women and 3% of men reported having two or
more sexual partners in the past 12 months, while only 20% of women and 51% of men who
had a non-cohabiting partner in the past 12 months reported using a condom during last
sexual intercourse with such a partner 38. However, the distribution and the magnitude of
these behaviors differ from region to region depending on the level of urbanization,
prevailing cultural/traditional practices, the labor market etc.

2.4. HIV Epidemic Trends in the general population (Incidence)

Based on modelling, the HIV incidence (Fig 12.a) and the number of new infections (Fig 12.b)
showed steady reduction over the last 10 years though the rate of decline has stalled in
recent years. In 2019, the national HIV incidence rate in the adult population is estimated at
estimated at 0.02% (0.03% in females and 0.02% in males) with an estimated total of 15,000
(9,000 females and 6,000 males) new infections in 2019. The majority (67%) of the new
infections are occurring in the age group below 30 years; in that age group, the highest (20%
of all new infections) occur in the age group 20-24, followed (19%) in the 0-4 age group.
There is a six fold higher incidence in women aged 15-19 than men; and a twofold greater
incidence among women aged 20-24 years. (Fig 12.c).

Figure 12.a. Trends in adult (15-49) HIV incidence (%) by sex and year, 1990-2019 per 1000 (all
ages)

2
1.8
0.67
1.6
1.4
IHIV Incidence (%)

1.2
1 0.48

0.8
0.6
0.4 0.58
0.07
0.2
0.04 0.03
0 0.05 0.02
2000
2001
2002
2003
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999

2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019

Both Male Female

31
Figure 12.b. Trend of HIV new infection per 100,000 by sex and year, 1990-2020sex and year, 1990-
2019

160

140
134
120

100
Thousands

80 76

60 58

40
28 13
20 16
10 8
0 5
1992

2002
2003

2013
1990
1991

1993
1994
1995
1996
1997
1998
1999
2000
2001

2004
2005
2006
2007
2008
2009
2010
2011
2012

2014
2015
2016
2017
2018
2019
2020
Male Female Both

Figure 12.c. HIV new infection distribution by age and sex, 2019

2,000
1,800
Number of New Infections

1,600
1,400
1,200
1,000
800
600
400
200
0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Male 1,644 0 0 232 905 968 781 550 368 231 132 87 52 33 20 9
Female 1,585 0 0 1,481 1,894 1,420 951 594 359 215 134 80 51 35 21 10

2.5 Mother to child transmission

Mother-to-child-transmission has also declined significantly in the last two decades,

especially since the introduction of the B+ option in 2013 (Fig 13). However there remain
regional variations with HIV prevalence among women attending ANC clinics in urban
hotspots in Amhara was 6.4% 39, in urban Tigray was 5%40, and 7.3% in Gambella.41 Although
Ethiopia also integrated syphilis elimination in its HIV program in 2017, based on current
WHO guidelines for dual HIV syphilis and HIV testing to address the gap in syphilis testing
(45%) against a much higher HIV testing (92%), this has yet to be put in place.

32
Figure 13. Mother to child transmission rate at 6 week and final transmission rate including
breastfeeding 2000-2019

45 39.55
40
35 30.2
30
MTCT Rate (%)

25
21.48
20 16.90
15 15.83
10 8.87
5
0

MTCT rate at 6 weeks Final transmission rate including breastfeeding period

Overall, there has been a 46% reduction in MTCT in 2019 as compared to 2019. Despite this
decline in HIV prevalence and the decline in MTCT transmission from 39.55% to 16.90%, (Fig
13), this level of MTCT is still far too high.

2.6 AIDS mortality in the general population

Since the rapid expansion of the ART program in Ethiopia, the number of AIDS deaths has
shown dramatic decline from 117.7/100,000 in 2001,to 11.73/100,000 in 2019 (Fig 14). At
the peak of the death curve, an estimated 70,173 AIDS deaths occurred within one year.
Compared to the 2010 level, there is a 52% reduction in AIDS deaths in 2019. With declining
mortality rate the number of orphans due to AIDS has also decreased by more than half,
from 628,000 in 2010 to 309,000 in 2019.

33
Figure 14. Trend on AIDS mortality per 100 thousand by sex and year 1990-2019

140.00
AIDS Death per 100 thausand

120.00

100.00

80.00

60.00

40.00

20.00

0.00 1990 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2010 2011 2013 2015 2016 2017 2018 2019
Both 35.49 45.81 68.63 90.85 108.25 117.53 117.77 111.25 94.84 63.51 38.02 31.19 26.18 19.47 16.66 14.94 13.57 12.32 11.73
Male 38.53 48.88 70.84 90.75 104.60 109.83 106.48 97.59 81.33 54.43 33.21 27.51 23.22 16.54 13.94 12.71 11.94 10.79 10.09
Female 32.49 42.78 66.44 90.94 111.87 125.18 128.99 124.86 108.33 72.59 42.82 34.88 29.15 22.41 19.39 17.17 15.21 13.86 13.37

2.7 HIV in Key and Priority Populations (KPPs)

In Ethiopia, although the prevalence and incidence of HIV steadily declined in the general
population, the magnitude in certain population groups who have high risk behaviors
remains largely unknown with very limited available data. The list of key and priority
populations identified by the National Roadmap for HIV prevention (2018-2020) and the
HIV/AIDS Strategic Plan (revised for 2019 and 2020) include: female sex workers, prisoners,
widowed, separated and divorced women, long distance drivers, PLHIV and their partners,
mobile and resident workers in hotspot areas, adolescent girls and young women due to
their sheer size, increased vulnerabilities and the barriers to access services, and HIV
negative partners of sero-discordant couples.

Female Sex Workers: Availability of data on the size of FSW population is limited and dated.
However, according to a recent extrapolation made based on size estimates conducted by
PSI and EPHI, there are about 210,967 FSWs in Ethiopia. Review of few available
programmatic sources indicate a range of HIV test yield among female sex workers from
2.8%, as dePITCed in the MOH HMIS routine HIV testing data, to 28% among FSWs tested
through index case testing (ICT) and partner services across selected PEPFAR supported
woredas. Assuming an average 23% prevalence reported in 2013, the total number of FSWs
living with HIV(LWHIV) could be 48,522.

34
Figure 1542. HIV prevalence in Female Sex Workers, by region.

Mekele - TI 33
Gambella - GA 32.8
Bahirdar-Am 31.6
Kombolcha -AM 30.4
Adama- Or 24.2
Semera Logia - Afar 23.9
Diredawa -DD 23.7
Shasheme-Oro 18.3
Metema-Ama 17.2
Hawassa-SNNPR 15.2

0 5 10 15 20 25 30 35

Prisoners: Estimates show that there were about 85,000 prisoners in Ethiopia incarcerated
in 106 prisons in 2013. HIV prevalence data is scarce but a national rapid assessment
conducted in 2013 among 846 inmates (686 males and 160 females) indicated a prevalence
of 4.2%; 4.3% in males and 3.8% in females 43. Ministry of Health (MOH) 2018/2019 (2011
EFY) data also reveals that out of 22,040 prisoners tested for HIV in 2018/2019 (2011 EFY 44),
2.2% were positive.

People with Injecting Drug Use (PWID): There is sparse information on this emerging
population. In 2017 OSSHD estimated that there were about 4,000 PWID in Addus Ababa
and about 448 in Hawassa. From a study conducted in Hawassa and Addis Ababa by the
Organization for Social Services, Health and Development (OSSHD) which included 426
PWID of which three quarters were below 35 years of age, high risk sexual practices and
syringe and needle sharing were common. Of the 177 who said they had been tested for
HIV, 39.5% were HIV+; of the 99 who had been tested for Hepatitis B, 77.4% were positive,
and of the 46 who had been tested for Hepatitis C, 28.3% were positive. 45

Widowed, separated and divorced women: In 2017, there were an estimated 1,522,702
women of reproductive age who were divorced /separated and 555,907 widowed. The HIV
Prevention Roadmap identified 200 high burden woredas or areas of geographic priority
with an estimated 295,000 divorced, separated and widowed women. According to EDHS
2016, HIV prevalence was 11.5% among women and men who are widowed, and 2.9%
among those divorced or separated. According to the Ethiopia Population-based HIV Impact
Assessment (EPHIA) 2017-2018, urban HIV prevalence was highest among widowed adults
(14.7%). HIV prevalence was twice as high among women who were divorced or separated
(8.6%), and almost five times as high (15.1%) among women who were widowed in
comparison to married women and women living with a partner, among whom HIV
prevalence was 3.1% and 3.4%, respectively. The total number of widowed, divorced and

35
separated women living with HIV is estimated to range from 100, 000 to 150,000 46. Some of
the reasons that HIV prevalence is high among this group could be that they had been
married to an HIV positive partner who has since died, or they are involved in transactional
sex as a survival mechanism.

Long Distance Drivers: According to the latest data from the Ministry of Transport in
Ethiopia, there are about 30,000 long distance drivers in the country. The only prevalence
data from a study in 2013 indicated an HIV prevalence of 4.9%. There is limited information
on whether this group accessed outreach or static services.47

Migrant, Seasonal and Daily Laborers: In the absence of an actual size estimation, the NSP
2015-2020 estimated a total of 1,000,000 laborers in hotspot areas including over 400,000
seasonal laborers in sesame, sorghum and cotton farms in the northern part of the country
and about 600,000 daily laborers in the large development schemes, flower plantations and
mining areas. There is no information on daily laborers in construction and other sectors
across the country. The formative assessment conducted by FHAPCO, in 2016 shows the
population size of workers in major development schemes is 867,000 48. The burden of HIV
in this population group at a national level remained largely unknown. In the regional HIV
synthesis carried out in Tigray HIV prevalence was highest in the Western Zone (2.2%)
where most seasonal farm workers are found (ANC routine data, E.C. 2010 (G.C.
2018/2019). According to the HIV strategic plan revised for 2019-2020, the sexually
transmitted disease prevalence among daily labors in building and construction was 9-12%.
The MOH routine service data shows that out of 257,485 mobile/daily laborers tested for
HIV, 1.6% were found positive.

Adolescent girls and young women (AGYW): AGYW (10-24 years) constitute an estimated
17% or over 15 million of the total population with 80% living in rural areas. EPHIA reports
an overall HIV prevalence of 0.8% (121,144) among urban young women and adolescent
girls which accounts for about 18% of the total HIV burden in the country. A recent venue-
based study49 conducted in Addis Ababa and Gambella among out-of- school adolescent
girls and young women indicated a higher HIV prevalence of 2.1% (95% CI 1.3-3.4) in Addis
Ababa and 3.3% (95% CI 2.2-4.9) in Gambella. The prevalence of any STI (HIV, syphilis, or
chlamydia) was 10.0% (95% CI 8.6-11.7%). The study also showed only 17% consistent
condom use for vaginal sexual acts in the prior 12 months and 12% reported engagement in
transactional sex, increasing from 6% among 15-19 year old girls to 16% among 20-24 year
old young women. The 2016 EHDS indicated 24% of women age 15-24 and 39% of men age
15-24 have comprehensive knowledge of HIV. Comprehensive knowledge is still low, but
much higher among the urban youth, with 42% among women and 48% among men,
compared to 19% and 37% among women and men in rural areas. About 37% of girls and
43% of boys aged 15-19 year consume alcohol. About 57% of boys chew Khat50.

HIV negative partners of sero-discordant couples: There are no reliable data source/s on
the level of discordance. However, more than 60% of adult PLHIV and 80% of sexually active
PLHIV are currently married and report relatively little extramarital risk behaviors. Roughly

36
two-thirds of these have sero-discordant sexual partners44. Lifetime remarriage rates exceed
40% regardless of gender or urban-rural residence.

2.8 The Response to HIV/AIDS Epidemic in Ethiopia

2.8.1 Combination HIV Prevention

Combination HIV prevention services included various social behavior change

communication (SBCC) activities targeting the general population, condom distribution,
voluntary medical male circumcision, PrEP, STI diagnosis and treatment, and PEP. SBCC
including public meetings, community dialogue (conversation), print and electronic SBCC
materials development and distribution, documentaries, and TV/Radio spot messages have
been conducted; condoms were distributed through the public sector, via social marketing
channels and private outlets. The free condom distribution was mainly for KPPs distributed
through DICs, KPP clinics and peer service providers. There have been multiple distribution
and quality problems.

Male circumcision rates are >90% in Ethiopia except in Gambella and some woredas in
SNNP. The VMMC program started in Ethiopia in 2009 in Gambella where HIV prevalence
was high (6.5% at that time) and there was low male circumcision coverage (<10%) among
the indigenous Gambella population, new military recruits and the refugee population. By
September 2020, VMMC coverage is expected to reach 64% (101,586 men aged 15 years
and above) with a remaining gap of 41,187 to reach 90% coverage in Gambella. 51

People with disability have greater difficulties in accessing both information and HIV
services because of barriers in physical access, problems with understanding the intricacies
of lifelong treatment and stigma and discrimination among health workers 52. In a study
undertaken in Addis Ababa, young people with disability were more likely to be illiterate,
unemployed and impoverished. Their knowledge and perceptions of risk of acquiring HIV
infection was low.53 There is also evidence that the combination of poverty, gender and
disability increases exposure to gender based violence. Girls and young women with
disabilities are vulnerable to sexual violence precisely because of the difficulty they face to
hear, understand, communicate, see, or defend themselves, possibly increasing their risk to
HIV infection. 54

2.8.2 Prevention in Key and Priority populations

The country has put efforts to cover 90% of key and priority populations with
comprehensive behavioral , biomedical and structural interventions during implementation
of the 2015-2020 HIV/AIDS strategic plan.

Adolescent girls and young women: The National HIV Prevention Road Map 2018-2020
stipulated combination prevention activities for AGYW to reach 90% of AGYW in 200 high
burden woredas by 2020. These included, design and implementation of evidence-based
and comprehensive HIV/SRH intervention packages; scaling up of implementation of school
health program; improving scope and quality of HIV/SRH services of youth development

37
centers; implementing interventions that address structural barriers through community
structures; and enhanced use of media to reach adolescent girls, young women and their
partners. However, HIV prevention services targeting adolescents and youth are generally
very limited. A significant number of youth development centers are either not functional or
repurposed; efforts to integrate, youth-friendly HIV and reproductive health services,
including HIV counseling and testing and STI treatment in universities and colleges and life
skills education in primary, secondary and higher learning institutions have essentially
faltered.

The school-based HIV prevention program, that addresses specifically the needs of students
at high school and college level, includes promotion and distribution of condoms, HIV
testing, mini-media, AIDS clubs, curriculum integration and prevention of a risky
environment around schools has variable performance across regions and universities. In
2018/19 (2011 EFY), 646,543 out of school youths were reached with small group level HIV
SBCC interventions and 2.8 million students received some life skills education. During the
same year a total of 2.4 million AGYW aged 15-24 were tested for HIV through routine PITC
and VCT constituting 30% of the total HIV tests in the year 55. Among young women age 15-
24 who have had sexual intercourse in the 12 months preceding, 27% were tested for HIV
and had received the results of their last test56. Similarly, 25.4% of AGYW reported testing
and receiving results in the 12 months preceding the EPHIA survey in 2017. EDHS 2016
report shows that only about one-fourth (24%) young women reported using condom at last
sex with a non-marital, non-cohabiting partner; this was 55% among young men. According
to PEPFAR Strategic Direction Summary, Country Operational Plan 2020 (COP20), there are
an estimated 40,747 AGYW living with HIV out of whom 22,226 knew their status and of
those 68% were on ART with a viral suppression rate of 83%. Taking into account the risk of
HIV infection among young women, it is critical to reinstate HIV/SRH/Gender/Life skill
freshman course in higher learning institutions and increase the availability of adolescent
friendly services in health facilities.

PrEP: Ethiopia started rolling out PrEP in late 2019 targeting female sex workers and HIV
discordant couples. For the initial phase, 15,400 female sex workers and 4,762, couples in
discordant relationships were targeted. By December 2019, the number of people screened
for PrEP services were 4,128, of which 1589, were found eligible, 971 were initiated while
601 declined. The program is available in public health facilities and community drop-in
centers.

Sexually transmitted infections: Information on the prevalence of other STIs is scanty.

Although patients with diagnosed STIs are targeted for HIV testing, there are missed
opportunities as well as shortages of STI treatment kits and, Diagnosis and treatment for
adolescents is even more limited with only a few of the health centers having adolescent
and youth friendly services including STIs treatment as part of SRH services. Although most
health facilities implement partner notification and treatment services for partners of STI
cases, this is problematic with many clients refusing for fear of violence and adverse
outcomes.

38
Female sex workers: From 2017, targeted programs for female sex workers were running in
about 80 public health facilities located in various regions. This approach is designed to
increase the sustainability of FSW programming by promoting government ownership.
Thirty drop-in centers (DICs) in Addis Ababa and Amhara are currently providing FSW
targeted comprehensive HIV prevention, care, treatment and SRH services including family
planning, GBV, harm reduction counselling for substance abuse on site or through referral.
The DICs are a one-stop center, located in strategic hotspots based on a user-centered
design, able to attract the hardest-to-reach and most vulnerable key populations. The ability
to reach these clients with a menu of services, close to where they live and work, results in a
high level of operational efficiency. Yields of above 20% were achieved through index case
testing (ICT) and partner notification (PNS), and social networking services with FSWs.57. . All
services including laboratory tests such as test for hepatitis, which is a pre-requisite for
initiation of PrEP are free to clients. DICs and the surrounding community program play a
crucial role in epidemic control in Ethiopia. CSOs play important roles in reaching KPPs
through strong referral linkages such as peer navigators and use a coupon system to link HIV
positives; in the provision of youth friendly services; and SBCC. 58.

Prisoners : HIV prevalence data for prisoners in Ethiopia is scarce. A national rapid
assessment conducted among 846 inmates (686 males and 160 females) indicated a
prevalence of 4.2%; 4.3% in males and 3.8% in females59 . The HIV prevalence was higher in
federal prisons (4.5%) compared to regional prisons (2.5%) and highest in Gambella region
(11.4%).

Seventy-six of the 106 prisons have health services but few of these meet MOH standards
for health care. Condoms are provided to prisoners on release from prison and SBCC, using
the recently developed standardized prisoners’ Social Behavioral Change Communication
(SBCC) manual. HIV testing services are provided onsite in all five federal level prisons, but
many of the prisons across regions do not provide HTS on site; inmates in prisons which do
not provide HTS on site are transported to public health facilities for testing. Only two of the
Federal Prisons provide onsite ART with other prisoners requiring HIV and/or TB treatment
transported to community health centers. Guards are needed to escort patients off prison
sites for testing and treatment but there is a shortage of guard staff. This is particularly
problematic for prisoners receiving ART60.

Widows and divorced women: There are no unique service delivery models designed to
reach these priority population groups. Widows expressed, during the field assessment,
preference to get HIV service with the general population in health facilities, and be
organized in women’s groups for economic empowerment where they can receive HIV SBCC
to avoid stigma and discrimination.

Daily laborers: Complete data on service access and utilization was not available.

Discordant Couples: A minimum service package comprising condom promotion and

distribution, screening and management of STIs using a syndromic management approach,
screening and management of intimate partner violence, sexual and reproductive health

39
services, HIV services, including counseling and testing, ART and adherence support, and
Post Exposure Prophylaxis (PEP) following GBV was offered during the last strategic plan
period between 2015-2020. PrEP was included in the 2018 National Comprehensive HIV
Care Guidelines targeted on FSWs and HIV negative partners of sero-discordant couples.

2.8.3 HIV Case Finding and Testing Strategies

HIV testing services are offered through Index Case Testing and Partner Notification Services
(ICT/PNS) , Voluntary Counseling and Testing (VCT) and Provider Initiated Counseling and
Testing (PITC) in outpatient departments, TB, family planning, maternal and child health
clinics (ANC, delivery, postnatal services), inpatient departments, specialty clinics,
KPPs/youth friendly clinics, and other health service delivery points and HIV self-testing
(HIVST). The PITC service is designed to be provided using a standardized risk screening tool
for better yield and effectiveness of the program but this was used inconsistently. Yields
from index case testing among children <14 years was 2.1%, which is 7-fold higher than the
national average yield of all other pediatric testing modalities combined. in 2017 and 2018,
9.2 and 8.2 million HIV tests were used respectively, with a test yield of 0.8% (73,981) and
0.6% (51,093). These low yields resulted from overall poor performance of ICT/PNS, limited
outreach services, client refusal to disclose or notify sexual partners resulting in general
over testing. Unassisted HIV self-testing has recently been approved and will be pursued
through social marketing channels. There are few services which make special arrangements
for people with disabilities.

HIV Case Reporting and Recency Testing: In 2018, Ethiopia started implementing HIV case-
based surveillance (CBS) including HIV-1 recent infection to better target prevention
services and accelerate epidemic control. HIV case reporting with recency testing for recent
infection (RTRI) is integrated with the existing public health emergency management
(PHEM) system. A summary of the findings is shown in Fig 17-19 below. CBS and recency
testing provide information on location, occupation as well as age providing critical
information on where new infections are occurring (figures 16 and 18). This information has
provided a basis for targeting prevention and testing to be undertaken in the next NSP
period.

Figure 16. Summary of Recency Surveillance Findings, July 2019-Feb 14, 2020

40
Figure 17. Percent of Probable Recent Infection by Region of Residence, July 2019-Feb 14, 2020

41
Figure 18. Percentage of Probable Recent Infection by Age Group, June-Sep 2019 (n=409)

Prevention of mother to child transmission: Currently, comprehensive PMTCT services are

available in over 2,865 health facilities in an integrated one-stop approach using the MNCH
platform. The 2019 updated national comprehensive and integrated PMTCT guideline
endorses DTG based regimen as preferred first line ARVs for pregnant and breast feeding
women (PBFW) and women of childbearing potential. The country has also adopted
provision of enhanced postnatal prophylaxis (NVP+AZT) for the first 6 weeks and NVP alone
for the following 6 weeks) for all HIV Exposed Infants. The guideline emphasizes the
importance of retaining mothers on treatment and follow up care, recommends frequent
routine viral load monitoring (after three months of ART initiation and then every six
months for newly diagnosed pregnant women). It also gives a clear direction to improve
Early Infant Diagnosis (EID) coverage and to shorten the turnaround time (TAT). Point of
Care EID viral load testing using GeneXpert machines and same day results has been piloted
in some facilities and should be considered for scale up.

Most health facilities collect and send Dried Blood Sample (DBS) for DNA PCR test but there
is an extended turnaround time for results ranging from 2 to 6 months. Point of Care for EID
testing using GeneXpert machines and same day results has been implemented in 119
health facilities and should be strengthened and considered for scale up. Mothers Support
Groups (MSG) are available in most high volume and donor supported sites ; withdrawal of
donor support has challenged their sustainability.

The fact that Ethiopia is a large predominantly rural country with low national prevalence,
presents programmatic challenges towards elimination of MTCT. In EFY2011, (2018/2019)
from the 3,271,091 expected pregnancies, 84% (2,760,809) pregnant women were tested
for PMTCT. From the 21,561of estimated HIV-positive pregnant women, 17,516 (81%) HIV-
positive pregnant women received ART for PMTCT61. In 2018, 64% (13,799) of HIV exposed
infants had a PCR test. but as noted above turnaround time to receive results is prolonged..

42
In a review of DSHIS2 data over a one year period (2017/2018 EFY 2010/2011) of all the
2,865 PMTCT sites, 57.4% of all sites had no PBFW who started ART.. Out of the 1,242 health
facilities who did identify at least 1 HIV+ PW over a 1-yesar period, one third had <2 PW,
another third had between 3-5 cases, and only 398 sites had 11 or more pregnant women
who received ART for MTCT. These results indicate that efficiencies may be gained if other
options of service delivery are considered as not only are there inefficiencies if no PWBF are
identified at a PMTCT site but quality of care is also compromised if a health workers only
rarely provides ART.

Although there has been a major decline in MTCT transmission from 39.55% to 16.9% in
2019, (Fig 13), this level of MTCT is still far too high. Figure 19 shows the various points
where mother-to-child transmission occurs in a set of 14,000 cases indicating both initiation
and retention of mothers throughout the risk period is critical. Additionally, a number of
other challenges were identified. These include: poor performance in implementing
enhanced postnatal prophylaxis, gaps in linking HEI immediately after birth (most are linked
when they return for vaccination), failure to implement quality improvement interventions,
gaps in maternal and HEI cohort monitoring analysis, shortage of DBS kits and interruption
of EID testing, , stock out of cotrimoxazole syrup for HEIs, and lack of trained staff.

Fig 19 Mother-to-Child-Transmission by Source. (Note: This stacked chart explains the reason for
the MTCT rate generated from the spectrum based on the 14,000 cases on ART.)

More investment in reproductive age women is required to prevent Mother to Child

Transmission (MTCT), new infections among Adolescent Girls and Young Women (AGYW),
FSW and their clients, other key and priority populations; with particular attention paid to
enabling the program to become more effective against disproportionately affected groups.
Over the next strategic plan 2021-2025, it will also be useful to generate evidence through

43
sensitivity analyses and population-based studies to map out specific reasons for variances
in prevalence and incidence for each geographical area. Special attention and evidence-
based interventions including HIV/AIDS awareness campaigns, ART services with adherence
support and prevention of mother-to-child transmission of HIV should be targeted in areas
identified with hotspot clusters.

In order for Ethiopia to move towards elimination of mother to child HIV transmission,
programmatic interventions addressing the various points at which transmission can occur is
critical. Testing is the entry point for the elimination of MTCT. Based on a 4 country study on
whether a universal or more targeted approach should be followed, the study concluded
that a universal approach to antenatal HIV testing achieves the best health outcomes and is
cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It
is further a prerequisite for quality maternal and child healthcare and for the elimination of
mother-to-child transmission of HIV62.

44
2.8.4 HIV Care and Treatment

Free ART services have evolved from when they started in 2005, from CD4 based eligibility
to “Treat All” positives combined with re-testing prior to ART initiation, and then to rapid
ART initiation which was started in November 2016. Recently, shift to DTG based regimen
has materialized. ART services are provided in more than 1,100 public, private and NGO
health facilities and demonstrate a strong program with good referral and registration
systems.

Ethiopia has made good progress in linking HIV positive people to treatment and in overall
viral suppression. The EPHIA 2018 survey which was conducted in urban areas, indicates
that among the HIV positive identified during the survey, 83.3% and 70% of women and
men knew their HIV status respectively, indicating diagnosing men is an important, as HIV
positive men are lagging in terms of knowing their HIV status step to achieving better
outcomes regarding case finding. (Fig 20a).

Figure 20a. Progress to reach 90:90:90 EPHIA 2018

45
Fig 20b. HIV cascade in Ethiopia as of December 2019

Fig 20b shows the HIV cascade as of December 2019. Of the 79% of estimated PLHIVs who
know their status, 90% of them were on ART and 91% were virally suppressed. This indicates
that across ll age groups the most pressing gap is in identification of people who are HIV
positive. Linkage into treatment and viral suppression among 15-24 year olds are both
suboptimal as well. The percentage of children <15 years on ART however is considerably
lower; of the 65% of known status, 67% are on ART with an overall viral suppression rate of
74%. Further disaggregated age data among children shows that only 26% for children 0-4
years, 46% for those aged 5-10 years and 58% for those 10-14 years old are on ART. 63 There
are large regional variations in ART coverage from 28% in Somali to 81% in Harari.

There is encouraging involvement of private health facilities in the provision of ART services.
Private facilities provide the ART drugs and viral load testing through sample referral for free
and physician consultation is provided on fee basis. In addition, there is a fairly good two-
way referral system as the need arises. However, private health facilities lack adequate
number of trained staff, case managers and adherence supporters. They are not getting
adequate technical support, commonly lack drugs to manage opportunistic infections, and
are not adequately involved in monitoring and review meetings. They also do not have
strong system for tracing lost to follow up patients 64. As Ethiopia increases its ART coverage,
identification of new HIV infected individuals, linking them into treatment and ensuring that
patients are not lost to follow-up is critical.

Ethiopia has a large refugee and internally displaced population, estimated at 3 million at
times. While refugee camps and their services are under the management of the
Administration for Refugee Affairs (ARA), recent legislation indicates that refugees will now
be incorporated into regular health services within the vicinity of the refugees camps. ARVs
for the refugee population have always been incorporated into the national forecasting
quantities. The internally displace population has to access health services in the areas
where they have been displaced to which poses a greater challenge for those on ART.

46
Figure 21. PLHIV Map-ART Coverage and PLHIV Burden by Region, Ethiopia, January 2020

Key challenges in maintaining these gains and striving to reach the UNAIDS Fast Track
targets of 95:95:95 are hampered by: lack of funding for adherence supporters, shortage of
supplies including cotrimoxazole, and nutritional supplements, failure to provide primary
fluconazole prophylaxis due to lack of Cryptococcal antigen test and routine CD4 test for
assessing eligibility. One of the major reason why optimization of pediatric regimens is
lagging is because of worldwide shortage of pediatric formulations, like lopinavir/ritonavir
pellets.

Multiple strategies are needed to improve patient retention on ART. These include peer
counseling, appointment reminders, enhanced client-centered services including
strengthened pharmacy services and adherence support, full roll-out of -Multi-Month and
appointment spacing models. The scaling up of Urban Health Extension Program (UHEP)
managed Community Adherence groups (CAG) in selected regions (Addis Ababa and
Gambella), rapid pharmacy refills, rapid follow-up for unstable patients with high viral load
are also important approaches to improve efficiency of the service. Recent initiatives
including community based HIVST and referral of clients with a positive screen result to a
health facility for confirmatory tests, Peer Community Adherence Groups that provide
community based care and support including individual and group based routine and
interventional adherence counseling need also to be implemented in more scale. The peer
groups receive line list of clients with high viral load and provide intensive counseling and
follow up for the improvement of VL status. Engaging Faith-Based Organizations is also a
useful approach being implemented through support by community partners, so that the
FBOs contribute based on their comparative advantages, for example in passing consistent
messaging to addressing retention challenges, promoting the need for ART adherence and
mitigating stigma associated with ART.

47
Viral load coverage has reached 73% by June of 2019, with a viral suppression rate of 90%
(Fig 22). Both the viral load coverage and viral suppression rates vary across regions. Viral
suppression is similar among the pregnant, and breast-feeding women, and between male
and female ranging from 88- 92%. However, it is low among children of 0-14 years (78.9%)
as well as among adolescents and youth (81.8%). (Fig 23)

Figure 22: Trend of viral load test and suppression, 2015/16-018/19 (EFY 2008-2011)

100% 90% 90% 400,000

87%
VL Coverage % / VL Suppression %

76% 350,000
80%
73% 300,000

No. VL Tests
58% 250,000
60%
53% 200,000
40% 150,000

100,000
20%
50,000
5%
0% 0
2008 2009 2010 2011

Viral Load Tests VL Suppression (%) VL Coverage (%)

Figure 23: : % viral suppression by age, 2018/19(EFY 2011)

95.00%
92.26%
90.12%
90.00%

85.00%
81.78%

80.00% 78.90%

75.00%

70.00%
Below 15 15-24 25-49 50 or above

48
2.8.5 TB/HIV co-infection treatment

Ethiopia is among the 30 high TB, TB/Human Immunodeficiency Virus (TB/HIV) and Multi-
Drug Resistant TB (MDR-TB) burden countries, with an estimated 165,000 persons
(151/100,000 population) with all forms of TB; 1600 MDR-TB incident cases; and 24,000
(22/100,000 population) TB deaths in 2018 65 . Over the past decade there has been
significant decrease in TB incidence on average 8-9% per year, from 421/100,000 in 2000, to
151/ 100,000 population in 2018. Tuberculosis remains the leading cause of hospital
admission and mortality among people living with HIV. The prevalence of HIV among TB
patients is 7.34% with significant regional variations from 0.7% in Oromia to 14.5% in Afar.
The routine information system in Ethiopia does not track patients who continued ART after
completion of TB treatment or disaggregated treatment outcome by HIV status. Although
TB/HIV mortality has declined from 5.7/100,000 in 2014 to 2/100,000 population, TB
remains one of the major causes of deaths among PLHIV. Early and effective case finding,
optimized TB/HIV care and TB prevention activities form the foundation required to improve
outcome. Poor health care access, proximity to international borders, low wealth index and
adult literacy levels were significantly associated with the prevalence of TB/HIV co-
infection66.

Information from a TB patient pathway analysis using secondary health service data showed
that 76% of persons with TB initiated care in the public sector, 22% in the formal private
sector and the remaining in the informal traditional care settings67. Among those who
initiated care in public facilities, more than a third initiated with HEWs, who referred those
with presumptive TB to health centers for diagnosis. An additional one third initiated care at
health centers where around 80% had microscopy services but very few had access to
GeneXpert tests. In the private sector, where 22% of patients sought care, availability of TB
diagnostics was even more limited. Approximately 22% of private clinics offer smear
microscopy, 13% provide Xray, and only 1% had access GeneXpert tests.

Provision of preventive treatment has proven itself an effective intervention to avert the
development of active TB disease, with efficacy ranging from 60% to 90% 68. The
likelihood of progression of TB infection to active disease depends on bacterial, host,
and environmental factors. HIV infection is the strongest risk factor associated with the
development of active TB, with up to 40% of patients progressing to TB disease after
exposure. Treatment of Latent TB Infection (LTBI) in PLHIVs reduces the risk of TB
disease development by up to 35% 69 and plays a synergistic role in further risk reduction
when used with antiretroviral therapy. Early results from the Tuberculosis Preventive
Therapy (TPT) acceleration campaign showed an increase in TPT uptake among PLHIV
already on treatment. Further gains in TPT uptake among those currently on treatment can
be achieved with multi-month prescribing of TPT as many PLHIV are already receiving MMD
for ART, and with additional TPT regimen options such as a combination of weekly doses of
rifapentine and isoniazid for three months (3HP). Collaboration and integration with the TB
program will be strengthened during this NSP, including a joint Global Fund application with
HIV and TB.

49
2.8.6 HIV and Cervical Cancer

Women living with HIV face a fourfold to fivefold greater risk of invasive cervical cancer than
women who are not infected with HIV. But the few facility-based studies show, utilization of
the cervical cancer screening services is low among HIV positive women. The Ethiopia
Population-Based HIV Impact Assessment (EPHIA) 2017-2018, showed that, in urban areas,
only 16% of HIV-positive women aged 30-49 years reported being screened for cervical
cancer.

2.8.7 HIV and Hepatitis:

In a national sero-survey conducted by MOH and EPHI in 2017, the prevalence of Hepatitis B
Surface Antigen (HBsAg) was estimated at 9.4% among the general population aged 15
years and above, with regional variations and a slightly higher prevalence in rural areas.
Globally, viral hepatitis is a growing cause of mortality among people living with HIV. About
2.6 million people living with HIV are co-infected with hepatitis B virus and 2.9 million with
hepatitis C virus. The seroprevalence of hepatitis B surface antigen among adults of ages 15-
64 years in urban Ethiopia is 4.8%. The prevalence is 3.6% in women and 7.4% in men ages
15-64 years 70. A more recent survey on Hepatitis B seromarkers among HIV patients on ART
emphasized the unmet need of HBV screening prior to ART initiation. The presence of HBsAg
was 11.7%; 47.6% were also positive for anti-HBc, of which 58% were on an ART containing
tenofovir (TDF). Among those screened for the three seromarkers, 38.1% were negative for
all and 21% were positive only for anti-HBc (IAHBc).71 A meta-analysis published in 2016,
indicated a HBsAg in 8% of HIV infected people and an overall prevalence of HCV of 3.1% in
the general population, but 5.5% among PLHIVs72

In 2016, Ethiopia has taken the first step in responding to the problem of viral hepatitis
through the development of National Strategic Plan of Hepatitis (2016-2020) and adopted
national viral hepatitis guidelines.Hepatitis Screening options are available throughout the
country at all levels of the laboratory system using serological Rapid Diagnostic Tests (RDTs):
serological detection of Hepatitis B surface Antigen (HBsAg) for Hepatitis B Virus and the
detection of anti-HCV anti-body for Hepatitis C Virus. However, viraemic infections in both
cases need to be confirmed by the quantitative or qualitative determinations of the viral
nucleic acids or genomes (RNA for HCV and DNA for HBV) for initiation of treatments or
monitoring of responses to the same. However, care and treatment services for viral
hepatitis are only available at a few specialized sites. Integrated screening and management
of HIV and viral hepatitis infection is important for an early diagnosis and treatment of both
HIV infection and viral hepatitis infection.

2.9. Cross-Cutting Issues for the HIV/AIDS Response

2.9.1. Information Systems and Data Management Investments

Critical to the HIV response are effective information systems. Monitoring and evaluation is
done at different levels of the health system. Transition from HMIS regular program data to
the District Health Information System (DHIS22) was started in 2018. There are however

50
many quality issues around the collection and accuracy of regularly collected data, and gaps
in the availability of disaggregated data. Other sources of data include: ANC sentinel
surveillance, surveys (EDHS, EPHIA), Spectrum modelling, laboratory information system
(LIS), multi-sectoral response information system (MRIS), burial surveillance of AIDS related
deaths, integrated biological behavioral surveys, operational research and program
evaluations. The recent introduction of a pilot project to use case-based surveillance and
recency testing will assist in the identification of new infections.

As the country moves towards epidemic control, better designed and integrated health
information systems are increasingly critical. Linking records on the individuals from testing,
care and treatment, laboratory services and pharmacy will generate the data set for
granular site management across the entire clinical cascade – within and between health
facilities. Additionally, through PEPFAR support, the Pharmacy Management Information
System (PMIS) and pharmacy information sheets have been re-introduced in at least all ART
sites in Addis Ababa with additional trainings in other regions at high volume ART sites wth
plans to expand by the end of 2020 up to more than 200 High volume sites in coordination
with the Regional Health Bureaus. Currently, over 300 high HIV case load health facilities are
using Electronic Medical Record (SmartCare ART) kept at ART clinics to capture patient
enrolment and follow up information. The Implementation of the health information
systems is challenged by infrastructural gaps such as internet connectivity and the
availability of electric power.

An additional challenge to an overall HIV strategic information system has been the lack of
integration between DHIS22 (MOH) and the multi-sectoral response information systems
(MRIS) collected by FHAPCO, despite the three ones (one plan, one budget, and one report)
principle adopted by the country. Indicators collected by the MRIS are different to those in
DHIS2, reflecting multi-sectoral and community responses such as HIV primary prevention
mainly SBCC activities, school interventions, mainstreaming, community based care and
support programs, condom distribution etc. The community HIV information system is not
fully functional. The MRIS is a largely paper based system and does not have an effective
grassroots structure which is leading to practical problems in the collection, aggregation,
completeness and timeliness of reports, a lack of capacity to organize and interpret data for
decision making at the lower levels, lack of a HTS register and no data backup system in
some facilities. Some facilities run parallel HIV data systems. At lower levels there is a lack of
adequately trained and dedicated staff. The functionality and quality of data system in
private health facilities and sector offices are generally weak. All of these issues indicate
that the information systems at present are not at the level required to effectively guide the
current HIV epidemic control efforts. More investments on strategic information are
essential to generate the data required for effective and sustained control of the epidemic.

2.9.2 Supply Chain System

A well-functioning health commodities supply chain is critical for effectively delivery of HIV
related services. The Ethiopian Pharmaceuticals Supply Agency (EPSA) is an autonomous

51
government agency responsible for the supply chain management of the public health
sector basic health services and those neglected by the private sector. The forecasting of
HIV commodities is performed in a participatory process where all stakeholders contribute
their share and EPSA takes the lead. The procurement and distribution of HIV commodities
is also carried out by the agency. The agency manages its operations through an Integrated
Pharmaceuticals Logistics System (IPLS) which stretches from thousands of service delivery
points to a central warehouse through 19 branch warehouses situated logistically at
strategic locations. Using this platform, EPSA delivers supplies directly to over 1,500 health
facilities and indirectly to more than 2,000 additional facilities through woredas offices.
There are guidelines and SOPs for managing the IPLS at all levels and mechanism for
redistribution of overstocked commodities. However, the online data visibility only goes
down to EPSA entral to branch warehouses but not to health facility. All EPSA warehouses
or hubs and most of the health facilities/sites served by the hubs have a functional health
commodity management information system/HCMIS/. HIV laboratory commodities (VL,
CD4, hematology, Chemistry) monitoring is integrated with IPLS system and easily managed
by HCMIS dashboard.

A recent national survey indicated that, 21.8% of hospitals and health centers fulfilled more
than 80% of the storage conditions. Hospitals demonstrated better fulfillment of the storage
conditions as compared to health centers and health posts: 61.1% of tertiary hospitals,
50.0% of general hospitals, and 59.1% of primary hospitals fulfilled more than 80% of
storage conditions as compared to only 18.9% of health centers and 4.6% of health posts.
Comparison of data between 2015 and 2018 surveys showed that the percentage of
hospitals that met at least 80% of the storage conditions increased from 43.0% in 2015 to
71.4% in 2018. However, the percentage of health centers meeting 80% of storage
conditions declined from 63.0% to 44.6% 73. Most ART sites follow good storage practices in
terms of cleanliness, ventilation, and temperature. The ART pharmacies have separate space
for counseling and dispensing in most cases. A system for monitoring and reporting adverse
drug events is in place. All EPSA hubs and most of the health facilities/sites served by the
hubs have a functional health commodity management information system/HCMIS. HIV
laboratory commodities (VL, CD4, hematology, Chemistry) monitoring is integrated with IPLS
system and easily managed by HCMIS dashboard. With respect to adverse drug event (ADE)
monitoring and reporting system (pharmacovigilance), it has limitations related to
availability of reporting forms in all ART sites, poor awareness, and commitment among
providers to report ADEs, and low capacity building efforts in the area.

The challenges in the area of supply chain include lack of structure at lower levels to
interface with EPSA structure, lack of practice at the logistics units of regional health
bureaus in aggregating requisition and report forms (RRF) from lower levels for use to
provide feedback to EPSA and HIV program management, periodic stock outs of HIV
commodities partly due to failure to properly request (poor quality and untimeliness of RRF)
commodities by health facilities and inadequate supply by EPSA, weak disposal or reverse
logistics practices of health commodities congesting stores by expired items, inadequate
fleet management, poor HCMIS data quality and visibility, inadequacy in trained staff, and

52
connectivity difficulties affecting on line data visibility. The ART pharmacies have limitations
in properly implementing good dispensing and counseling practices, monitoring and
supporting patient adherence, and managing product and patient information for decision
making congesting. In the area of patient management, failure to regularly update patient
and product information management tools (including Patient information sheet, ARV drugs
daily and monthly summary registers, Patient Tracking Chart, ART pharmacy monthly
activity reporting forms), and failure to monitor adherence are considered to be important
gaps which need to be addressed74.

2.9.3 Laboratory

Ethiopia has a tiered laboratory system to support the health care delivery under the
auspices of the Ethiopian Public Health Institute (EPHI). There has been huge investment on
laboratory infrastructure development including construction of state-of the art national
and regional reference laboratories and renovation of many hospital laboratories; there are
about 4000 labs which include regional referral labs. Other activities undertaken by EPHI are
surveillance, research, public health emergencies, nutrition and vaccine production. Within
the HIV program, EPHI is responsible for laboratory test and instrumentation evaluations,
introduction and oversight of point of care testing, HIV viral load, infant virologic testing,
HIV and TB drug resistance testing, and new rapid TB diagnostics and ARV drug resistance
studies. A continuous laboratory quality improvement program has been implemented in
most of the laboratories and basic laboratory quality management system are in place in all
laboratories. Seventeen including five VL labs achieved ISO accreditation, an important
milestone in the laboratory services sector of the country.

However, the health laboratory system still struggles against a multitude of challenges.
These include lack of comprehensive equipment sourcing and management strategies,
poorly functioning sample referral system, limited implementation of quality management
system and challenges related to accreditation initiatives, inconsistent laboratory
commodity supply and absence of regular quality verification practices for laboratory
commodities, inadequate technical competency of the laboratory workforce and high staff
turnover, weak legislation enforcement systems for the implementation of standards, and
inadequate resource allocation.

2.9.4 Resources for HIV

Over the past two decades, financing of Ethiopia’s HIV response has been primarily
dependent on external resources (Fig 24), accounting for 90% of total funding for HIV
between 2011 and 2019. However, donor funding has declined by more than two-thirds
(69%) by 2019, compared to the amount in 2011, when the amount of fund from external
donors was at its peak. During the same period, U.S. Government funding through PEPFAR
has declined by US$237 million (79%). Global Fund resources have declined by US$68
million (51%). Less than US$10 million per year is provided through other donors. Domestic
resources for HIV have been low, and their measurement has been subject to different
methodologies. 75

53
External support has been the sole source of financing for most key components of the HIV
response, including all medicines and health commodities for HIV testing and treatment. In
2017, the Global Fund spent $60 million on antiretroviral drugs and rapid test kits, and
PEPFAR spent $11 million, primarily on laboratory commodities and reagents (PEPFAR,
2018). With further funding reductions and the growing need for ART, the procurement of
these commodities is jeopardized. 64

Fig 24: HIV Financing Trends, FHAPCO

Modest levels of domestic funding for HIV has been obtained from sources that include
public budget allocations for health and HIV, non-health sector HIV mainstreaming budgets,
the AIDS Fund and Community Care Coalitions, which together contributed less than 10%
during the current strategic plan period 2015-2020.

Table 3: Annual domestic financing estimates (2019)

Funding source Value

Federal HIV budget (MOH and FHAPCO) $750,000
Regional HIV budgets $1 million
Woreda HIV budgets $5 million***
HIV mainstreaming budget† Less than $1 million
Innovative financing for HIV $2–3 million
Community Care Coalitions > $1.2 million
Corporate and enterprise financing for HIV Negligible
HIV expenditure from insurance Unknown Unknown
Out-of-pocket expenditure on HIV $3 million (2014)
Woreda HIV estimate computed from small sample

54
The above sources of funding exclude health workers delivering HIV services that are employed by
the MOH, funding for capital expenditure as well as other MOH indirect expenses attributable in part
to the HIV program.

Allocation of budget for health sector HIV program through HAPCO and MOH was not more
than $1 million at Federal and$1 million at regional level. Though estimation is based on
small sample data, total woreda allocation for HIV programs could be estimated to reach
about $4 million.

The allocation of resources from non-health sectors to HIV programming through HIV
mainstreaming—has previously been a central focus of HIV domestic resource mobilization
efforts. However, implementation of HIV mainstreaming has its own limitations including
lack of legal basis to enforce the implementation of HIV mainstreaming funds, including
allocation and utilization of the budget; lack of operational tools to guide utilization,
tracking and reporting of the HIV mainstreaming budget, and lack of capacity to in the
allocation of the funds in alignment with national initiatives and priorities, to ensure
meaningful contribution in the HIV /AIDS multisectoral response of the country.

The AIDS Fund, is another source of domestic funding for HIV. The fund comes through
contributions (0.05%-0.5% of their salaries) from government employees., and utilized at
the respective sectors to provide care and support services to the needy PLHIV, OVC and
their families, e mostly from the employees within the same sector. AIDS funds are under-
utilized as some PLHIV do not want to disclose their status to access the benefit and also as
a result of poor management due to lack of guidelines and regulations.

Community care coalitions (CCCs) are kebele-level, volunteer-based committees that collect
annual community member contributions. It is implemented in some regions including
Tigray, SNNP, Amhara, Oromia, Dire Dawa, and Addis Ababa; Tigray and Amhara regions
have advanced it at larger scale and quality of implementation. The amount of fund
collected is utilized used to support disadvantaged/vulnerable population groups especially
people living with disabilities, the elderly, PLHIV and Orphans and vulnerable children.

Lack of institutionalization and high turnover of committee members, lack of leadership

support to sustain and scale it up, failure to fully collect the contributions, lack of capacity in
the planning, management and accounting of the fund, and the fact that the funds are
purposed only to care and support programs, disregarding HIV prevention are among the
challenges and limitations of the community care coalition.

Declining donor funding for the HIV program in Ethiopia requires attention to increased
domestic resource mobilization. A draft Domestic Resource Mobilization Strategy was
developed in January 2019 building on current experiences and best practices and is
awaiting ratification by Parliament.

55
2.9.5 Multi-sectoral aspects of the HIV response

The HIV epidemic negatively impacts the health, social, and economic status of the country,
requiring a multi-sectoral response approach but there are multiple structural and
coordination challenges. The country has designed an approach of HIV mainstreaming, with
the intention to ensure key development and social sectors, both public and private,
implement HIV mainstreaming through assessment and understanding of their risks and
vulnerabilities, and using their comparative advantages in responding to the HIV epidemic
with responsibility and ownership. The HIV mainstreaming guidance stipulates that a sector
which mainstreams HIV needs to have plan, should allocate budget, and establish a
structure enabling the sector to properly execute its response to HIV. The multisectoral
response coordination facilitates harmonization of plans, budget, structure, and responses
towards a common goal. Currently, the majority of the sectors have HIV/AIDS
mainstreaming plans with budget, as well as structures to implement HIV/AIDS
mainstreaming with job descriptions and trained staff. Some sectors also have “good”
support from their organizational leadership. Most sectors have good relationships with
FHAPCO and are involved in joint planning, review meetings and supportive supervision at
various levels. Coordination, and leadership are indispensable to an HIV/AIDS multisectoral
response to ensure harmonized, and effective engagement of diverse group of stakeholders.

The HIV multisectoral response in Ethiopia has a structure across federal, regional, zonal and
woreda levels. There are also governance structures including HIV /AIDS Prevention and
Control Councils, management boards and various forums, which are functional at national
level and across some regions and sub-regional levels.

There is a newly revitalized Grants Coordination Committee at the Federal MOH level, which
brings together development partners and other relevant stakeholders, is a promising
platform for coordination. The Committee is chaired by the State Minister of Health, and it
is mainly focused on prioritizing and resolving key grant implementation risks and intends to
enhance overall grant performance. MOH also has steering committee, which involves
heads of regional health Bureaus, director generals of all the agencies and various experts,
which provides feedback and follow up on outstanding key issues to regions.

The current experience of HAPCO in ensuring engagement and management framework

with RHBs and civil societies through the development and signing of commitments with
annual work plans, quarterly performance targets and budgets to which all implementers
are held accountable needs to be taken forward.

However there are also a number of gaps and challenges in the HIV coordination and
leadership structures of the country, which vary significantly across regions. These include:
inadequate leadership ownership and support, lack of adequate staffing, failure to fully
integrate HIV mainstreaming into organizational strategic and annual plans, lack of
adequate budget, poor monitoring and evaluation and lack of capacity to undertake risk
assessments. In addition to the fact that the coordination structure lacks consideration of
the current HIV response coordination needs, there is lack of clarity regarding scope of work

56
among various coordination and implementation units, inadequate staffing, and high staff
turnover across all levels.

The coordination roles between the MOH and FHAPCO at federal level, between the
regional health bureaus and HAPCOs, in regions where HAPCO structure exists
independently, as well as between the structure which coordinates the non-clinical and
clinical responses of HIV in regional health bureaus where the multisectoral response is
under the health bureau should be revisited and rearranged for better coordination.

The HIV/AIDS Prevention and Control Council and Management Boards are not functional
across most regions and at sub-regional levels. Across some regions which revitalized the
HIV/AIDS Prevention and Control Councils, the revitalization has not yet been cascaded to
sub regional levels. Partnership platforms including religious, Non-Governmental
Organizations (NGO) and government forums are weak and more-often non-functional; and
public private partnership is also weak across all levels. Local implementers and NGOs are
not coordinated in a harmonized manner at zonal and woreda levels.

At health facility level, the Multidisciplinary Team (MDT), Performance Monitoring Teams
(PMT) are functional and conducted regularly, addressing important HIV service delivery
agendas. In addition, in catchment area meetings are functional except in some areas.
However, participation in Catchment Area Meeting is unsatisfactory and is challenged by
shortage of budget and lack of Standard Operation Procedure (SOP). Previously when there
were heightened efforts to address the HIV epidemic, there was more robust community
engagement among multiple stakeholders through a combination of community led
participation as well as donor support for community activities. Now, community level HIV
activities are weak. Integration of HIV in health extension program is poor and the
performance evaluation of the HEWs does not emphasize HIV related tasks. This results in
lack of appropriate community level capacity in the response against HIV/AIDS.

Religious and social organizations are not sufficiently engaged to mobilize communities at
grassroots level for HIV prevention activities. PLHIV Associations’ functionality is limited by
lack of the necessary human resources, and budget. There is also lack of platforms to
organize the various key and priority populations to enable them play stronger roles in the
fight against the HIV/AIDS epidemic.

Overall, the HIV response seems to be lacking adequate leadership attention and
commitment at various levels due probably to complacency attached to reduced rates of
new HIV infections, and AIDS deaths which intern resulted from the successes of the HIV
response registered to date.

This calls for the need to conduct comprehensive assessment of the current HIV
coordination, leadership and governance structure and implementation of the
recommendations in order to ensure the country’s progress towards sustained HIV epidemic
control in the foreseeable future.

57
2.9.6 Strategic Planning

The strategic planning process involved many stakeholders but responsibilities for
implementing strategic activities appear to have not been well understood resulting in low
performance. Existence of two operational planning processes for the HIV program through
MOH woreda based plan and the FHAPCO multi-sectoral plan creates duplication sometimes
with conflicting targets. In absence of a woreda level structure to coordinate the multi-
sectoral response, there may be a need for the multi-sectoral response plan to be merged
with the woreda based planning process in order to have one plan coordinated at grass root
level by the Woreda Health Office.

2.9.7 HIV policy and laws

The HIV policy was issued in 1998. It fails to address the current HIV context in that it does
not adequately cover new HIV testing options, new treatment modalities, age of consent for
HTS, partner notification, school HIV programs, social network services, work place HIV
testing, HIV mainstreaming, and sex workers.

2.9.8 Stigma and Discrimination

According to the stigma index conducted by Networks of Networks of HIV Positives in

Ethiopia in 2011, stigma and discrimination occur at community, family, and institution
levels. The MARPs study of Ethiopia conducted in 2013 also shows fear of non-
confidentiality, stigma (family or others might learn that they do sex work), to be barriers to
accessing HIV services. Fear of stigma and discrimination also deter KPPs from using general
HIV services. A second Stigma Index is in progress.

The EDHS shows, 48% of women and 35% of men thought, children living with HIV should
not be able to attend school with children who are HIV negative; 55% of women and 47% of
men would not buy fresh vegetables from a shopkeeper with HIV, indicating stigma and
discrimination is an important factor in the transmission of HIV across communities.

The focus group discussions conducted among the female sex workers indicated the level of
stigma and discrimination the female sex workers experience by the community. They
however indicated they face no significant discrimination in health facilities.

Both self-stigma and stigma and discrimination remain major challenges for PLHIV.
Disclosing HIV status even among family members is not easy. Children are not openly told
about their status until their late adolescent ages for fear of stigma and discrimination at
school and in the community; they take ARVs without fully understanding why they are
taking the drugs and lack adequate emotional support. Peer support groups are few.

As high levels of stigma and discrimination act as major disincentives to the uptake of and
retention in HIV prevention and treatment, it is important to understand the level of stigma
and discrimination against key and priority population groups and among the PLHIVs across

58
communities and at service delivery places in order to design strategies and interventions
addressing stigma and discrimination.

2.9.9 Gender-based violence

The 2015-2020 national HIV Strategic Plan addressed gender equality and equity through
addressing gender related barriers to HIV and SRH needs of girls and boys; women and men
was identified as one of the four critical enablers that are necessary for the HIV Investment
Case to deliver results. Gender mainstreaming is at level of a directorate at FHAPCO. Gender
mainstreaming for HIV services, enhanced community mobilization against harmful
traditional practices such as early marriage, female genital mutilation and HIV vulnerability
reduction among women through strengthening economic interventions were also
implemented in the SPM-II period76. However, mechanisms for and indicators to track the
meaningful participation of women, gender responsive programing and gender responsive
budget allocation was limited.

Despite many policy, laws and strategies to close the gender gap, there is still significant
gender disparity in HIV prevalence, incidence, and AIDS-related deaths in Ethiopia. More
women than men are infected with and die due to HIV/AIDS related illnesses. Fewer women
than men have comprehensive knowledge about HIV and use condom with non-regular
sexual partners 77. Gender-based violence is still common in Ethiopia with 1 out of 4 (26 per
cent) of women age 15 – 49 experiencing physical and/or sexual violence by an intimate
partner or non-partner in their lifetime. Gender norms which are directly or indirectly
related to HIV are quite common in Ethiopia. These gender norms include early marriage,
harmful traditional practices and cultural norms on sexuality and gender roles that
contribute to creating barriers for HIV prevention and contributing to increasing the risk of
HIV transmission in women and girls 78.

In all regions, there are trained health workers capable of addressing GBV; health facilities
especially hospitals and KP clinics provide comprehensive HIV services for GBV victims
including HIV testing, treatment of STIs, emergency family planning and post exposure
prophylaxis. Victims are also linked to legal and psychosocial support. FSWs, bar owners and
law enforcement officers receive training on GBV prevention and mitigation. Although FSWs
are organized in support groups in a few regions; there is no comprehensive strategy to
protect FSWs against GBV at grassroots level. GBV prevention requires a budgeted
multisectoral response with better coordination among relevant stakeholders.

59
2.9.10 Stakeholder Analysis of the HIV Response

Stakeholders What we expect from them Their needs Resistance issues Institutional response
KPPs Participation in HIV prevention Access to health Dissatisfaction, low Expand KPP friendly service delivery
and behavior change information and services in uptake of services models, organize and build capacity of
user-friendly manner, KPP groups, engage them in planning,
avoidance of stigma, service delivery, M&E
confidentiality
PLHIVs Enrolment and adherence to Access to quality services, Dissatisfaction, low Improve quality of services,
HIV care and treatment uninterrupted supply of uptake of services, strengthen adherence support
ARVs, OIs, & reagents, poor adherence, loss systems, empower PLHIVs to engage
avoidance of stigma, to follow up in comprehensive HIV response,
confidentiality, strengthen community systems to
reduce stigma & discrimination
Parliament, Office of Leadership commitment and Effective implementation Administrative Have compelling business case for
the President, NAC, ownership of the national of policies, proclamations, measures, attaining and sustaining HIV epidemic
Prime Minister’s response, ratification and and strategies. Achieving organizational control, put in place strong M&E
Office, Council of enforcement of policy and goal, ensuring equity and restructuring, system and efficient capacity building
Ministers, Regional proclamations, domestic demonstrating efficiency, influence on budget mechanisms
Governments resource mobilization, ensure quality plans and reports allocation
accountability
Strategic sectors Allocate adequate budget to Capacity building support Fragmentation of Build institutional capacity for
implement HIV prevention for targeted HIV response, low reach effective response, provide
programs and address KPPs & prevention & coordination, and quality of guidelines, support for making social
surrounding population with legal framework for HIV services, contracts with CSOs for service
targeted prevention mainstreaming, HIV dissatisfaction, delivery and linkage with health
intervention in their sectors
commodity support, considering HIV as low facilities
evidence on epidemic & priority
response

60
Stakeholders What we expect from them Their needs Resistance issues Institutional response
MoH Enhance implementation of Effective coordination of Inefficiency, weak Strengthen sectoral ownership and
health sector response, adopt multisectoral response, coordination, less leadership of the response
and enforce guidelines based coordination, resource attention by other
on the national context, mobilization for HIV sectors
support in creating user friendly response, efficient
allocation and utilization,
service to KPPs, advocate for
coordination, engaging in
domestic resource mobilization,
Planning, M&E, quality
and leadership commitment to plan and reports
attain and sustain epidemic
control, ensure integration of
general population based
services into HEP and other
programs, and effective
mainstreaming across the
sectors, strengthen interagency
and sectoral coordination
EPHI Ensure quality assurance, build Financial support, Inefficiency, delays Strengthen engagement at Planning,
laboratory capacity, establish coordination, research with effects on M&E of HIV response at top
strong laboratory referral idea/agenda, engaging in program planning, leadership and directorate levels
system for specimen Planning, M&E service delivery, result (HAPCO-EPHI Forum)
transportation, testing, result monitoring &
reporting, undertake evaluation
surveillances and surveys with
timely reporting

61
Stakeholders What we expect from them Their needs Resistance issues Institutional response
EFDA External quality assurance, swift Financial support, Inefficiency, delays in Strengthen engagement at Planning,
registration of HIV commodities coordination, engaging in registration, M&E levels of HIV response at top
which are WHO prequalified Planning, M&E procurement, and leadership and directorate (HAPCO-
and registered with SRA, port clearance. EFDA Forum)
prompt approval of purchase
orders, and port clearance
authorization, Post Market
Surveillance
EPSA Ensure availability of HIV Jointly quantifying and Inefficiencies, delays Build capacity for IPLS including
commodities for prevention, sharing targets and needs, in procurement and creating visibility of items at down
care and treatment by financial supports distribution which streams of supply chain & on pipeline
implementing IPLS effectively, could result in stock of procurement, Strengthen
make real stock monitoring and outs engagement at Planning, M&E levels
enhance procurement, of HIV response at top leadership and
distribution, and avoid stock directorate (HAPCO-EPSA Forum)
outs.
Health professional Produce health professionals Policy support and Curriculum revision Strengthen collaboration in research,
training and research with the required Knowledge, guidance, collaboration in CPD, licensing, accreditation and
institutions, skills and ethics incorporating Continuous Professional providing policy support
professional recent developments in HIV Development (CPD)
associations prevention, care and treatment, research, accreditation &
engage in operational research licensing
& in-service trainings, support
in licensing and accreditation

62
Stakeholders What we expect from them Their needs Resistance issues Institutional response
Development Harmonized and aligned Efficiency in allocation & Fragmentation, Build implementation capacity for
partners support to national priorities & utilization of resources, inefficiency, targeted response, ensure
plans, provision of financial and assurance of the proper accountability, transparency &
technical support use of resources, efficient use of resources, build
transparency, financial management system,
coordination, involvement increasing domestic resource
in planning, mobilization
implementation and M&E,
reduce dependency
NGOs and CSOs Harmonize and align to national Involvement in planning, Dissatisfaction, Strengthen partnerships,
priorities and plans, engage in implementation & M&E fragmentation, scale transparency, enhance engagement in
provision of HIV prevention, down and withdrawal social contracting, linkages of
linkage to care, treatment and community and facility based services
adherence support
Private for profit Be alternative options for Receive updates on Mistrust, rent seeking Strengthen public private
entities provision of prevention, care national policies, partnerships in service delivery,
and treatment services guidelines, creation of create conducive policy environment
including social marketing enabling environment for
their engagement
Civil servants Commitment, Participation Conducive environment Dissatisfaction Motivation, Involvement
Transparency Incentive Unproductive
Attrition

63
3. Sustained HIV Epidemic Control Framework
There is a growing interest among the global AIDS community to institute appropriate
indicators to monitor progress to the HIV epidemic control at country, regional and global
levels. It is within this context that a policy decision was made to integrate the definition
and sustenance of the HIV epidemic control along with the development of the next cycle of
the NSP. A framework has been developed to guide a sustained and accelerated response
that aims at expanding and improving the reach and quality of HIV interventions in order to
achieve epidemic control targets by 2030 and ensure that those gains are sustained in the
long term79. This will:

a) Propose a country framework to guide the response to the HIV epidemic

control in the next decade
b) Demonstrate the return on investment and the gains in health and other
parameters of evidence-based HIV interventions to control the HIV epidemic
c) Showcase the application of HIV epidemic control metrics in the Ethiopian
setting and contribute to the global discourse in refining and finalizing the
proposed metrics.
d) Introduce metrics to guide the attainment of epidemic control in the
Ethiopian context.

Table 4. Ethiopia’s Standing in Meeting the Proposed Epidemic Control Metrics, 2020 80

Milestone for Ethiopia’s

Proposed Metrics
Epidemic Control standing
Percentage reduction
a) Reductions in new infections from 2010 levels 75% 52%
b) Reductions in AIDS related mortality from 75% 53%
2010 levels
Absolute rate
a) HIV incidence of less than one per 10,000 <1 1.29
population
b) AIDS related mortality of less than one per <1 1.10
10,000 population
Incidence Mortality Ratio <1 1.17
Incidence-Prevalence ratio 0.33 0.019

The proposed metrics to track progress in epidemic control are:

a) An HIV incidence of less than 1 per 10,000; as the main metric, complemented by:

i. An incidence mortality ratio (IMR) of less than 1; and,

64
 ii. The three 95’s : 95% of PLHIV know their status, 95 % of PLHIV who
know their status are on ART, and 95 % of PLHIV on ART are virally
suppressed.

The rationale for the selection of these indicators among those proposed by UNAIDS is
discussed in the epidemic control framework document. Progress in epidemic control will be
monitored annually at national and subnational levels and population groups. The three 95’s
are included as supplementary indicators to track progress in program performance and
maintain vigilance particularly at subnational levels.

65
4. The Investment Case Analysis
The NSP was informed by Investment Case modelling produced by Spectrum Goals (Aviner,
Ethiopia output, 2020) to prioritize the most cost-effective interventions whilst investing in
critical social and program enablers, including rights-based programming to achieve this.

Table 5: Selection of priority interventions and year 5 coverage targets in the NSP

Intervention Coverage: 2025

Key and priority populations 90%
High risk AGYW 90%
Condoms 254 million
VMMC 95%
PMTCT 95%
Differentiated Testing 7.56 million
Treatment (PLHIV) 90%

The choice of investment strategies in this NSP are built upon evidence based options using
the GOALS modeling in Spectrum to estimate the cost, impact and cost-effectiveness of
alternative HIV interventions. (Fig 25)

Interventions that demonstrated evidence to be most cost effective, using the Goals model
and other available evidence, were prioritized for scale up. These interventions included
female sex workers, PrEP, condoms, VMMC, SBCC and differentiated ART.

Fig 25: Cost per infection averted by intervention

66
In moving forwards, dependent on available funding, choices will need to be made on the
focus on the optimum basket of interventions for maximum public health impact within the
available funding envelope. Results are based on the following funding scenarios which have
developed by building on a full costing of the NSP and an assessment of the funding
landscape ( Table 6) and shown graphically in Fig 26.

Table 6. Funding scenarios

Domestic finance constrained by COVID but increases from 2% pa to 5%

growth pa by 2025
Conservative funding
PEPFAR 10% decline pa until 2025 and then constant
All other partners constant
Domestic finance constrained by COVID but increases to 5% growth pa
Optimistic domestic by 2025
funding PEPFAR 5% decline pa until 2025 and then constant
All other partners constant
Optimistic domestic Domestic finance constrained by COVID but increases to 5% growth pa
funding & full partner by 2025
commitment PEPFAR, GF and other development partners constant at 2021 levels

Fig 26: Resource needs, funding and gap by scenario (USD)

350

300

250
Millions

200

150

100

50

-
1 2 3 4 5
Optimistic domestic funding & full commitment from partners
Optimistic domestic funding increment
Conservative funding
Gap with full commitment
Gap with conservative funding

Interestingly, the funding gap is reduced by 72% with the additional funding from the
optimistic domestic funding scenario and the NSP is almost fully affordable with optimistic

67
domestic funding and continued donor support at 2020 levels. If the latter scenario is
achieved, 9842 HIV infections may be averted according to Goals modelling.

2021 2022 2023 2024 2025

Optimistic and full commitment $253 $273 $285 $294 $303
Optimistic $253 $262 $268 $275 $282
Conservative $237 $231 $223 $225 $228

Figure 27. Funding available and required

$350

$300

$250
Millions of US$

$200

$150

$100

$50

$0
2021 2022 2023 2024 2025

NSP Targets Optimistic Conservative

With Ethiopia so close to reaching epidemic, sustained funding and the targeted focus
outlined in this NSP, with bring definitive results as shown in the graphs 28-28 below.

68
Figure 28. New infections based on funding scenarios

16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
2019 2020 2021 2022 2023 2024 2025

Base NSP Targets Optimistic Funding Conservative Funding

Fig 29: The impact funding scenarios on AIDS deaths based

14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
2019 2020 2021 2022 2023 2024 2025

Base NSP Targets Optimistic Funding Conservative Funding

This modelling exercise provides the foundation upon which, on review of performance and
funding availability, optimization of interventions has the effect of achieving better results
within constrained funding.

If the NSP program had to be optimized further to align with reduced funding, the modelling
suggests that in the Optimistic Funding scenario funding for VMMC, PMTCT and youth could
be maintained with small reductions in treatment, testing and, condoms and SBCC and a
larger reduction in PrEP. For the Conservative Funding scenario, the optimization suggest
large decreases in funding for youth, KPPs, condoms, PrEP and SBCC and only moinor

69
reductions in treatment and testing. Under this scenario, there are slightly more people on
ART because there are more new infections and people in need of treatment.(Fig 30)

Fig 30: Ratio of funding 2021-2025 by funding scenario

120%
100%
80%
60%
40%
20%
0%

NSP Targets Optimistic Funding Optimized Conservative Funding Optimized

70
5. Strategic Framework Vision, Goal and Guiding Principles
Vision: An AIDS free Ethiopia

Mission: Institute effective HIV/AIDS prevention and control programs; coordinate the
national HIV/AIDS response, strengthen health systems, programmatic and social enablers
to ensure sustained epidemic control in the foreseeable future.

Goal: To attain HIV epidemic control nationally by 2025, by reducing new HIV

Expected impact results :

a) Number of new HIV infections reduced to less than 1 per 10,000 population
(Disaggregated by sex, region and population group)

b) HIV related deaths reduced to less than 1 per 10,000 population

c) Incidence Mortality Ratio reduced to minus 1 (Target: From 1.08 to 0.9)

d) Percentage of child HIV infections from HIV- positive women delivering in the
past 12 months reduced from 13.39% to less than 5% by 2025; and less than 2%
by 2030.

infections and AIDS mortality to less than 1 per 10,000 population.

Guiding Principles: The NSP will be implemented with adherence to the following guiding
principles:

a) Multi-sectoral: A multisectoral approach and partnership that builds on HIV being

the responsibility of all sectors and constituencies.

b) Inclusiveness: An inclusive and people-centred approach that recognizes different

prevention options that individual may choose at different stages of their lives.

c) Gender Responsiveness: A gender-sensitive approach that caters for the different

needs of women, girls, men and boys in accessing HIV information and related
services.

Furthermore, The NSP will be delivered through a Value for Money (VfM) Framework, that
defines how to maximize and sustain equitable and quality health outputs, outcomes and
impacts in a constrained economic and financial environment 81 .The VfM Framework
comprises 5 dimensions which will be applied during the design, execution and evaluation of
HIV programs included in this NSP.

71
a) Equity: Inequalities in health outcomes will be addressed through rights-based
programing and through improving the understanding of, and response to, human
rights and gender related barriers to accessing services. The NSP will focus on key
and vulnerable populations that frequently face hardship and stigma, and have
disproportionately higher risks and burden. At a system level, the HIV response will
be gradually integrated into the broader health and development agenda of
achieving universal health coverage by 2030 – where all people receive high-quality
health services and medicines they need without experiencing financial hardship. 82

b) Economy: The NSP requires that HIV programs strive to minimize costs of inputs for
service delivery, whilst attaining acceptable levels of quality.

c) Effectiveness: The strategic interventions in the NSP have been designed according
to the epidemiological context in Ethiopia, key drivers of the epidemic and patterns
of transmission. Interventions were selected and prioritized based on published
evidence on relative cost-effectiveness.

d) Allocative efficiency (prioritization across interventions, geographies and population

groups): The NSP has applied an investment case approach to determine the optimal
mix of prevention and treatment interventions, and which interventions to scale
within a constrained funding envelope to maximize impact. In the context of a
heterogenous HIV epidemic, a location-population approach prioritizes investments
in populations and Woredas with the highest vulnerabilities and burden.

e) Technical efficiency: The NSP requires that the HIV program systematically seeks
technical efficiencies during the design, execution and evaluation of the HIV
program, and reprograms savings from efficiency gains back into priority HIV
interventions.

f) Sustainability: A sustainable program that includes reliance on domestic resources,

increasingly strategic partnerships with external funders, community ownership and
leadership commitment.

72
The monitoring framework for this NSP has introduced VfM indicators to ensure that the
above dimensions of VfM are tracked and managed.

Figure 31 : Dimensions of Value for Money 83

73
6. Strategic Objectives
6.1 Strategic Objective 1: Reach 90% of Key and Priority populations
with targeted combination HIV prevention interventions by 2025

Result 1: Comprehensive knowledge about HIV and AIDS reached 90% by 2025 for key
and priority populations

Result 2: Condom use among key and priority populations engaged in risky sexual
behavior reached 90% by 2025

Result 3: 90% for key populations will know their HIV status by 2025

6.1.1 Context
During the strategic plan period (2021-2025) 90% of the estimated 3.75 million key and
priority populations will be reached with combination prevention (behavioral, bio-medical
and structural) interventions. The prevention program will be built on principle of
population and geographic prioritization for maximum impact. Client centered, integrated
and sustainable service delivery models will be used to deliver combination prevention
services and interventions. While the focus of the program is on key and priority
populations in 265 high incidence woredas, general population and KPPs in intermediate
and low incidence woredas will be reached through integrated and sustainable prevention
interventions within strategic sectors and community initiatives. ANC level services will be
offered in all geographical areas.

6.1.2 Population and Geographic Prioritization

Geographic Prioritization

The country has about 1076 woredas. Based on HIV incidence ((annex XX), woredas are
categorized into three geographic priority areas (Fig 31) :

High (265): Woredas with HIV incidence of ≥0.03% of people aged 15-49;

Medium (326): Woredas with HIV incidence of 0.01- 0.029% of people aged 15-49;

Low (485) : Woredas with HIV incidence of < 0.01% of people aged 15-49

High priority woredas will be reached through comprehensive HIV prevention targeting
KPPs. The low burden areas will be reached through integrated and sustainable HIV
prevention interventions mainstreamed in the health and non-health sector programs, as
well as through media and community initiatives. Medium burden woreads, in addition to
the services listed for the low burden areas, will also have some of the HIV services for the
key and priority population groups integrated into sustainable service delivery models.
Based on evidence, woredas may shift from one category to the other, and the response will
also be also tailored accordingly.

74
Fig 32: Woreda level HIV incidence (SPECTRUM estimates 2019)

Population Prioritization
KEY POPULATIONS:
Defining Key and Priority Populations (KPPs)
 Female Sex Workers (FSW)
The following population groups are defined as  Prisoners
Key and Priority Populations taking into  People with injecting drug use
consideration local epidemiology, HIV prevalence, (PWID)
high risk behaviors increased morbidity and
PRIORITY POPULATIONS:
mortality or higher vulnerabilities.
 Widowed and divorced men
Key Populations (Operational definitions) and women
Female Sex Workers are defined as women who  Long distance drivers
regularly or occasionally exchange sex for money  Workers in hot spot areas
in drinking establishments, night clubs, local drink  High risk adolescent girls and
houses, “khat” and ‘’shisha’’ houses, “on the young women
street”, around military and refugee camps,  PLHIV and their partners
construction sites, trade routes, red light districts,
and at their homes. Their paying and non-paying clients are included within this population.
A sex worker can be self-identified or identified by others as sex worker.

They can be further categorized by where they work as:

• Venue-based: female sex workers stationed in hotels and bars,

• Street based: female sex workers who are mobile or street based
• Home based: female sex workers stationed at home, ‘areque’ and ‘tella’ houses and
”khat” and “shisha”houses

75
 • Phone/SMS/Social Media based: female sex workers who can be accessed and
accept sexual appointment through telephone call and social media 84

Prisoners are all people detained in a criminal justice and prison facility, including adult and
juvenile males and females, during the investigation of a crime, while awaiting trial, after
conviction, before sentencing and after sentencing.

People with injection drug use are those men and women, who, because of using illegal
injectable substances are at high risk of acquiring HIV infection. They require special
arrangements to access HIV services and harm reduction and rehabilitation interventions.

Priority Populations

Long Distance Drivers

Long distance drivers are drivers who are obliged to regularly travel for more than 24 hours
on the road that involves overnight stay out of their home. This group includes heavy truck
drivers, bus drivers, Isuzu drivers, and tour-car drivers.

Widowed and divorced men and women

Widowed men and women are those whose spouse has died and who have not remarried.
Divorced men and women are those who have legally dissolved or terminated a marriage
under the rule of law of the country and not remarried.

Workers in hotspot areas

A hotspot area is a work area with 500 or more daily laborers or workers . and HIV
prevalence more than 1.6% or defined as hot spot by program people based on other HIV
risk behavioral attributes of workers. This mostly includes large construction projects,
industrial parks, factories/industries, commercial farms and sugar plantations, dry ports,
mega projects (i.e electric dams), mining, other investment and infrastructure development
projects. These sites are characterized by the fact that the people working in these sites are
likely to be migrant labor away from their homes and have some disposable income. These
sites will therefore attract female sex workers, taxi drivers,, Petty traders etc. These
conditions result in the potential for risk behaviors associated with the acquisition and
spread of HIV.

PLHIV and their HIV negative Partners

• PLHIV: People who have got tested for HIV and are found positive.
• PLHIV Partners: People who have sexual relationship with PLHIVs that includes
spousal and non-spousal partners.
• Discordant couples are those in which one spousal partner is HIV positive.
Partners of PLHIV are those people who have sexual relationships with
PLHIVs, the relationship can be spousal or non-spousal.

76
High risk adolescent girls and young women (AGYWs)
These are defined as females aged between 10-24 years who are sexually active (defined as
having sex at least once in the past 12 months) and who meet one of the following
characteristics:

• Have multiple sexual partners

• Are involved in transactional sex or are victims of sexual exploitation (irregular
exchange of sex for money or materials)
• Are involved in substance abuse
• Have a history of sexually transmitted disease
• Have been victims of gender based violence
• Have a history of unintended pregnancy or abortion

This group of adolescents and young women are found in higher learning institutions, high
schools, or work as waitresses, domestic workers or are out of school including those
unemployed. It also includes girls who are working (coffee sellers, petty traders) or living on
the streets.

Size Estimation of Key and Priority Populations

There are major data gaps in estimating the size of key and priority populations. Table 7
attempts to estimate the size of the various KPPs using existing scanty data and
assumptions85.

Table 7: Estimated size of Key and Priority Populations

KPP 2020 2025

Female Sex Workers 210, 000 240,000
Prisoners 86,500 86,500
People with Injecting Drug use 11,000 9,000
Widowed divorced men and women 956,475 1,114,931
Distance Drivers 65,000 85,000
Workers in Hot spot areas 840,000 1,050,000
PLHIV and their partners 678,095 813,610
High risk adolescent girls and young women 134,341 147,426
Total KPP size estimation 2,771,411 3,546,667

77
6.1.3 Strategic interventions

During the period of 2021-2025, combination HIV prevention interventions will be

implemented in the three incidence levels of woredas (high, medium and low incidence
woredas) as shown in Table 8 (a), (b) and (c).

Reaching high risk adolescent girls and young women, women age 25-34 years and
out of school.

High risk adolescent girls and young women including those sexually active in school and out
of school, those involved in transactional sex, house maids, those working in hotels and
cafeterias, working and living on street will be reached with combination HIV prevention
interventions by peer service providers, school intra and extra-curricular sexuality education
programs, KPP friendly clinics, outreach services of health facilities, adolescents and youth
friendly clinics and other HIV services delivered through general and integrated HIV services.
In addition, the disadvantaged segment of adolescent girls and young women will be
reached with economic empowerment interventions. Prevention of gender based violence
and providing support to survivors of GBV will be integrated with the HIV prevention
interventions including establishing safe houses, providing comprehensive medical and legal
support.

The majority of key and priority population constitute women aged 25-34 years who
contribute towards a significant proportion of new infections among women. Most female
sex workers fall in the age group 25-34 years, a significant proportion of workers in hot spot
areas and widowed and divorced women are estimated to be females in this age group.
Most high risk women in the age group 24-34 will be reached with combination HIV
prevention, HIV testing and treatment services through peer service providers, community
outreach, drop in centers, KPP friendly clinics and other health facility HIV prevention,
testing and treatment services. In addition disadvantaged segment of these women will be
provided economic empowerment interventions.

78
Table 8 (a) For Woredas >0.03% HIV incidence:

Prevention interventions Service Delivery models

• Intensive social behavioral change • KPP friendly Clinics

communication and demand creation • Friendly services at the general HIV
• HIV education through Print and services
electronic mass and social media • Peer service Providers
• Condom promotion and distribution, • Drop in centers
including lubricants
• Integrated HIV prevention services
• Pre exposure Prophylaxis (PrEP) (VMMC, harm reduction, Prison, work
• Voluntary medical male circumcision place, and higher learning institution
(VMMC) in selected geographic areas of clinics)
high prevalence and low circumcision rate • Integrated into other health services
of the country (mental health, TB, Hepatitis, SRH)
• Harm reduction: needle and syringe • Targeted out reach
programs through social marketing and
• Social marketing , private sector and CSO
CSO channels and opioid substitution
service delivery outlets
therapy
• HIV mainstreaming
• Screening and treatment of sexually
transmitted infections • Community Care Coalitions
• Blood safety and Infection prevention • Health extension program
practices at health facilities
• Prevention and management of Gender
based violence
• Economic empowerment of women;
especially high risk adolescents and young
girls
• Empowerment of communities especially
KPPs
o Intra- and extracurricular school HIV
education programs

79
Table 8 (b) For medium HIV burden Woredas with HIV incidence of 0.01-0.03%

Prevention interventions Service delivery models

• Social Behavioral change communication • Friendly services at the general HIV
and demand creation services
• HIV education through Print and electronic • Integrated HIV prevention services
mass and social media (VMMC, Prison, work place, and higher
• Condom promotion and distribution, learning institution clinics)
targeting KPPs • HIV interventions integrated into other
• Pre exposure Prophylaxis (PrEP) at friendly health services (mental health, TB,
clinics of public health facilities Hepatitis, SRH
• Screening and treatment of sexually • Social marketing, private sector and CSO
transmitted infections service delivery outlets
• Blood safety and Infection Prevention • HIV mainstreaming
Practices at health facilities • Community care coalition
• Prevention of Gender based violence • Health extension program
integrating with other sectors
• Intra and extra-curricular HIV education
across schools

Table 8(c) For low HIV burden Woredas with HIV incidence <0.01%

Prevention interventions Service delivery models

• Demand creation SBCC through HEP and • Integrated HIV prevention services
CCC (Prison, work place, and higher learning
• SBCC through mass and social media institution clinics)
• Condom promotion and distribution • HIV interventions integrated into other
health services (mental health, TB,
• Screening and treatment of sexually
Hepatitis, SRH,
transmitted infections
• Social marketing, private sector and CSO
• Blood safety and Infection Prevention
service delivery outlets
Practices at health facilities
• HIV mainstreaming
• Intra-curricular integration of HIV across
schools • Community care coalition
• Health extension program

80
Social behavioral change communication and demand creation

Expected Result 1: Proportion of key and priority populations reached with HIV prevention
programs with a defined package of services increased to 90%

Expected Result 2: Percentage of key populations who both correctly identify ways of
preventing the sexual transmission of HIV and who reject major misconceptions about HIV
transmission increased to 60% by 2025

Expected Result 3: Percentage of young women and men aged 15-24 who have had sexual
intercourse before the age of 15 reduced from 9% for females and 1% males to 5% and 0.5%
respectively by 2025.

Intensive behavioral change communication intervention (SBCC) will be implemented

targeting key and priority populations in the 265 priority woredas. This will be mostly peer
based facilitated small group learning with at least 85% of the intended sessions
implemented over two to three months by community level implementers. Demand
creation interventions will include any communication targeting KPPs and the general
population through mass media (radio and television), mini-media, print media (leaflets,
posters, magazines and newspaper), social media and interactive digital applications. Social
media and interactive applications will be optimized to reach large group of KPPs and
general population (mainly youth) to create demand and raise awareness about HIV
prevention, HIV testing, care and treatment, consolidated through integration and
strengthening of community level implementers. During the strategic period 90% of KPP in
the 265 priority woredas will be reached with intensive tailored behavioral change
communication at least once.

Integration of HIV into the school curriculum will be implemented nationally targeting
adolescents and youth in school. All schools across the country will implement curricular
and extracurricular activities to educate adolescents and youth about HIV and safe sexual
practices. Colleges and universities across the country will implement a credited course on
HIV, SRH, Life skills and Gender as part of the first semester first year academic program.
Schools will have extracurricular HIV prevention education and activities through mini-
media and clubs.

81
 Expected Results 1: Percentage of adults aged 15–49 who used condoms during their last high
risk sex act in the past 12 months increased from 20% for females and 51% males to 90% by
2025.

Expected Results 2: Percentage of FSW reporting use of a condom with their most recent
partner increased from 98% with paying partners and 37% with non-paying partners to
99 % by 2025
Condom promotion and distribution

The condom program will be implemented through a total market approach. Approximately
60% of free condoms will be distributed targeting KPPs in the high (265) and medium (326)
burden woredas; the social marketing and private sector will reach the general population
and KPPs in all woredas across the country. Condom-compatible lubricants shall be
distributed to FSWs through the social marketing and private sectors. The Condom Strategy
will be widely disseminated and translated into action.

Condom skill building and Demand creation

Condom demand creation will be central theme of all social behavioral change
communication interventions targeting key and priority populations as well as the general
population. Over the strategic period 90% of key and priority populations will be reached
with peer education. One of the six sessions of peer education will address clearing
misconceptions about condom use and skill building on consistent and correct condom use.
The Print media (information kits and leaflets) on information and step by step
demonstration of correct condom use will be produced and distributed targeting key and
priority populations. Correct and consistent condom use is one of the key messages and skill
component of curricular and extracurricular activities of schools including higher education
training institutions. Correct and consistent condom use will be promoted through
discussions and communication of mass media (radio and television) and social media. The
digital application that aims to enhance prevention behaviors among key and priority
populations, adolescent girls and young women and adolescent boys and young men will
have entertainment education on correct and consistent condom use. Free condom
distribution to key and priority populations will be conducted through peer service providers
door to door distributions at hot spot areas, health workers outreach programs, distribution
at hotels and bars as well as hot spot workplaces. In addition, condoms will be distributed
through static outlets of health facilities hotels and bars and work places.

Correct and consistent condom use skill building and demand creation efforts targeting
female sex workers will emphasize condom use with nonpaying sexual partners where
condom use is relatively low (37%).

82
 Expected Result 1: % and number of eligible people who received oral PrEP at least once
during the last 12 months increased from 1% (200) of discordant couples and 2% of(800
FSW) currently to 80% of discordant couples and 90% of FSWs respectively.

Expected Result 2: % of PrEP users who continued oral PrEP for 3 consecutive months
after having initiated PrEP during the reporting period sustained at 95%

Pre exposure Prophylaxis (PrEP)

Pre-exposure prophylaxis is the use of antiretroviral drugs by HIV-negative people before

potential exposure to prevent the acquisition of HIV. Oral PrEP will be provided to people at
substantial risk of acquiring HIV which in the Ethiopian context are female sex workers and
HIV negative partners of people living with HIV (PLHIV) who are not virally suppressed.
Activities to increase PrEP among the sub-group of FSWs who are considered at greater risk
of acquiring infection either because of non-consistent condom use or as victims of gender
based violence, include increasing awareness and literacy, adherence support led by peers
and integration through referrals to and from HIV/STI testing, treatment, and care services.
HIV negative partners of non virally suppressed PLHIVs on ART are at substantial risk of
infection. Efforts will be made to encourage adherence among the partner on ART or to
identify true regimen failure. The starting of PrEP for their HIV negative partner will require
full disclosure and measures to prevent potential intimate partner violence. During the
strategic period 90% of eligible Female sex workers ( about 37,400 by 2025), 80% of eligible
HIV negative partners (around 11,000 by 2025) of PLHIV will be reached with PrEP.
Additional eligibility criteria and target population for PrEP will be defined in the service
delivery guidelines and can be updated as appropriate. Screening for Hepatitis will be
provided without charge.

Voluntary medical male circumcision (VMMC)

Expected Result: % of males aged 15-49 circumcised at Gambella and Selected woredas of
SNNP region increased from 72% to 90%

Voluntary medical male circumcision will be implemented integrated in primary

health care facilities targeting male infants and men 10-49 years in high HIV
prevalence and low circumcision prevalence settings (Gambella region and selected
woreda in SNNP).

People with Injection and other substance use - Harm reduction:

Expected Result 1: % of PWID benefiting from needle exchange programs increased

from 0% to 90% by 2025

Expected Result: % eligible PWID receiving Opioid Substitution Therapy elevated from 0
to 90% by 2025

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In the first year of this NSP, a multi-sectoral approach to address policy issues around
developing a program for people with injecting drug and iliicit drug use will be undertaken.
This will lay the ground-work for the introduction of a needle and syringe exchange
programs with opioid substitution therapy. The needle syringe exchange program will be
implemented through non-governmental, civil society organizations and private sector.
Mental health services are limited in the country but there are new efforts to expand both
the capacity of health workers to address mental health as well as the number of facilities
who will be in a position to provide services. The opioid substitution therapy will be
integrated in these mental health services of government non-governmental and civil
society organizations. PWID will also be screened for Hepatitis B and C. Multisectoral
collaboration will be used to prevent the expansion, circulation and use of illicit and
injection drug use across the country involving the Ministry of Health, regulatory agencies,
law enforcement sectors, the transport sector and others.

Screening and treatment of sexually transmitted infections

Expected result 1: Percent of people 15-49 years with STIs treated increased from 32% to
60% by 2025.

Expected result 2: Percent of FSWs with STIS treated increased from 56% to 90% by
2025.
Active screening and treatment of STIs using syndrome approach will be provided to KPP
particularly FSWs and high risk adolescent girls and young women and their partners
integrated through community and health facility level service delivery outlets. Currently, a
syndromic approach will be used to screen and treat STIs although consideration for rapid
and laboratory STI testing and same day/early treatment especially for women presenting
with STIs may be considered in the future. There is a need to build the capacity of HCWs on
syndromic management and guidelines and manuals will be distributed to health facilities
for all population groups.

Prevention and Management of Gender based violence

Medical, legal and social services will be provided to prevent and mitigate GBV through
evoking a multi-sectoral response. Selected health facilities in the 265 priority woredas will
provide comprehensive medical services to survivors of GBV with strong referral linkages to
sectors and community actors providing legal and social services. Law enforcement and
community stakeholder’s capacity will be built to provide legal and social services including
safe houses for survivors or women escaping GBV. Community dialogue on prevention and
management of GBV will be undertaken, also involving the HEP, in collaboration with the
Ministry of Women’s Affairs to bring about social change for the prevention of GBV.
Community scorecards on GBVs will be used to monitor level of GBV. Similarly,
community/quality score card activities will be scaled up to the public KP friendly clinic in
collaboration with FMOH, FHAPCO and RHBs to ensure confidential and quality of services
at the pubic KP friendly services.

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In the intermediate and low burden woredas, community elders, including tribal and
religious leaders, will be engaged to advocate and create platforms for dialogue, especially
through the Community Care Coalitions to address gender issues, preventing GBV and
promote change in social norms related to gender.

Economic empowerment of vulnerable women

Economic empowerment interventions (job creation, vocational skills training and income
generating schemes) will target disadvantaged women, especially adolescent girls and
young women, in the 265 priority woredas as a structural HIV prevention intervention,
integrated with economic empowerment initiatives of key sectors.

Table 9: Summary of Implementation of HIV prevention interventions by population and

geographic prioritization

Intervention Target Population Geographic Focus

Intensive social behavioral change
265 high burden woredas,
communication (peer education, life All KPPs
prisoners
skills)
Education and demand creation All KPPs Nation wide
interventions: Print materials, audio
visuals, mass-media, mini-media, General Population
hotlines, interactive applications, social All woredas
Uniformed services
media
Intra and extracurricular School HIV
Adolescent and youth All Woredas
programs
High and medium incidence 265
Free condoms
woredas and medium burden
targeting KPP
Condom Programs: Total market woredas
approach for condoms, lubricants Social marketing /
private sector to reach All Woredas
all that can afford.
265 high burden woredas
through health facility
Female sex workers community approaches; for
Pre-exposure Prophylaxis (PrEP) intermediate incidence woredas
through health facilities
Discordant couples All woredas
For the high incidence 265
woredas both through health
KPPs
facilities and community
STIs screening and treatment outreach
General population, All woredas through Health
Uniformed services facilities
Infants and
Gambella Region and selected
VMMC Demand creation and services uncircumcised males
SNNP woredas
10-59 years

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Intervention Target Population Geographic Focus
Introduce harm reduction and standard
drug rehabilitation therapy with People with injection
Selected high burden urban
Methadone at Mental health services and other illicit drug
areas
and Integrate HIV services within the use
mental health service outlets
Blood safety and infection prevention All health facilities and blood
All people
practices banks
265 high burden woredas
Strengthen GBV prevention and Medium and low burden
response (legal, social and clinical) at KPPs woredas prevention and change
health facility and community level of norms integrated with other
sectors
Female sex workers,
Economic empowerment: government
divorced widowed
job creation, micro-financing initiatives,
women and high risk 265 high burden woredas
private sector and community level
adolescent girls and
initiatives
young women

6.1.4. KPPs Service Delivery Models

In order to reach key and priority populations, a mix of client centered service delivery
models will be used with strong linkages and coordination among the different models.
These include the following:

Key and Priority population friendly clinics:

These are HIV/SRH clinics within public health facilities which provide one stop shopping
HIV/SRH services for key and priority populations. There will be at least one KPP friendly
clinic in each of the 265 woredas. The KPP clinic will have a trained provider who can provide
friendly service to KPPs. The KPP friendly clinics will provide comprehensive services (SBCC,
counseling, condom, HIV testing, PrEP, STIs screening and treatment, family planning and
referral linkages for treatment and PMTCT). The KPP friendly clinic will serve FSWs, high risk
AGYW as well as other KPPs based on their preference. The KPP friendly clinic will be open
off working hours and linked with peer service providers and community mobilizers to create
demand and mobilize KPP to the friendly clinic services. Bi-directional referrals between
communities to facility will be strengthened.
Drop in Centers (DICs): Sustainable and low cost DICs will provide comprehensive
behavioral, bio-medical and structural interventions to key and priority populations
especially FSWs at selected hot spot towns. The DICs will be implemented with government
ownership and in partnership with development partners. DICs will be established in
government owned houses, where government will assign staff when appropriate and with
referral linkages to KPP friendly health facilities. FHAPCO/MOH/Regional HAPCO/Woreda
Health Office will play a leadership and coordination role. DICs will provide comprehensive
HIV/SRH services (SBCC, counseling, Condom, HIV testing, PrEP, STIs screening and

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treatment, family planning and provision of or referral linkage for treatment and PMTCT). In
addition, DICs will provide or link to social services of community and development partners.

Friendly services delivered at the General HIV service delivery outlets of health facilities:
The HIV service delivery outlets of health facilities will be made friendly for KPP through
training of service providers and flexible working hours to respond for needs of KPP who
prefer to use the general HIV service delivery outlets. At least one health facility in the 265
priority woredas as well as across the medium incidence woredas will have friendly services
delivered through the general HIV service delivery outlets. Referral linkage with the peer
service providers and community level services will be strengthened.

Condom Use among FSWs with non-paying partners: Condom distribution and utilization
interventions will emphasize increased condom use by young females, and in particular seek
to increase use by female sex workers with their non-paying clients (estimated at 37%,
IBBS). Demographic projections on clients of FSW and previous modes of transmission
studies show that non-paying clients of FSW, comprising less than 1% of the total male
population, are particularly efficient bridges of transmission to the general population, and
are often the channel of transmission to other sex workers. Condom distribution will be
accompanied by SBCC interventions to increase comprehensive knowledge on HIV
prevention tailored to some ages and venues, and at appropriate times and seek to reach
more young women and non-paying partners of FSW through partner tracing and other
social network strategies. These interventions will be integrated with differentiated HTS
services and SGBV prevention services, and will be led by trained FSW peer networks,
including lay counselors among them, and groups of male champions to relay critical
prevention messages effectively to other males.

Integrated HIV prevention services: Integrated VMMC service: VMMC will be implemented
in Gambella and selected woredas in SNNP region targeting men 10-49 years and newborn
infants. The medical circumcision will be implemented at primary health care facilities as
part of minor procedures within the surgical services. Primary health care facility staff will be
trained to undertake routine male circumcision services at the health facilities. The health
facilities will be equipped with required equipment and supplies. Regional health bureaus,
woreda health offices and health facilities will lead and implement the services in
collaboration with development partners. Civil society organizations will support community
mobilization and demand creation at community level.

Integrated harm reduction services: Initially, harm reduction programs, which includes
needle and syringe exchange and opioid substitution, will use a social marketing approach
and engage private facilities in collaboration with NGOs and civil society organizations. The
program will subsequently be expanded and included with the planned expansion of mental
health services of public and private health facilities in big towns; condoms and HIV testing
will be offered at these outlets or through referral to HIV clinics within the health facility.

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HIV services for Prisoners: Health facilities in prisons will have HIV prevention services
integrated in their general health services. All prisons will provide and coordinate social
behavioral change communication including peer education, HIV testing, screening and
treatment of STIs and GBV, provision or referral of treatment services. In addition condoms
shall be provided on release from the prisons. It will also be important to sensitize and build
the capacity of prison staff.

Integrated HIV services at hot spot workplaces: All hot spot workplaces with HIV prevalence
>1.5% or more with total of 500 or more staff of all types, shall have at least a clinic that
provides integrated health and HIV services (condom, HIV testing, screening and treatment
of STIs and GBV, referral for treatment). The work place will coordinate and implement
social behavioral change communication interventions and demand creation targeting staff.
In addition, there will be outreach HIV services delivered by nearby government health
facilities. Workplaces/projects will finance and manage integrated HIV and health services at
work places. RHB/Woreda health offices and development partners will support and build
capacity of the workplaces HIV programs in hot spot work places.

Targeted outreach Program: Health facilities especially those KPP friendly clinics will have at
least quarterly outreach programs to reach KPPs at nearby hotspots. Targeted outreach HIV
services will be led by a health worker and supported by peer service providers and
community groups. Civil society organizations and development partners will play a
significant role to mobilize KPPs to attend the outreach HIV services. KPP targeted outreach
programs will be implemented in all the 265 priority woredas.

Peer Service Providers (PSP) Program: There will be 30 trained peer service providers
working full time with a monthly standard incentive package per woreda in all the 265
priority woredas. There will be around 8,400 trained full time PSPs selected from KPPs, will
deliver a standard package of services (SBBC especially peer education, condom, self-
testing, information and referral for PrEP and referral linkage for other HIV prevention and
treatment services) to KPPs in 265 woredas. The PSPs will be linked with the KP clinics, DICs
and other service delivery models. And will create demand and mobilize KPPs to the
different service delivery outlets. The PSPs will support health facilities with adherence
support and tracing of lost to follow ups. The PSP program will be managed and led by
Regional and Woreda health offices with support of CSOs and development partners.

Social Marketing and private sector services delivery: Condoms will be distributed through
social marketing and private sector outlets (pharmacies, shops, hotels and bars, peer service
providers) targeting the general population in all woredas. Lubricants will be distributed
through pharmacies and private facilities.

HIV mainstreaming: The 10 identified strategic sectors will allocate up to 0.2% of their
annual budget to HIV prevention programs and implement HIV prevention interventions
targeting KPPs and general population. The HIV prevention interventions include SBCC,
condom and HIV testing services and the sectors will assign staff and facilities to implement
these HIV prevention interventions. The strategic sectors can collaborate with civil society

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organizations and the private sector to implement HIV prevention interventions through
social contracting arrangements. The following table summarizes the ten strategic sectors
and populations targeted.

Mainstreaming
Strategic Sector Office Key and Priority Populations
Type
Direct Ministry of Labour and Social Affairs Workers in hotspot areas;*
mainstreaming (MOLSA); regional bureaus and woreda people living with HIV
offices
Ministry of Women, Children, and Youth Adolescent and young girls
Affairs; regional bureaus and woreda offices Female sex workers; widowed
and divorced women
Transport Authority; regional bureaus and Distance drivers
woreda offices
Federal and regional prison administrations Prisoners
Ministry of Education; regional bureaus and Adolescent girls and young
woreda offices, Ministry of Science and women
Higher Education and technical and
vocational training agency; colleges
Government Development Enterprises Workers in hotspot areas and
Agency and its entities (Sugar Corporation, female sex workers in their
Construction Corporation, Design Works and project catchments
Supervision, Metal and Engineering
Corporation)
Infrastructure Ethiopian Roads Authority; regional offices Workers in hotspot areas and
mainstreaming female sex workers in their
project catchments
Ministry of Construction and Urban Workers in hotspot areas and
Development its projects and line offices female sex workers in their
project catchments
Ministry of Mines, Petroleum, and Natural Workers in hotspot areas and
Gas; regional offices female sex workers in their
project catchments
Ministry of Water, Irrigation, and Electricity Workers in hotspot areas and
female sex workers in their
project catchments
Sectors with Ministry of Defense, Police Commission, Uniformed services in camps
special Agency for Refuges and Returns Affairs and or confined setups
consideration Federation of People with Disabilities Refuges
People with disability

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6.1.5 General Population Prevention Interventions and service delivery models

Expected Result: Percentage of women and men aged 15-49 who both correctly identify ways of
preventing sexual transmission of HIV and who reject major misconceptions about HIV
transmission increased from 20% for females and 38% males currently, to at least 70% for males
and 50% for females respectively by 2025
50% by 2025

Although the focus of targeted prevention activities in the NSP is mainly on KPPs and the
265 high incidence woredas, targeted HIV prevention services will also be available in the
medium incidence woredas, integrated into existing service delivery models (general HIV
service outlets in health facilities, through the health extension and community care
coalition programs, mass and social media,, as well as school HIV programs). In the low HIV
burden woredas, only basic HIV prevention interventions will be implemented targeting the
general population. Such interventions will be delivered through health facility and
community outlets by health and non-health sectors, community and civil society actors.
Uniformed service members, particularly those living in camps away from home will also
received these services delivered primarily through the Ethiopian National Defense Force.
Ethiopia hosts a large refugee population who will also receive the following interventions
through the Administration for Refugee Affairs as well as through UNHCR. These include:

• Social Behavioral change communication and demand creation through mass

media (national and local/regional public and private radio and television) as part
of social corporate responsibility with technical support from HAPCO and the
Health sector;

• Curricular and extracurricular activities of schools (Mini-media, clubs)

supported through the Ministry of Education including the use of available
school electronic platforms (radio and plasma);

• Use of risk screening tools at higher learning institutions and high schools to
identify and provide intensive behavioral change communication and condom as
well referral linkage to health facilities

• Revitalize and scale integration of HIV/SRH/gender/life skill course in the higher

learning institutions and revise the high schools curricular HIV content to make
interactive and skills focused

• Scale-up of Community Care Coalitions and allocation of funds to HIV prevention

especially SBCC;

• Material development both print and audio visual as well as the use of social
media and interactive digital applications;

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 • Integrate HIV program into health extension program performance monitoring
scorecard.

• Strengthen Targeted HIV mainstreaming in key sectors.

• Use national events to create demand among the general population

• Education through the involvement of religious institutions

• Condoms distribution mainly through social marketing and private sector while
free condom is distributed to those who cannot afford to buy

6.2 Strategic Objective 2: Enhance HIV case finding to attain 95% of

PLHIV knowing their HIV status and linked to care by 2025

Result: HIV testing, and counselling services scaled up and at least 95% people who
know their HIV status by 2025

6.2.1 Context

Case finding will be enhanced to enable 95% of PLHIV to know their status. HIV testing
services will be available in public and private facilities as well as community outreach
programs. In 2017 and 2018, 9.2 and 8.2 million HIV tests were conducted respectively, with
low test yields of 0.8% (73,981) and 0.6% (51,093), respectively. Therefore, it is essential to
adopt HIV testing approaches with better yield, which will provide cost savings through
technical efficiencies. High yield case finding modalities include index case testing and
partner notification, social network services and PITC using an HIV risk screening tool at the
health facilities. An adult HIV risk screening tool (HRST) is in place with variable use but
there is a need to validate this HRST as well as rolling out a pediatric and adolescent
assessment tool. HIV self-testing will be made available through social marketing. The free
and targeted HIV testing services will prioritize KPPs, symptomatic children and pregnant
women. HIV testing services will also be available to the general public on a fee basis
through voluntary counseling and testing service outlets at public and private facilities. This
will be implemented by integrating the HIV test kits into revolving drug fund (RDF) modality
of the public facilities and allowing private facilities to procure HIV test kits. HIV self-testing
(HIVST) will be expanded through social marketing outlets for those testing positive, and
through integration with ICT/PNS to reach the hard to reach contacts of index cases, same
day linkage to care and treatment will be facilitated.

6.2.2 Population and Geographic Priorities

HIV testing will be optimized using higher yield testing modalities such as index case testing
and partner notification, social network strategy (SNS) for KPPs. All pregnant women,
patients with TB and STIs and those undergoing VMMC will be tested. The priority for HIV
testing will be key and priority populations in the 265 high burden woredas. Vigorous

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optimization in the rest of the country will be based on use of a Risk screening tool both for
adults and children administered at various entry points within health facilities. VCT will be
available on a fee basis and HIVST will be expanded using a social marketing approach.

Expected Result 1: % of women and men aged 15-64 years living with HIV who know
their HIV status increased from 78% to 95% by 2025.

Expected Result 2 : Percentage of HIV-positive results among the total HIV tests
performed during the reporting period increased from 0.6% to at least 2% by 2025

6.2.3 Case finding strategic interventions and service delivery models

The HIV tests and case finding will use the following interventions and service delivery
models. All modalities of case finding will facilitate same day linkage to treatment.

Index case testing and partner notification services (PNS)

Index testing is to be offered to all newly HIV diagnosed clients, those with high viral loads,
and all children of HIV+ parents. Counselling is accompanied by screening for intimate
partner violence. Case finding also uses data from CBS/Recency testing to enhance PNS
among index clients who have recent infection. Providers offer PNS to all clients who have a
positive recency test result and follow up until all partners have been tested. Facilities will
use community outreach to find index cases. CSOs and peer service providers will support in
the implementation of index case testing.
Social Network Strategy (SNS) is a recruitment strategy using social network connections to
locate individuals at the highest risk for HIV who are unaware of their HIV status and
provide HIV counseling, testing, and referral services. SNS can be particularly useful in
finding key and priority populations that have limited access to HIV testing. Initial results
from SNS among KPs have provided yields around 20. SNS will be scaled up in the 265 high
burden woredas using a peer led approach near KPP hotspots. Peer service providers will
ensure linkage to health facilities for those testing positive. Appropriate quality control and
auditing for repeat testers will be part of this strategy implementation. CSOs will support
implementation of SNS.

Provider initiated testing and counselling (PITC) is offered in all health facilities at various
service entry points (e..g.. inpatient, outpatient, TB and STI clinics, malnutrition and
postnatal clinics), based on the results of the risk screening tool. The risk screening tool
currently on use for adults will be validated and a risk screening tool for children and
adolescents will be further developed and validated. Only children <5 years who have a
positive risk screening assessment will be tested . Thisis a change from current practice.

HIV testing integrated with MNCH is offered to all pregnant women attending antenatal
care those who are laboring and attending postnatal care who are not on ART. In line with

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Ethiopia’s progress towards the elimination of syphilis, dual testing will be offered to
pregnant women. Pregnant women will be tested at least once with subsequent tests at
labor and delivery and during the breast feeding period based on using the Risk screening
tool. Early Infant Diagnosis (EID) for HIV Exposed Infants will be expanded on both
conventional and point of care platforms.

HIV testing integrated with TB/STIs/VMMC: All clients attending these clinics will be tested
for HIV.

HIV Self-testing: Self-test will be available through social marketing and private providers to
KPPs and the general population on fee basis. HIVST will be scaled up and used by
integrating with ICT, so that contacts of index cases who prefer to self-test, in a place where
they feel comfortable, can be reached. A secondary distribution approach can be used by
index cases, to deliver the test kits and self-test packages to their contacts. HIVST will also
be scaled up to all KP friendly public health facilities and provided to reach FSWs that could
not otherwise be reached through facilities based HTS. Instructions for those self-testing for
HIV will indicate that if a person tests positive they must go for a test to the nearest health
facility using the national testing algorithm.

Voluntary counseling and testing (VCT): VCT services, including pre-marital testing will be
available on fee basis to general population at the public and private health facilities. As
demand creation activities are strengthened and HIVST is scaled up, clients who learn their
risk behavior and clients who self-tested and need confirmatory testing may opt to come to
the VCT clinics. Separate documentation will be ensured at these clinics for premarital
testing against other clients.

in order to implement these targeted testing approaches, health workers will be trained on
different HIV testing strategies (ICT, PNS, SNS, self-test etc), the use of risk screening tools for
both adults and children, improved counseling techniques and in completing accurately HCT
testing registers. Supportive supervision will include review of yields and swift remedial
actions where non targeted testing is found. There will be improved community-facility
communication and linkages, involving PLHIV Associations and community actors, addressing
stigma and discrimination.

Service delivery
Intervention Target Population Indicator
location/outlet
Index Case Testing Proportion of Partners
PLHIV, their partners Health facility &
and partner and children tested for
and their children outreach
notification HIV
Social Network Proportion of KPP tested Health facility and
KPP
Strategy through SNS and Yield outreach
Heath facilities –
Disaggregation by
multiple entry points
PITC All woredas population group by age
(TB, STI. In patient,
and sex
malnutrition wards)

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 Service delivery
Intervention Target Population Indicator
location/outlet
Disaggregation by Public and Private
VCT on a fee basis General population population group by age health facilities VCT
and sex services
Public health facility
KPP, pre-marital testing based distribution
HIV Self Testing # of kits distributed
Contacts of index cases ,Social marketing and
private sector outlets
# returned for
confirmation, positive,
initiated
Initial and follow up
Testing in Pregnant mothers tests, positive, ART Health facilities
initiation
Uncircumcised males in
PMTCT Gambella and selected DIC for PrEP
areas in SNNP
VMMC FSWs and Discordant
PrEP couple

6.2.4 Linkage to Care and Treatment

Expected result 1: >95% of all people with newly diagnosed HIV infection will be inked
to and initiated on antiretroviral treatment by 2025.

The HIV testing cycle will only be considered complete when there is linkage of HIV positive
people to care and treatment immediately or within a maximum of 7 days. The following
strategies will be used to ensure linkage to care and treatment: a) escorted referral for
linkage; b) written referral; c) coupon systems for community to facility or facility to facility.
Peer service providers, CSOs and CBOs have critical role to play in linking those testing
positive to care and treatment. Community education and demand creation, including
education on minimizing repeat testing and addressing stigma and discrimination is needed.
Referral directories should be made available to all testers and there should be active
involvement of PLHIV Associations. In order to monitor successful linkage has occurred, a
closed loop and auditing system of incoming and outgoing referrals should be in place with a
quality assurance mechanism for monitoring and accountability.

6.3 Strategic Objective 3: Attain virtual elimination of MTCT of HIV

and Syphilis by 2025
6.3.1 Context

Reaching elimination of mother to child transmission of HIV and Syphilis within the
Ethiopian context presents significant challenges outlined in section 2.8.3. above. The 2019
updated national comprehensive and integrated PMTCT guideline endorses Dolutegravir

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(DTG) based regimen as the preferred first line ARVs for pregnant and breast feeding
women (PBFW) and women of childbearing age. The country has also adopted the provision
of enhanced postnatal prophylaxis (NVP+AZT) for the first 6 weeks and NVP alone for the
following 6 weeks) for all HIV Exposed Infants.

6.3.2 Strategic Interventions and Service delivery models

Expected result 1 : Mother-to-child transmission of HIV during pregnancy, childbirth and

breastfeeding reduced to less than 5% by 2025
Expected Result 2: Percentage of pregnant women who know their HIV status increased
from 84% to 95% by 2025

Expected result 3: At least 98% of expectant mothers living with HIV are virally suppressed
at labor and delivery

Expected Result : Percentage of infants born to women living with HIV receiving a virological
test for HIV within 2 months of birth increased from 64% to 95% by 2025

PMTCT services will be offered in over 3,000 health facilities at MNCH clinics. In order
to improve MTCT outcomes, the following strategies will be employed:

• Strengthen primary prevention

• Adoption of dual HIV and syphilis testing (RTK)

• Expand Provision of DTG based ART regimen for PBFW and enhanced
postnatal prophylaxis for HEI

• Sustain the experience of Mothers Support Groups (MSG) to support the

adherence and retention in care at least at the high burden geographic areas.

• Enhance implementation of continuous quality improvement strategy

• Strengthen and scale-up PoC for EID and viral load testing for pregnant and
lactating mothers

• Enhance capacity of health workers on treatment provision – (training, counseling,

mentoring)

• Strengthen the referral network between PMTCT and ART sites (linking HIV +
mothers to nearby ART clinics after completion of lactation)

• Strengthen PMTCT cohort monitoring system

• Strengthen index testing in the PMTCT setting and self-testing (partner)

• Need based ART/PMTCT service scale-up in private sector

• Strengthen family planning service among HIV positive women in reproductive age
group.

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Early Infant Diagnosis and Management of HIV exposed Infants
In 2020 there were 190 PCR machines working at about 40% capacity and 340 GenXpert
machines with the potential to expand their diagnostic platforms to include EID; 64%
(13,799) of HIV exposed infants had a PCR test. But turnaround time to receive results is
prolonged which may result in delayed linkage of identified HIV positive infants to care and
treatment service. The protocol for enhance postnatal prophylaxis for HEI was not routinely
followed in all facilities and for those infants diagnosed HIV positive in 2019, only between
57-80% were linked to ART. Reasons for this include poor documentation and reporting as
HEI-POS-ART is not part of HMIS reportable Indicators.

In this NSP period the following will be implemented:

• Both expansion of EID through PCR and increased opportunities for using new POC
technologies will result in an EID coverage of 95%. Consideration will be given to
other WHO EID diagnostic POC platforms

• Improved sample referral transport and the timely return of results will occur

• HIV exposed infants will receive dual Prophylaxis (AZT+NVP) and cotrimoxazole syrup

• Efforts will be made to better link

REGIMEN OPTIMIZATION
mother-infant pairs to care and
Adults:
treatment • Introduction of Dolutegravir, lower
dose Efavirenz
• Adjustments in DHIS2 to track
• Phase out Niverapine
mother-baby pairs on ART treatment • 2nd line regimen at health center level
• Increased availability of 3rd line
• The country will apply for validation
regimens
for path-to-elimination. The already
established Validation committee will Pediatrics:
work to ensure there is timely • Introduce lopinavir/ritonavir pellets
application and validation. Details on • DTG regimens for children when
available
the roll out/expansion for the
national EMTCT of HIV and syphilis Ongoing pharmacovigilance
will be addressed through a separate ART Drug resistance surveillance
EMTCT strategic plan.

6.4 Strategic Objective 4: Enroll 95% of PLHIV who know their status
into HIV care and treatment and attain viral suppression to at least
95% for those on antiretroviral treatment
6.4.1 Context

Ethiopia has made excellent progress towards achieving the 2nd and 3rd 90s. Test and start
with rapid ART initiation (where clinically indicated) was included in the MOH guidelines

96
(2018) and has been scaled up across all health facilities providing ART. In line with the
latest WHO guidelines, optimization of adult ART includes the introduction of fixed dose
combination tenofavir, lamivudine and dolutegravir (TLD), lower dose Efavirenz (EFV), and
phasing out of Nevirapine (NVP). As of December 2019, of the 79% of estimated PLHIVs who
know their status, 90% were on ART and 91% were virally suppressed.

The percentage of children receiving HIV treatment <14 years however is considerably
lower; 26% for children 0-4 years, 46% for those aged 5-10 years and 58% for those 10-14
years old. 86 There are large regional variations in ART coverage from 28% in Somali to 81%
in Harari.

Private health facilities also provide HIV services with free ART drugs but they lack an
adequate number of trained staff, case managers and adherence supporters, adequate
technical support, commonly lack drugs to manage opportunistic infections, and are not
adequately involved in monitoring and review meetings; and they do not have strong
system for tracing lost to follow up patients. As Ethiopia increases its ART coverage,
identification of new HIV infected individuals, linking them into treatment and ensuring that
patients are not lost to follow-up is critical.

Refugee populations have been included in quantification of drugs for cre and treatment.
Refugee camps are administered through the Administration for Refugee Affairs as well as
UNHCR.

Improving adherence and retention in care

Viral suppression among adults on treatment remains high suggesting that adherence to
treatment is strong. However further improvements can be achieved by using the following
approaches.

a. Maintaining involvement of case managers and adherence supporters under

Regional Health Bureaus

b. Differentiated service delivery models such as 6-month multi dispensing, community

adherence groups (CAG), rapid pharmacy refills improves adherence and also
provides increased technical efficiency

c. Client-centered services: extended working hours, week-end services, relatively

permanent health care providers at ART clinic

d. Improved/ complete documentation of patients’ address (Client’s

physical/telephone address & contacts, use of personal identity to avoid wrog name
and address as applicable)

e. Enhanced facility-community collaboration to trace LTFU

f. Greater involvement of PLHIV and their associations

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6.4.2 Viral Load Coverage and Suppression

Ethiopia has increased viral load testing coverage over time as well as continued high VL
suppression rates. The VL monitoring coverage reached over 70% with an overall viral
suppression rate of 90% in 2020. Viral load coverage and viral suppression rates vary across
regions. During this NSP, viral load coverage will reach 90% with 95% viral load suppression.

Improvement is particularly needed for quicker turnaround time to inform those patients
with high viral load and timely management of high VL. Modalities to achieve this a more
efficient sample transport system, same-day high viral load result notification to expedite
patient notification, increasing access to POC viral load machines (e.g. GenXpert), and
expansion of electronic test order and result reporting.

6.4.3 Children and adolescents lagging behind

Expected Results 1: % of children < 15 years who are on ART increased from 67% to 95% by
2025

Expected Result 2: % of all children < 15 years PLHIV who are virologically suppressed increased
from 74% to 95% by 2025
Successful care and treatment for children and adolescents lag behind the progress made
in adult treatment for HIV. There are multiple factors involved including that children rely
on their parents for access to treatment, limited accurate and timely diagnosis,
inappropriate community attitudes and knowledge about HIV in children, poor linkage
into treatment, low access and optimization of pediatric formulations and regimens,
limited capacity among primary health care workers to treat children and lack of
adolescent friendly services.

Children on Treatment

In comparison to the success shown among adults on treatment, the percentage of children
<15 years on treatment is considerably lower; 26% for children 0-4 years, 46% for those
aged 5-10 years and 58% for those 10-14 years old87. Viral suppression among children <15
years is 78.9%.

Based on modelling, 19% of all new infections occur in children <4 years. Early detection for
at-risk children and early treatment for those living with the virus are crucial to saving lives.
However, cultural, social, and economic stigmas are barriers to pediatric HIV testing.
Caregivers face numerous challenges, including HIV disclosure and the child’s ability to
understand, fear of social rejection and isolation, parental sense of guilt, and concerns of
inadvertent disclosure by the child, revealing an HIV diagnosis to others. Additionally,
societal norms, such as male decision making roles affect the utilization of healthcare
services for women and children.

Human-Centered Design (HCD) is a problem solving framework grounded in empathy and

understanding. Applying HCD in the global HIV response, specifically in pediatric HIV testing,

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will provide a platform to recognize not only the types of experiences clients want but also
how to design the delivery of their desired experience.

Identifying more children will be achieved through information gained through human
centered design operational research, as well as the emphasis put on index case finding,
increased coverage of early infant diagnosis for HIV exposed infants, and targeted PITC at
critical entry points where sick children are seen at health facilities. All positive children will
be linked into care and treatment and initiated on optimized pediatric regimens in
accordance with the the latest WHO guidelines. Where possible, in facilities with larger
patient loads, child friendly clinic areas will be created.

Procurement of pediatric formulations remains challenging with worldwide production

constraints supply shortages. The Government of Ethiopia will explore options through the
Global Fund such as pooled procurement.

In addition to improved case finding, strategies to improve pediatric outcomes will include:

• Family friendly clinics with harmonized appointment schedules

especially when parents are enrolled for DSM

• Optimization of pediatric regimens

• Parent/caretaker adherence education

• Health worker capacity building (through training, mentoring, case

conferences, etc) for care and treatment of children and addressing
disclosure

• Expanding options for differentiated service delivery models for

children.

• Working with community care coalition to reach OVCs and provide HIV
services.

• Education through audiovisual media outlets

• Adopting best global experiences

Adolescent Services

Despite improved access to HIV treatment, globally, the adolescent is the only age group
with increasing HIV related mortality (up to 50%) while all other age groups (children and
adults) combined experienced a decline of 38% in AIDS-related deaths between 2005 and
2013. Mental health is becoming another emerging public health priority. About 50% of the
mental health problems start before the age of 14 years (late childhood and early
adolescence) with 23% of years lost to disability are due to mental health problems. Most
cases go unrecognized and untreated88. If an adolescent is HIV positive, there are additional

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triggers which can predispose the adolescent to feelings of anxiety, depression and even
possible suicide. The training of health workers can facilitate them having an important role
in identifying mental illness among adolescents living with HIV. 89

Although there has been success in decreasing prevalence among 15-24 year olds, once
diagnosed as HIV+, adolescents on treatment have sup-optimal viral suppression rates
(81.8%). One of the major factors in improving viral suppression and improved adherence is
disclosure of HIV status. This has continued to be a major challenge within the program.
More often than not, disclosure is best undertaken jointly between the health worker and
parent/caretaker. This requires the health worker to have been adequately trained is
disclosure to children and adolescents. There are few adolescent friendly health facility
services. Adolescents living with HIV do not like being seen with children or adults - they
prefer their own clinic. Another key sensitive point is when adolescents are old enough to be
transitioned to the adult clinic. The exact time for this transition should be discussed with
the patient and not be entirely dictated by age alone.

This NSP provides a number of options for health facilities and other stakeholders to
improve outcomes for adolescent HIV care and treatment. These include:

Adolescent HIV Clinic day: Selected health facility ART clinics in urban towns (mostly health
centers) will dedicate one of the five working days and Saturday as adolescent HIV clinic day

• Specific day within the general HIV clinic setup on which only ALHIV are offered care
and treatment.

• Operates within the same infrastructure as the adult clinic

Adolescent HIV clinic: Health facilities which already have functional adolescent and youth
friendly clinics will integrate HIV care and treatment services for HIV positive adolescents
and youth
• Separate/Stand-alone clinic setup for only HIV+ve adolescents

• Clinic operates outside the adult clinic infrastructure but mostly inside same health
facility

The following will be the minimum package of services delivered at adolescent and youth
friendly clinics or adolescent clinic days

• Information on reproductive health issues, body hygiene and environmental hygiene

• Counseling on sexual relations and safe sex
• Life skills education
• Condoms
• Treatment (ART) and adherence counseling
• Pregnancy testing

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 • Psychosocial support
• Counseling on alcohol and substance abuse
• Counseling on mental health
• Counseling & management of sexual abuse
• Sexual Reproductive health services (e.g. Antenatal care, safe deliveries, post-natal
care, STI prevention, screening, and treatment; family planning method and Post
abortion care)
• Referral and follow up

In addition to trained health workers, HIV positive adolescents support groups, adolescent
peer service providers can play an important role in providing adherence support, promoting
positive living, promoting access to services, identifying and reaching key populations of
adolescents in their communities and engaging in, community participation and advocacy.
The role of the following approaches/groups should also be examined and promising
experiences expanded :

 Adolescent and Youth Peer-to-Peer support groups

 Involvement of Adolescent (youth) ambassadors
 Adolescent Adherence supporters
 Greater participation of Associations of ALHIV

6.4.4 Management of co-morbidities

Results from EPHIA showed that 22% of patients were presenting with advanced HIV disease
(CD4 <200 cells/mm3). Important co-morbidities and required treatment include:

• Cryptococcal disease: Screening for cryptococcal disease (CrAg) for adults and
adolescents with CD4<100 cells/mm3 with additional consideration for screening for
those with CD4 <200 cells/mm3 and pre-emptive treatment with fluconazole for those
with advanced HIV disease; treatment with antifungal regimens and monitoring for
Amphotericin drug toxicity90.

• Cervical cancer: In 2015, MOH introduced cervical cancer (CxCa) screening and
treatment for all women between 30-49 years irrespective of their HIV status.
However national scale up has been hampered by some of the key programmatic
challenges. These include lack of up-to-date national guidelines and job aids; weak
demand creation at community and HCWs level; stigma; lack of capacity to maintain
trained HRH at different level of the health system; lack of capacity for preventive
maintenance and troubleshooting resulting in frequent equipment failure; frequent
shortage of medical supplies and accessories; lack of capacity to introduce new
technologies; poor referral networking; and, lack of system for mentorship, coaching
and quality improvement. The Ethiopia Population-Based HIV Impact Assessment
(EPHIA) 2017-2018, showed that, in urban areas, only 16% of HIV-positive women

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 aged 30-49 years reported being screened for cervical cancer.

To increase the uptake and treatment of cervical cancer screening services, PLHIV
associations swill promote the use the use of these services and link HIV+ women to the
nearest health facility where this services is available. HSTP II aims to increase cervical
screening among 30-49 year old women from 5% to 40% by 2024. In this NSP, PLHIV women
aged between 25-49 will be screened for cervical cancer and referred for treatment.

• Mental Health: General mental health services remain very limited within the
country but as much as possible, clients attending ART clinics will be screened for
possible mental health conditions and managed or referred for its management.

Result 1: Percentage of people living with HIV newly enrolled in HIV care started on TB
preventive therapy increased from x% to 95% by 2025

Result 2: % of PLHIV on ART who completed a course of TB preventive treatment among

those who initiated TPT

6.4.5 Tuberculosis Co-infection

Optimized case finding will include:

a. Routine TB screening for PLHIV on ART
b. Strengthen TB and HIV case finding activities at all other service delivery points
within facilities
c. Investigate TB contacts for TB and HIV at TB clinics
d. Ensure efficient referral for TB diagnosis

Optimized TB /HIV care includes:

a. Improve access to TB diagnostic tests, integrated sample referral systems,

functioning laboratory systems for more sensitive tests (eg urine LAM). Timely
diagnosis of TB among PLHIV by improved turnaround time for test results and new
POC diagnostic tests (XpertMTB/Rif Ultra, Urine LAM).
b. Adopting models of patient centered care such as anti-TB and ART optimization,
cotrimoxazole preventive therapy for TB patients who are also HIV+, integrating TB
case finding, TPT follow up, adherence support within DSM}DM service delivery
models.
c. For people living with HIV/AIDS, both 3HP and 3RH are safe to give with efavirenz-
based ART without any dosing adjustments. In adults, 3HP is safe to give with
dolutegravir-based ART without any dosing adjustment. Both 3HP and 3RH reduce
lopinavir-ritonavir and nevirapine levels. Thus, dosing adjustments are needed. So,
neither can be used together with lopinavir-ritonavir or nevirapine. As a

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 consequence, for HIV-infected children taking lopinavir-ritonavir, nevirapine, or
dolutegravir, the preferred TPT regimen is represented by 6H (preferably with the
dispersible formulation), which does not require dose adjustment 91.O: ERIC BOND/
TB prevention activities include:

a. The Ethiopian national guidelines prioritize PLHIV, children and adolescents for
treatment of latent TB infection, using shorter TB preventive treatment (TPT)
regimens: 3RH for TPT among HIV negative children <15 years exposed to TB in 2019.
In 2020, a combination of weekly doses of rifapentine and isoniazid for 3 months
(3HP), for PLHIV, will be introduced as the preferred regimen 92.
b. Strengthening TPT uptake and course completion by demand creation for TPT,
strengthening the evaluation and screening for presumptive TB, strengthening TPT
adherence, patient follow-up and pharmaco-vigilance, ensuring adequate and
uninterrupted supplies of TPT drugs

Building on the concept of Value for Money, synergies between the TB and HIV programs
include improved integration at health facility level, improving efficiencies within the
laboratory diagnostic platform and integrated sample transport system, efficiencies within
the supply chain, synergistic interventions at community level building on the HEP, PLHIV
associations and peer supporters and integrated program planning, supervision, monitoring
and evaluation. (Fig 33)

Fig 33: Opportunities for TB/HIV program synergism

6.4.6 HIV and Hepatitis B and C Co-infection

Expected Result 1: % people on ART who were screened for Hepatitis C during the reporting
period increased to 30% by 2025
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Expected Result 2: % people diagnosed with chronic HCV infection who initiated treatment
during the reporting period
HIV profoundly impacts on the course of hepatitis B & C virus infection, resulting in higher
rates of chronic hepatitis infection, accelerated fibrosis progression with increased risk of
cirrhosis and hepatocellular carcinoma, and higher liver-related mortality compared with
people who do not have HIV. Integrated management of HIV and viral hepatitis infection
should be provided, with early diagnosis and treatment of both HIV infection and viral
hepatitis infection.
A comprehensive approach is required in managing HIV and hepatitis B & C co-infection
includes:
• Integrate HIV, HBV and HCV infection prevention interventions (SBCC)
• Scaling-up the HBV and HCV screening/testing among PLHIV
• Provision of hepatitis B vaccination for non-immune HIV positive clients
• Ensure provision of tenofovir-based regimen for PLHIV who are co-infected with
hepatitis B (provided there is no contraindication to tenofovir)
• Ensure linking PLHIV who are co-infected with hepatitis C to viral hepatitis treatment
services
• Strengthen the monitoring of adherence to treatment
• Strengthen the integration/linkages between HIV services and viral hepatitis services
• Integrate the diagnostic platforms and laboratory services used for other diseases
(for diagnosis and treatment monitoring)
o multi-disease serological rapid tests (HIV, Hepatitis, Syphilis)
o multi-disease platforms for viral load testing (GeneXpert, conventional viral
load testing machines)

• Ensure inclusion of key HIV and hepatitis indicators in to DHIS2 and improve data
quality and use at all levels

6.4.7 Models of service delivery

ART is currently provided in 1100 public health facilities throughout the country. This will be
continued with expansion of differentiated service delivery models to include six monthly
refills, peer-led ART refills, community based ART service delivery including LTFU tracing,
treatment literacy and adherence and community led HIV service monitoring.
In order to improve pediatric outcomes, family centered service model will be utilized with
harmonized appointment schedules with parents and their children and the establishment
of adolescent friendly services as outlined above. There will be appropriate networking of
PMTCT only sites with ART sites for continuation of treatment and follow up after
completion of 2 years follow-up for mothers and children living with HIV. Private health
facilities have role to play in providing and complementing HIV care and treatment services,
ensuring that they are supported to follow national guidelines and also comply with
providing service reports into the health information system.
Coordination for the management of co-infected TB/HIV patients will take into consideration
the following service delivery options:

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 • For those health facilities which have a TB program but no HIV services, co-infected
TB patients will be referred to the nearest health facility where ART is available
• For those facilities where there are TB and PMTCT services, options for ART provision
linked to the PMTCT service will be considered
• For those facilities where there are both TB and ART clinics, once TB therapy has
been started, patients will be referred to the ART clinic for ongoing management of
both their HIV disease and continue their TB treatment at the TB clinic. The option of
integrating ART services at TB clinics will be explored and decided accordingly.
• The co-infected MDT TB patients will receive both services at the MDR TB Clinic
settings and be transferred to ART clinic at completion of the MDR TB treatment

6.5 Strategic Objective 5: Mobilize resources and maximize efficiencies

in allocation and utilization
6.5.1 Context

Ethiopia has had an annual economic growth rate of 10% over the past 15 years and growth
was projected to remain at around 7-8% for the foreseeable future. However, the country is
facing a pronounced economic slowdown owing to the COVID-19 pandemic. The shock is
expected to significantly reduce growth this fiscal year and next (IMF Country Report, May
2020), and is most likely to impact on the fiscal space for public expenditure on Health and
HIV over the first few years of NSP implementation.

Notwithstanding this economic context, Ethiopia has established ambitious goals for health
spending and domestic resource mobilization for health as part of its Health Sector
Transformation Plan II that has been formulated for 2020/21 – 2024/25. In recent years
Ethiopia has dramatically increased domestic government expenditure on health, primarily
through increased allocations at the regional and local levels and a renewed focus on
primary healthcare. Total health spending during 2016/17 was $3.1 billion, a 45% increase in
nominal terms from $2.5 billion in 2013/14 (FHAPCO 2020).
However, a report on achieving sustainable health finance in Ethiopia prepared by the GoE
and the Global Fund93 , describes how Ethiopia’s health sector needs are significant. At
current levels of budgetary prioritization, government resources alone will leave a financing
gap of as much as US$2.5 billion annually—or more than 50% of the resource need—by
2020 (pre-COVID-19). The report advocates for a focus on increasing the amount of
resources allocated to health and on using these investments more efficiently and
effectively.

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6.5.2 Investment trends for the HIV program

Over half (53.6%) of government spending on Health goes into the areas of infectious and
parasitic diseases (up from 46.5% in 2015, World Bank, 2016). According to the 2016/17
NHA (FHAPCO, 2020), HIV accounts for the single largest share of health expenditure (17%).

The vast majority of spending on HIV is sourced from external partners, primarily PEPFAR
and the Global Fund. Between 2010 and 2015 external funding comprised 80-90% of
funding, although this has been decreasing in recent years due to the international trend of
declining donor investments in HIV94 and increased commitment by the GoE in domestic
financing of health programs. Funding from external partners declined by more than half
from 2011 to 2017 ($197 million in 2017).

Expenditure analysis for 2018 shows that approximately 80% ($198.8 million out of a total of
$236 million), of the national HIV program expenditure was financed through external
partners, demonstrating the increasing proportional contribution domestic funding of the
national HIV program. Out-of-pocket expenditure accounted for 2% of total HIV spending in
2016/17.

Donor funding primarily supports provision of antiretroviral therapy (ART), which accounted
for 60% of total PEPFAR and Global Fund financing for HIV in 2016 (PEPFAR, 2018). The
Global Fund procures all antiretroviral drugs and almost all rapid test kits, while PEPFAR
support is primarily focused on improving quality of clinical care and treatment,
procurement of viral load monitoring pharmaceuticals and early infant diagnostics,
community-based care; key populations prevention and support for orphans and vulnerable
children.

6.5.3 Available funding for the HIV programs

A resource mapping exercise was undertaken to determine current sources and levels of
funding for the HIV response and to project expected funding for the upcoming period of
the NSP.

Due to the unpredictability of future domestic and external allocations to HIV, three funding
scenarios have been developed, to which the HIV program may have to be further optimised
based on funding constraints. (Table 10)

Table 10: Potential funding scenarios for the NSP Period

Domestic finance constrained by COVID but increases from 2% pa to 5%

growth pa by 2025
Conservative funding
PEPFAR 10% decline pa until 2025 and then constant
All other partners constant

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 Domestic finance constrained by COVID but increases to 5% growth pa by
Optimistic domestic 2025
funding PEPFAR 5% decline pa until 2025 and then constant
All other partners constant

Optimistic domestic Domestic finance constrained by COVID but increases to 5% growth pa by

funding & full 2025
partner commitment PEPFAR, GF and other development partners constant at 2021 levels

In estimating the total available funding for the implementation of the NSP, it is expected
that funding from PEPFAR will continue on its long-term trend of declining investments in
Ethiopia, by an estimated 10% per annum to approximately $72 million by 2025 in the
conservative scenario. In the optimistic funding scenario, it is expected to decline by 5% per
annum and in the full commitment scenario, funding will remain stable at 2021 levels.

Over all the scenarios, the Government of Ethiopia expects that funding from the Global
Fund will remain stable at approximately $88.5 million per annum (including a contribution
of $2.5 million from the HSS grant). A number of other development partners play a
significant role in supporting the Ethiopia HIV response, including UNAIDS, and these
contributions have been aggregated and estimated at approximately $7 million per annum
and expected to remain stable over the NSP period.

Domestic resources for HIV comprise funding from the public sector (health and other
sectors) and the private sector. For the conservative funding scenario, domestic funding for
HIV is expected to increase by a modest 2-5% over the NSP period to current economic
context in Ethiopia. In the optimistic and full commitment scenarios, it is expected that
domestic resources will increase according to the Ethiopia Domestic Resource Mobilisation
Strategy (DRMS), which outlines a number of tactics that will be implemented to mobilise
additional funding for HIV over the next 5 years (described further in the section below).
This is expected to contribute an additional $58 million in domestic funding over the 5-year
period.

The expected available funding for HIV over the NSP period, under the conservative funding
scenario, is shown in table 11 below. Available funding will decrease from $236 million in
2021 to $214 million in 2025. By 2025, domestic funding is expected to comprise 23% of the
HIV budget.

Table 11: Projected funding by source, 2021/22 - 2025/26, conservative funding scenario

Source 2021 2022 2023 2024 2025

Domestic sources 43 44 45 47 49
PEPFAR 99 89 80 72 72
Global Fund 88 86 84 86 86
Other external partners 7 7 7 7 7

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Total 236 226 216 212 214

6.5.2 Resource needs to implement the NSP

The NSP 2021-2025 reflects a highly prioritized and cost effective response over the NSP
period. The resources required to achieve the NSP goals are calibrated to the latest
investment case modelling for Ethiopia that used the Goals models to guide a cost effective
and allocatively efficient response.
The Resource Needs Model was used as the primary tool to estimate the financial costs of
implementing the NSP over the 5-year period. The costs for each intervention are estimated
as the population in need of the service multiplied by the coverage (the percentage actually
using the service) multiplied by the unit costs. Unit costs were computed from a mix of
sources, primarily published studies, HAPCO and development partner budgets, HAPCO
procurement and expenditure data and additional ingredients-based costing for some
interventions. For some interventions, efficiency savings were factored in to the unit cost
computations to reflect planned technical efficiency interventions by government (for
instance community led delivery models for key and priority populations and efficiency
gains in procurement and distribution of ARVs and condoms). Interventions for most social
and program enablers were estimated as annual fixed costs.
Figure 34: Annual resource needs for HIV 2021 – 2025 (USD)

The annual resource needs for the NSP increases from $267 million in 2021 to $299 million
in 2025 (12% growth). This annual increase is largely driven by scaling up prevention and
treatment services to reach more people, so that the NSP goals can be reached.

Over the 5-year period, primary prevention interventions will drive 15% of financial resource
needs, HIV testing 11%, PMTCT 8% and care and treatment services, 39%.

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The annual cost of prevention almost doubles over the period (91% increase) as coverage of
combination prevention services for key and vulnerable populations is rapidly scaled up.
Resource needs for HIV testing also increases, notwithstanding those efficiencies will be
sought through more targeted testing strategies to increase testing yields.

The resources required for care and treatment increases by only 8% over the NSP period,
even though the number of people on ART increases by 77,000 (16%), due to expected
efficiencies in differentiated service delivery.

Additional increases in resource needs would be needed to scale up programs to reduce

stigma and address violence against women. The cost of OVC support interventions decline
by 22% as the number of AIDS-related orphans is projected to decline.

The NSP calls for greater investment in the 5 pillars of prevention, and in particular
combination prevention programs for key and priority populations.

Sex worker interventions comprise 8% of the prevention resources required and other key
and vulnerable populations, 14% of the total. Condom programming comprises 32% of the
total cost of prevention, notwithstanding expected efficiency savings in the delivery and
management of the program (after benchmarking the baseline unit of expenditure to
regional averages). PMTCT drives the largest share of the prevention cost, at 36% due to all
pregnant women attending ANC who do not know their status receiving the HIV testing
service.

Table 12: Costs of Prevention interventions

2021 2023 2025

PMTCT 24 504 580 24 206 643 23 885 003
Condom promotion 16 402 373 21 825 315 26 312 216
VMMC 997 400 997 400 997 400
STI prevention/ treat 3 248 335 4 598 976 5 947 618
SBCC 1 040 628 1 665 004 1 665 004
FSW PrEP 278 167 1 390 835 2 503 504
FSW services 2 325 633 4 295 962 5 814 084
Key and priority pops 5 336 591 9 778 291 13 371 310
Total 54 133 707 68 758 426 80 496 139

Financial gap

The annual funding gap is calculated by comparing available funding with financial resource
needs over the period of the NSP.

The figure 35 below shows that under the conservative funding scenario, the financial gap
increases steeply from $30 million in year 1 to $72 million in year 5, as universal coverage of

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key and priority populations are reached with services from the 5 pillars of prevention as
Ethiopia gets closer to supporting 95% of PLHIV with life-long ART. Significant further
optimization of prevention programs would need to be undertaken if this scenario
materialize and over 9000 additional new infections may result.

However, if the targets of the DRM strategy are met, then approximately 72% of the funding
gap would be reduced. In the full commitment scenario, only a small funding gap would
remain by year 5.

Figure 35: Resource needs, funding and gap by scenario (USD $ millions)

350

300

250
Millions

200

150

100

50

-
1 2 3 4 5

Optimistic domestic funding & full commitment from partners

Optimistic domestic funding increment
Conservative funding
Gap with full commitment
Gap with conservative funding

6.5.3 Sustainable financing of the response

The financial gap analysis shows that it is critical, for the sustainability of the HIV program,
that the GoE successfully achieves, and more ideally, exceeds its domestic resource
mobilization targets, whilst its development partners continue to invest strategically and in
a well-coordinated manner with GoE.

With economic growth severely impacted by COVID-19 in the short-term, and fiscal space
for health under pressure by other sector needs to address, inter alia food security,
domestic resource mobilization will need to be well-executed to achieve its goals.

As outlined in the DRMS, meeting the challenge of fully funding the NSP will require a
combination of approaches, namely:

1. Mobilizing additional public sector funding for HIV and reprioritizing existing health
budgets

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 2. Leveraging other health financing mechanisms, including community health
insurance and private sector financing options
3. Improving allocative and technical efficiencies in service delivery
4. Co-ordinating strategic investments with external partners
5. Investing in financial systems and capacity

These strategic approaches are further elaborated below.

Mobilizing additional public sector funding for HIV and reprioritizing existing
health budgets

The following describe the 10 public resource mobilization initiatives (see Table 9):

1. Increase allocation of general government revenue to health, and specifically HIV,

at federal and regional levels

FHAPCO, the MOH, regional HAPCOs (RHAPCOs), and regional health bureaus will
strengthen advocacy and negotiation efforts, using evidence from the Investment Case
approach of the NSP, to secure an increase in budget allocations for the HIV program from
the Ministry of Finance (MOF) and regional finance bureaus. Annual budgets should
increase progressively over the 5-year period, from US$0.7 million to US$9.1 million at the
federal level and US$1.2 million to US$7.3 million at the regional level. The government
budget allocation will be negotiated and tracked through evidence based communication
targeting key stakeholders.

2. Reprioritize public budgets to spend effectively

The GoE can increase fiscal space for HIV programs through ensuring that public health and
sector budget allocations are performance-based and aligned with the priority
interventions, populations and geographies described in the NSP. Funding for ineffective or
under-performing activities should be reprioritized during the annual public budget cycle.

3. Improve management and targeting of funds mainstreamed for HIV within priority
sectors
Government offices in 10 strategic sectors should allocate at least 0.2% of their budgets to
HIV, including from the contract value of infrastructure projects. This will generate
approximately US$32 million over the 5-year period, which will be used to target the
beneficiary key and priority populations of each sector with services, including
comprehensive HIV prevention, testing, and linkage to care and treatment. Legal
frameworks and guidelines will be developed. Ten strategic sectors’ capacity will be built to
implement package of HIV prevention interventions targeting key and priority populations
within their mandate. In addition sectors might use social contracting arrangements with
the civil society organizations and the private sector to deliver packages of HIV services to
key and priority populations.

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Mainstreaming Type Strategic Sector Office Key and Priority Populations
Social sector Ministry of Labour and Social Workers in hotspot areas;* people
mainstreaming Affairs (MOLSA); regional bureaus living with HIV
and woreda offices
Ministry of Women, Children, and Adolescent girls and young women
Youth Affairs; regional bureaus Female sex workers; widowed and
and woreda offices divorced women
Transport Authority; regional Distance drivers
bureaus and woreda offices
Federal and regional prison Prisoners
administrations
Education sector: Ministry of Adolescent girls and young women
Education; regional bureaus and
woreda offices, Ministry of
Science and Higher Education and
technical and vocational training
agency; colleges
Infrastructure Ethiopian Roads Authority; Workers in hotspot areas and
mainstreaming regional offices female sex workers in their project
catchments
Government Development Workers in hotspot areas and
Enterprises Agency and its entities female sex workers in their project
(Sugar Corporation, Construction catchments
Corporation, Design Works and
Supervision, Metal and
Engineering Corporation)
Ministry of Construction and Workers in hotspot areas and
Urban Development its projects female sex workers in their project
and line offices catchments
Ministry of Mines, Petroleum, and Workers in hotspot areas and
Natural Gas; regional offices female sex workers in their project
catchments
Ministry of Water, Irrigation, and Workers in hotspot areas and
Electricity female sex workers in their project
catchments

Leveraging other financing mechanisms, in the form of voluntary employee

contributions, earmarked taxes and private sector financing options

1. Increase voluntary contributions of public and private sector employees in the AIDS
fund

In coordination with FHAPCO, voluntary participation of an estimated 65% of employees in

the government sector offices and 40% among private employers (40%) will congtribute to

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the AIDS Fund. The recommended contribution will be 0.2% of pre-tax salary, generating
an estimated US$36 million over 2021–2025. The legal framework and guidelines will be
developed and robust communication and advocacy will be conducted to enable
government and private institutions to enrol their employees into AIDS fund, deduct
payroll contributions monthly and transfer contributions to priority HIV programs of
HAPCO and the health sector through Ministry of Revenue and its regional offices.

2. Implement an earmarked tax on the profits of large public and private enterprises.

To ensure sufficient domestic financing of HIV, a new tax on large public and private
enterprises will be implemented and specifically earmarked for the HIV program. The tax
will apply to companies with an annual income of ETB 100 million or more and be
equivalent to 0.2 percent of taxable income, mobilizing an estimated US$93 million over
the 5-year implementation period. The legal framework and guidelines will be developed
and robust communication and advocacy will be conducted targeting public enterprises
and private companies. Earmarked tax will be collected through Ministry of Revenue and
its regional offices to finance priority HIV Program interventions and commodities.

3. Strengthen private health sector engagement in the provision of HIV testing,

counseling, and treatment services

Increasing the number of HIV patients able and willing to seek services in the private sector
will reduce the saturation of public health facilities and financial burden on the
government. Developing mechanisms for private sector facilities and patients to provide at
least partial cost sharing for commodities can provide a more sustainable source of
commodity financing.

4. Explore the potential for eventual integration of HIV services into social and
community-based health insurance benefits packages

Expansion of health insurance coverage is a central component of Ethiopia’s ongoing

health financing reforms and proposed Health Care Financing Strategy. Although only
covering approximately 11% of the population in 2018, CBHI and SHI are still seen as a
primary conduit for mobilizing new resources and achieving financial protection by the
GoE.95

Integration of HIV and other exempted services into the benefits packages of prepayment
schemes is critical to ensure their long-term financing. However, further investigation into
the implications for the scheme’s financial sustainability is needed. Therefore, during the
strategic period feasibility of integration of the HIV services into the insurance schemes will
be explored and consensus will be built on its implementation.

Improve allocative and technical efficiencies in service delivery

Allocative and technical efficiency are two dimensions of the Value for Money Framework
adopted by the NSP.

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Allocative efficiency

Allocative efficiency refers to allocating investments by intervention, geographic area and

population to maximize cost-effectiveness and impact of the HIV program.

The core programs of HIV testing, treatment, VMMC, condoms and prevention services for
key populations have shown to avert substantial numbers of new infections and AIDS deaths
if an appropriate enabling environment is in place. Modelling of the impact of implementing
the NSP 2021-2025 as part of the Ethiopia Investment Case for HIV (2020) demonstrated
that it could avert 31,000 new infections during the period at a cost per infection averted
(undiscounted) of approximately $11,000.

Testing and treatment are the most cost-effective interventions since they are together cost
saving over the period 2021-2025.

While treatment programs are needed everywhere there are PLHIV, prevention programs
will be more cost-effective in the high incidence woredas defined as an incidence >0.03%.
These 265 woredas account for about one-third of all new infections and thus constitute a
geographic core where prevention interventions should be scaled up first to achieve
maximum cost-effectiveness

Using surveillance to strategically target high-value, high-impact interventions towards

woredas and priority populations where impact will be greatest will increase the allocative
efficiency of the response.

Technical efficiencies

Technical efficiency refers to optimizing the delivery of each service to provide quality
outputs at the lowest possible cost. Improving the efficiency of the delivery of HIV services
will result in improved outcomes and, in some settings, financial savings which can be re-
invested into NSP programs.

Strategies that will be prioritized to achieve greater technical efficiencies and thereby
improve the return on investments include more targeted testing, expanding differentiated
ART, and establishing additional adherence clubs in facilities and communities. Table 13
below summarizes current efforts and opportunities for further technical efficiency gains in
the national HIV program.

Table 13: Public resource mobilization initiatives

Population/ Economy/ technical

Explanation
Service Area efficiency intervention

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Population/ Economy/ technical
Explanation
Service Area efficiency intervention
Scale up Flexible and efficient CSO Fixed Drop-In Centres for KPs may be inefficient in
services for key led models of delivery in some areas that have lower demand.
populations communities CSOs are better placed for demand creation,
linkage to care and adherence support, leading to
increased productivity of resources and
intervention outcomes.
Moving towards universal access for key and
priority populations would generate efficiencies
through scale.
Integration of HIV Integration of HIV prevention into Community
prevention into Care Coalition activities, as well as into activities of
community activities community associations and religious structures
Strengthen public sector Ensure non-health sector interventions for HIV by
mainstreaming of HIV other public agencies are optimised and more
Scale up through civil society targeted through facilitation from experienced
services for key support civil society partners
and priority
populations Community-based PLHIV associations and networks to increase
adherence treatment literacy and support to increase the
cost-effectiveness of ART
Community-led Community monitoring should reduce stock-outs,
monitoring stigma and discrimination and increase targeted
investments to improve effectiveness and impact
of HIV program
PMTCT Integrating PMTCT with Continue integration of PMTCT with other clinical
MNCH services as well as HIV and MNCH services
PMTCT+ with ART. Universal HIV testing of pregnant mothers ensures
a human-rights approach to HIV prevention and
care (In 2018, only 43% of facilities had 1 or more
HIV+PW. Of those facilities, 65% had <10 cases).
PrEP Scale up intervention in Efficiencies expected through scale and integration
eligible groups with other clinical prevention services
Increase efficiency of program through enrolling
those with substantial risk and use peer service
providers for recruitment, screening and
adherence support.
VMMC Integration Transition from vertical program to integration
into primary health care service

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Population/ Economy/ technical
Explanation
Service Area efficiency intervention
HTS Index case testing Scale up index case testing and Partner
Notification Strategy

Risk assessment screening Increase HIV yield through PITC with the rigorous
tool use of a Risk screening tool for all ages

ART Scale up switch to most Efficiency savings already achieved from unit cost
cost-effective 1st line reductions in drugs and commodities through
regimen (TLD) higher volumes and better demand predictability
provided by MoH/ HAPCO to suppliers.

Continued scale up of switch from TLE to TLD will

generate efficiency savings, not only from the
lower price of the fixed dose combination
regimen, but also due to increased effectiveness of
viral suppression and reduction in patient
transitions to 2nd line treatments. 96
ART Differentiated Service Early experiences in Ethiopia and regional studies
Delivery: show potential for reducing program costs and
Multi-month scripting Out-of-pocket expenditure and improving quality
of care.97
Community Pick-up Points
Appointment Spacing
Model
Health system Integration of services Integration of TPT into HIV clinical care package
HIV testing integrated with TB/STIs/VMMC
A number of studies show increased cost
effectiveness and cost savings from integrating
HTS, ANC, PMTCT, FP, HIV care etc., although
mostly at a pilot level or modelled.98
Health system Procurement and supply Continue process to integrate pharmaceutical and
chain management logistics management, including RDT kits and
condoms
Refine quantification assumptions and increase
forecast accuracy
Expand long-term framework contracts for HIV
commodities and medicines to prevent supply
chain disruptions, reduce emergency procurement
and reduce stock expiry

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Population/ Economy/ technical
Explanation
Service Area efficiency intervention
Health system HRH Optimisation and Levels of efficiency varies significantly across
productivity at PHC facility districts, and a study showed that up to 50% may
level be inefficient.99
For instance, absenteeism in the health sector
in Ethiopia is around 10%, far lower than other
countries in sub-Saharan Africa.100
Health system Improve budget efficiency Strengthen co-ordination and joint planning with
development partners to ensure optimal
allocation and utilisation of resources
Strengthen PFM to ensure that allocated funds are
expended on the intended budget area.
Routinize monitoring of VfM across interventions
and at a system level and management actions for
bottlenecks and inefficiencies identified.

6.5.4 Co-ordinating strategic investments with external partners

Although the GoE is committed to significantly increasing the domestic share of funding for
HIV over the NSP period, it’s development partners should continue to play a pivotal role in
investing in strategic areas of the HIV response to support Ethiopia in attaining and
maintaining epidemic control. The Global Fund and PEPFAR are expected to continue
playing an important but decreasingly prominent role in financing medicines, health
commodities and laboratory reagents, whilst consistently supporting the scale up of
prevention programs for KPPs. The partners should, together with the Ministry of Health,
ensure that there are no disruptions to HIV programs due to economic shocks or sudden
reprioritization decisions.

FHAPCO will play a central role in coordinating planning and investments between GoE and
its partners to sure that funding is efficiently allocated and spent.

FHAPCO will ensure the appropriate structure and staffing will be in place, and tasked to
mobilize and utilize both domestic and external resources. FHAPCO, through is resource
mobilization committee, will lean on a number of tools to achieve sustainable financing of
the HIV response, including robust monitoring and reporting systems, capable governance
structures and indicators to measure VfM across the dimensions of economy, efficiency,
effectiveness, equity and sustainability.

6.5.5 Investing in financial systems and capacity

1. Strengthen government capacity for financial management and sustainability

management

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 FHAPCO, in coordination with other key partners, will strengthen capacity at all levels of
government and across sectors to implement the domestic resource mobilization strategy
and to monitor the sustainability of the response. High-level coordination, including with
broader health financing efforts and donors, also will be critical to ensure success of the
strategy.

Advocacy and capacity building interventions to implement the domestic resource

mobilization strategy will be conducted across the various levels. The follow up and
feedback mechanisms will also be standardized and implemented. The interface of
HAPCO’s HIV resource mobilization structures with the regional and sub-regional level
similar structures of health and Ministry of Finance and Economic Development will be
designed for more efficient implementation of the strategy.

2. Promote transparency and accountability in financial management and improve

resource tracking and monitoring.

In addition to NHA and NASA studies on health and HIV expenditure, FHAPCO and MOH will
develop a standardized tool for routine tracking HIV allocations and expenditures. They will
also develop an online dashboard and database for HIV financing and programmatic data
and reporting, with analytic and data visualization capabilities.

Implementation of the domestic resource mobilization and sustainable financing strategies

will be overseen by FHAPCO and its partners, guided by supportive legal framework and an
implementation road map, which defines a set of activities and responsible parties to
implement each initiative.

The initiatives to be pursued under this sustainability agenda will represent a critical step in
achieving self-sufficiency and long-term sustainability for addressing the HIV epidemic in
Ethiopia.

Table 14: Public Resource Mobilization Targets, by Strategy and Use (US$ millions)101

Baseline Increase
Year 1 Year 2 Year 3 Year 4 Year 5
(2020) Baseline – Y5
General
Government $6.9 $7.9 $9.4 $11.8 $15.5 $21.3 $14.4
Revenues
AIDS Fund(s) $1.7 $3.0 $4.6 $6.6 $9.2 $12.6 $10.9
Targeted
mainstreaming $4.5 $5.0 $5.6 $6.3 $7.0 $7.9 $3.4
Community
Care Coalitions $1.0 $1.5 $2.0 $2.6 $3.4 $4.4 $3.4
Earmarked Tax $15.2 $16.8 $18.5 $20.4 $22.5 $22.5
Total $14.2 $32.6 $38.4 $45.8 $55.5 $68.6 $54.4

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6.6 Strategic Objective 6: Enhance generation and utilization of
Strategic Information for an accelerated evidence-based response
6.6.1 Context

Strategic Information:

The Federal Ministry of Health, FHAPCO and partners have made major progress in rolling
out systems and tools to generate and manage strategic information. These include an
upgrade of HMIS through adaptation of the electronic District Health Information System
(DHIS 2) and integration of some HIV data (PMTCT and care and treatment) into it. EMRs
deployed at higher volume health facilities have been effective in supporting the
implementation of HIV prevention, care and treatment programs. Viral Load indicators have
also been integrated from EPHI’s central electronic database for Viral Load and EID which
collects data from the VL testing centers in the country. The patient monitoring system
remains a strong data source for monitoring HIV care and treatment service and has been
integrated into the national HMIS. Monitoring and evaluation of the non-health sector
response falls fully under the mandate of FHAPCO and is implemented via the multi-sectoral
information system. In addition, several HIV surveys and surveillance activities have been
conducted, while stakeholders have deployed and trained human resources for M&E.
However, the health and HIV AIDS information system still faces a few challenges:
Obtaining reliable and high-quality data for decision-making is still a challenge owing to
marked discrepancies between routine and survey data, inadequate human resources and
nascent unique patient identification and tracking systems.
• EPI, HIV and TB data systems are yet to be merged, while segmented deployment by the
Global Fund and better funded PEPFAR implementers have led to an unbalanced HMIS
system. DHIS 2, the community information system, financial and human resources
information systems are yet to be merged as recommended globally; while key
population; unique patient identification, and social assistance information data is not
integrated inDHIS 2 leading to potential duplication and some inefficiencies in program
design and implementation. In addition, development partners such as PEPFAR and
Global Fund collect intervention data including ART, Key Populations and vulnerable
groups through their own systems and process these internally.

• There is still no reliable source for HIV sensitive social protection or social
development beyond the health sector, including the agriculture, labour and finance
sectors, hence an information system for social assistance is yet to be linked to the
HIV and health sector information system.

• Data quality assessments, M&E supervisions and validations need to be standardized

and conducted jointly. There still remain issues with data quality; the use of
numerous data collection and reporting tools, the continued use of paper-based

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 reporting; lack of unique identifiers, and inadequate internet connectivity to allow
expansion of the DHIS2.0 platform into more facilities and Woredas.

The strategic information system needs to be readied for the changing epidemic in Ethiopia by:

a. Integrating the various data sources

b. Collecting baseline indicator values for Key and Priority Populations

c. Mapping hotspots to enable better segmentation of populations, granularity and

differentiation of service delivery

d. Improving compliance in reporting through increased timeliness, accuracy and

consistency / standardization of data

Currently, strategic information for HIV is collected, stored, managed and shared through at
least eleven disparate systems and surveys, about 75% of which can gradually be integrated
into a single information system and fewer surveys for different purposes and stakeholders.
These include:

1. Ethiopian Demographic Health Survey (DHS) – conducted every 5 years

2. SPECTRUM modelling - used since 1999 to generate national HIV estimates using
EDHS and other data

3. ART & PMTCT routine program data - for monitoring the HIV care and treatment
program, and patient monitoring, aspects of which have been integrated into HMIS
since 1999

4. District health information system DHIS 2 - recently introduced to provide program

level HIV information

5. Laboratory information system - established by the Ethiopian Public Health Institute

(EPHI) to monitor viral load coverage and suppression for both adults and children. A
similar central database has been put in place for early infant diagnosis (EID).

6. Electronic Medical Record (EMR) is deployed in high HIV case load health facilities and
is used for recording patients ever enrolled on treatment, individual patient care
tracking and generation of aggregate reports.

7. Electronic multi-sectoral information system- developed in 2014 to monitor and

measure the community level HIV responses including for key and priority
populations, and interventions such as SBCC, condom distribution, workplace
interventions, HIV mainstreaming activities across sectors and care and support for
PLHIV and OVCs

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 8. National program evaluations through surveys such as the ART effectiveness study in
Ethiopia in 2009 and 2013, the midterm PMTCT program evaluation in 2014 and the
national HIV testing and evaluation in 2016.

9. National and regional Epidemiological Synthesis

10. HIV Impact Assessment (HIA)

11. Burial sentinel surveillance

12. Integrated biological behavior surveys in key populations (MARPs survey)

13. HIV Case Reporting and Recency Testing

Data Quality and Gaps

There is a scarcity of data particularly for key and priority populations. The most recent
nationally representative data available is limited to a bio behavioral survey of female sex
workers and long-distance truck drivers conducted in 2013, a rapid assessment of HIV
prevalence and behavior among prison inmates in 2013 and a survey among PWID in Addis
Ababa in 2015.

Data quality of routine program data is also an issue. Data collected via HMIS including EID
and sex, age and viral load suppression are not readily disaggregated for use in monitoring
progress toward NSP targets including analysis of HIV care and treatment cascades. Data
quality improvement activities are underway in EMR sites using standardized approach In
addition, the case base surveillance is at its infancy stage and the data quality needs to
improve. Delays in the implementation, publishing and dissemination of relevant HIV survey
and surveillance activities including IBBS for key populations and the 2016 round of the
PMTCT based surveillance has meant data has not been availed in a timely manner to
inform decision making.
Data on value for money indicators, useful to the program, is sparse and not routinely
collected.

6.6.2 Strategic Interventions

Health Information System scale up and sustainability plan: Stakeholders will collaborate to
develop a Health Information System scale up and sustainability plan (M&E Plan). Besides
integration of data and patient tracking systems (using unique identifiers or blockchain
technology 102 for patient tracking, or both), computerization of the HMIS system will be
expanded to all health facilities, and private facilities with a large volume of patients also linked
to feed into DHIS 2. This will entail a nationwide capacity building process. Data and
information sharing systems will be created at Woreda, district and national levels based on
the NSP Program Results coordination framework. An automated dashboard updating key
indicators on a quarterly basis will be shared with all stakeholders through the ubiquitous DHIS
2, available on mobile phones, tablets and computers.

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Extension of e-MRIS and DHIS; and integration LMIS, HRIS and FMIS data into DHIS 2

Using the HIS scale up and sustainability plan, an extension of the eMRIS to communities
through FHAPCO, will be simultaneously performed in collaboration with FMOH and
partners. This will include:

1. Availability of the necessary internet connectivity and equipment, including computers

to strengthen systems

2. Standardized data collection and reporting tools

3. Training and maintaining M&E personnel including at Woreda level

4. Putting in place a mentorship plan for the about 20% of health facilities that are not
incompliance

5. CBOs to contribute to the national information systems.

Linking records on the individuals from testing, care and treatment, laboratory services and
pharmacy will generate the data set for granular site management across the entire clinical
cascade – within and between facilities. Currently, 395 high HIV case load health facilities
are using Electronic Medical Record (SmartCare ART) kept at ART clinics to capture patient
enrolment and follow up information. The SmartCare ART records are regularly updated at
ART clinics. As Ethiopia reaches HIV Epidemic Control, using accurate, de-duplicated, and de-
identified patient level information becomes paramount for monitoring the performance of
the clinical cascade, and supporting longitudinal case-based surveillance.

Granular Mapping and Availing Strategic Information for Key and Priority Populations
FMoH and EPHI will revise the HIV surveillance road-map and follow the WHO
recommendations to match with the current epidemic situation of Ethiopia, focusing
surveys and surveillance activities on key populations and identify if there are other at-risk
groups, while ensuring that bio-behavioral surveys to be conducted include size estimations.

Expanded Data Quality Assessments

FMOH and FHAPCO will develop and implement data quality assessment, monitoring, and
feedback strategies, and ensure capacity at various levels to improve the quality and use of
data.

Integrating, individualizing and digitizing data collection tools

A standard set of data collection tools will gradually be expanded to be used by all
stakeholders for routine monitoring purposes; the system will gradually be evolved and
transitioned into an electronic system. Data will increasingly be individualized through
expansion of EMR, DHIS II and eMRIS to enable more accurate information collection,
analysis for use in decision-making and program improvement.

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Evidence generation: Special Surveys and Mapping of Key and Priority Populations
Currently unavailable baselines such as those for Key Priority Populations, Test and Treat
Cascade, and other data will be collected through special surveys, as indicated in the Results
Framework. The LMIS will be extended to cover at least 80% of health facilities by 2025.

Enhanced Data Analysis and Use for Policy and Decision-making

A vast amount of data or evidence will continue to be generated through the system. This
will be analyzed and applied in several ways to enhance policy and decision-making, and
enable planners to fine-tune the program periodically based on emerging evidence,
especially on quarterly results and value for money, among others. In order to assess the
effectiveness of interventions and linkages between services along the continuum of care,
analysis of the data collected through DHISII, EMRs and from other points of service will
help program and health facility managers assess the effectiveness. Such information is
essential to detect and respond to bottlenecks or gaps in program performance and to
adequately characterize and respond to patient attrition. Patient monitoring systems are
also important to support people receiving treatment over time to ensure retention in care
as they move between clinics and districts.

Emphasis will be placed on data quality, analysis and use at all levels.

The regular monitoring information system will be complemented by targeted periodic

performance reviews, supportive supervisions, and mid-term and end term program
reviews. Reports will be analyzed and summarized monthly and quarterly using the DHIS 2,
Global Fund and other dashboards for policy and decision making. Policymakers including
the Ethiopia CCM have been trained on data analysis and use for oversight and decision-
making, and this training will be extended to the Regional Health Bureaus, FHAPCO, FMOH
and senior management at all levels.

Enhanced Tracking of 95-95-95

a. FMOH and EPHI will expand case-based surveillance linked to the patient monitoring
system to enable tracking of the first 90 target as well as enable longitudinal follow
up of patient outcomes through the HIV treatment and care cascade: and into
communities. EMR data primarily used at the facility-level to guide clinical
management of patients will be used at the above site level to establish a case
surveillance system.

b. EPHI, FMoH and FHAPCO will ensure timely dissemination of HIV survey and
surveillance data to inform decision-making; more stakeholders at decision-making
level will be trained on data analysis for decision-making; and, a recommendation
tracker included in both DHIS 2 and Global Fund dashboards

c. Reducing TAT for VL testing through integration of mobile based reporting

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 d. Availing of individualized and disaggregated data to enable efficient expansion of POC
Technology

Results Framework and Indicator Reference Sheet: A Results Framework outlining

baselines, annual targets and standardizing indicators to be collected is annexed to this
plan.

Monitoring and Evaluation Plan (Annex XX) An M&E Plan accompanying this NSP Outlines
Indicator Definitions, Reference Sheets and Measurement, a description of data collection,
analysis and management processes, as well as the systems strengthening and resources
required to monitor, evaluate and report on the NSP.

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7. Social and programmatic enablers to maximize the reach and
impact of Ethiopia’s HIV/AIDS response
The multi-sectoral and social nature of the HIV epidemic highlights underlying critical social
and programmatic situations and circumstances which, if not addressed, can diminish
efforts to maximize the reach and impacts of Ethiopia’s HIV/AIDS response.

7.1 Gender and Gender based Violence

Gender inequalities and gender based violence place girls and women particularly at
increased risk of HIV infection as described in relevant sections throughout this NSP. Young
women with disabilities face even higher risks.

The span and scope of addressing gender inequalities and gender-based violence is broader
than just within the health sector. It requires multi-sectoral responses and investments and
should include gender responsive programing and gender responsive budgeting in the HIV
response. This includes training of program people on gender-responsive and gender-
transformative HIV programming and implementation.

The following interventions will be addressed over the NSP period:

Within the health sector:

• Training of health workers on comprehensive management of GBV

• Build capacity of health facilities to provide comprehensive GBV services

• Empowerment of women in health sector management including assignment to such

decision making positions

• Provide comprehensive services in health facilities for survivors of GBV that includes
but not limited to medico legal examination, HIV, STIs and Pregnancy testing, PrEP,
Emergency contraception, treatment for STIs, counseling, referral for social and legal
services.

• Strengthen school girls clubs, make youth centers and health clinics gender sensitive
and girls’ friendly and provide integrated services including psychosocial support,
HIV, SRH and GBV related services.

• Undertake community dialogue on promoting gender equality and avoiding GBV

integrated into health extension program /women to create consensus in the
community at large on severity of the problem, its causes, and possible solutions
with concrete actions to be implemented, such as issuing community bylaws to
promote gender equality and avoid GBV in collaboration with other strategic sectors.

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 Community scorecards will measure the level of GBV interventions in their
community.

• Ensure that there are clear gender disaggregated indicators to track progress in
programing and budgeting, service access, new infection and AIDS related mortality.

Through a multi-sectoral response:

• Review gaps in fully enforcing current laws and policies to inform ways of effective
implementation and/or legal and policy reforms

• Implement interventions that address the underlying/structural (social, cultural and

economic) causes of gender inequality including addressing harmful traditional
practices and social norms, increased risks because of disabilities, and empowering
women and girls through inter-sector collaboration

• Provide gender awareness training for decision makers, health service providers, law
enforcement bodies and media personal about the exiting national policy and legal
instruments to ensure gender equality and women empowerment, and to protect
the rights of women and girls and men and boys.

• Training and engagement of law enforcement bodies and Bar/Hotel owners on GBV
prevention and mitigation (schools, universities, workplaces)

• Build institutional capacity of women networks and organizations of women living

with HIV, woman most affected by HIV to ensure women’s and girls’ voices are
heard and define meaningful participation of women and girls living with and
affected by HIV.

• Strengthen linkage between health, legal and social services for GBV survivors

• Build capacity of program managers (training) to identify, analyze root cause and act
on gender disparities in service access and HIV burden

• Empower women to reduce vulnerability and increase service access

• Protection or safe houses for GBV victims or vulnerable women

• Carry out a Violence Against Children (VACS) Survey

• Undertake assessment on gender towards the end of the NSP period to assess
progress

7.2 Stigma and discrimination

Despite more than a decade on interventions and the successful treatment for HIV/AIDS,
levels of stigma and discrimination both internalized and externalized at all levels remain
high.
Interventions to address decreasing sigma and discrimination will:

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 • Educate, advocate and communicate with the public through religious and
community leaders

• Empower and engage PLHIV and their associations in advocacy and communication
to address both internalized and externalize stigma

• Engage media in communication and advocacy

• Assess health workers attitudes towards PLHIV and KPPs and train them to influence
their attitudes

• Monitor and enforce anti-discriminatory laws and regulations

• Conduct a Stigma Index Review

• Conduct community dialogue on reducing stigma & discrimination integrated into

regular programs of HEP, health/women development army and CCC.
7.3 The role of civil society, communities, PLHIVs and the private
sector

The successful implementation of programs to address the HIV/AIDS epidemic requires

eliciting joint responses from multiple levels of society. These include civil society
organizations, key and priority population groups, PLHIV themselves and their associations,
communities and the private sector.

Communities are the best way to reach key and priority populations, people living with and
affected by HIV. They have the trust of the people they serve, and community-led
organizations are the most effective way of reaching people living with HIV and key
populations. Organizations led by the PLHIV and key and priority populations, including
youth groups, are partners in the implementation of HIV prevention services, HIV treatment
and care services, community-based monitoring of HIV service quality, barriers, ARV
procurement, advocacy campaigns, human rights monitoring, and decriminalization
initiatives.

To support the implementation of the response:

• PLHIVs and PLHIV Networks of Associations will be involved in supporting program

interventions ( e.g. through peer support groups, adherence supporters) advocacy
and communication activities, monitoring program results through community led
monitoring, economic empowerment.

• Civil society organizations will play a role in supporting key and priority populations
and vulnerable groups such as orphans and KPP groups with a basket of targeted
interventions through building the capacity for possible social contracting
arrangements.

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• CBOs, FBOs, and communities partake in awareness creation campaigns to reduce
stigma and discrimination, gender based violence, and promote use of HIV services
and provision of care and support to vulnerable population groups- OVCs, PLHIVs,
and destitute women, disabled, and elderly.

• Key and priority populations will be empowered and supported to be organized

through clubs, saving groups, and peer groups based on the country’s legal context
so that they can be meaningfully engaged in the response and they contribute to the
response.

• Professional Associations will support the technical aspects of the response

• The private healthcare providers engage in the provision of HIV prevention, care, and
treatment services

• Private for profit companies create an enabling environment to mainstream HIV

prevention and control interventions in their workplaces.

• The private sector, depending on capacity and comparative advantage, will play roles
in the delivery of HIV services through different modalities, in creating enabling
environment for implementing HIV/AIDS mainstreaming and partaking in resource
mobilization. Specifically, the private sector will:

 involve in promotion & distribution of condoms and lubricants through social

marketing, retail outlets, bars and shops

 Engage in harm reduction for PWID through provision of needle and syringe
exchange services through social marketing

 Serve as alternative option for provision of HTS to general population on fee

basis

 Provide HTS and STIs service to KPPs, PMTCT and ART services, and TB
diagnosis and treatment through public private partnership arrangement.

 Support the provision of care and support to needy OVCs and PLHIVs,

 Engage in initiatives for reduction of stigma and gender based violence

 Take part in domestic resource mobilization through voluntary contribution of

0.2% from employees salary to AIDS fund, and earmarked tax of 0.2% on large
companies taxable income,

 Creating opportunities for economic empowerment of vulnerable population

groups as structural HIV prevention intervention,

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  Take part in planning, implementation, monitoring, and evaluation of the
health systems

7.4 Embracing a Human rights approach to the HIV response

In partnership with other government sectors (e.g. Ministry of Women’s Affairs, Human
Rights Commission), the following interventions will be implemented to ensure human
rights are respected and protected in HIV service provision and reduce barriers to HIV
services:

Human rights and medical ethics related to HIV for health care providers

• Training of health care providers, including facility and non-facility based, health care
administrators and health care regulators on non-discrimination, duty to treat,
informed consent and confidentiality, violence prevention and treatment;

• Development of institutional policies and accountability mechanisms for health care

facilities to respect and protect human rights

Advocacy and policy dialogue on human rights and to address policy and regulatory barriers
to HIV services

• Assessment of policy and regulatory challenges to address human rights in HIV

services and service barriers

• Advocacy and dialogue on policy and regulatory frameworks that hinder Human
rights in HIV services provision and access

• Revision of policies and legal frameworks for better address human rights in HIV
service provision and access

Sensitization of law-makers and law-enforcement agents

• Training, information and sensitization programs for parliamentarians, the General

Attorney Office, judges, prosecutors, police and traditional and religious leaders on
legal, health and human rights aspects of HIV and KPP including gender-and age-
based discrimination and inequity and on violence prevention as well as their
relation to HIV;

• Facilitation of discussions and referral linkages among service providers and law
enforcement officers to gain police support for health programs;

• Training of prison personnel (both in prisons for women and men) on public health,
human rights and HIV and HIV/TB responses;

• Assessing impact of policies/practices on informed consent and confidentiality on

access to services;

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 • Legal Environment Assessments, and community-based monitoring of laws and their
implementation in terms of their impact on health and access to services;

• Advocacy and mobilization for law and policy reform to increase KPP access to
services.

Legal Literacy (“Know Your Rights")

• Legal/patients’ rights literacy trainings and education programs for key and priority
populations through mass media, social media and digital platforms as well as
integrated in the peer learning;

• Mobilization of key and priority populations and empowerment to ensure their

voices are heard that includes supporting them to form clubs, support groups, saving
and credit associations and contribute to educate, monitor and enforce human
rights principle in programs and HIV services.

• Establishment of crisis response mechanisms to prevent abuse, including gender-

based violence at work places, bars and hotels as well as through women groups in
the communities

HIV related legal services

• Legal information, referrals, advice and representation related to HIV including

through peer paralegal community support systems and institutional support
mechanisms of lawyers associations, PLHIV associations and KPP support groups and
clubs;

• Legal services and counseling for women and girls and KPP through institutional and
community arbitration, dispute settlement mechanisms;

• Support to community forms of dispute resolution, including engagement of

traditional leaders and customary law in support of people affected by HIV and KPP

Reducing HIV- related gender discrimination, harmful gender norms and violence against
women and girls in all their diversity

• Development and reform of laws and law enforcement practices on age of consent,
domestic violence, sexual consent, early child marriage;

• Reform of family law, property, inheritance and custody laws;

• Gender assessment in HIV;

• Community consultations to identify specific gender-related barriers to accessing HIV

services;

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 • Ensure HIV service providers have the orientation to human rights

• Development of age-appropriate curriculum for sexuality and life-skills education

including gender equality;

• Address harmful gender norms and traditional practices, and gender-based violence.

Community mobilization and advocacy

• Community-led outreach campaigns to address harmful gender norms and

stereotypes and other program related barriers;

• Monitoring suspects of HIV service delivery quality, including stigma, discrimination,

confidentiality and privacy and informed consent;

 Improve the legal and KPP group mobilization

 Human rights related literacy of HIV service providers

 Strengthen community structures of the KPPs , PLHIVs with orientation to

advance their rights

 Establish a system whereby community groups have strong and building

transparent monitoring of the HIV services

 Establish community capacity/supporting community-led advocacy efforts. in

the monitoring , auditing , and reporting of HIV services

7.5 Health Systems

The six building blocks of health systems underpin the health system’s efforts to address the
HIV epidemic.

7.5.1 Supply Chain System

The importance of a well-functioning supply chain is essential in the HIV/AIDS response.

Although much has been achieved, Table 15 outlines some key challenges with solutions to
be implemented during this NSP period.

Table 15: Issues , challenges and strategic interventions in supply chain management

Issues/ Challenges/Gaps Strategic interventions

FORECASTING & PROCUREMENT
i. Lack of proper data for a. Conduct operational studies to refine
quantification: poor Forecasting quantification assumptions and increase
accuracy forecast accuracy
ii. Long process of procurement : long b. Improve procurement lead time through
strengthening framework contract, suppliers’

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Issues/ Challenges/Gaps Strategic interventions
lead time, products with low volume performance management, market intelligence
& sole supplier and product bundling
iii. Procurement of lab reagent is not in c. Pool procurement for low volume product and
bundles bundling lab reagents
d. Redefining governing laws to allow long term
contracts with reliable suppliers and enforce
access to maintenance and after sales services
in-country for any capital medical devices
DISTRIBUTION
i. Distribution disparity different parts a. Ensure data visibility at all levels across the
of the country in access to HIV/AIDS supply chain
medicines and related health b. Expand and strengthen a web based interface
technologies in public health facilities between health facility and EPSA
ii. Regimen and other program data not c. Create interface between DAGU2and HCMIS
availed to EPSA hubs: inadequate
d. Revitalize /strengthen performance monitoring
cross checking of stock consumption
team
with service-related data
iii. Upstream supply chain data not e. Strengthen the technical assistance provision to
visible at facility level facility warehouse managers and dispensing
units
iv. Lack of trust by facilities on the
f. Strengthen paper based IPLS for quality
supply system
essential logistics data and ensure regular
v. Logistics units at RHB level do not reporting
aggregate Requisition and Report
g. Strengthen supply chain data ownership and
Forms (RRF) from lower levels and
use them to provide feedback to use at all levels including at points of
health facilities, EPSA and HIV generation.
Programs h. Establish a vigilant stock monitoring system
vi. Poor and inadequate fleet i. Redesign the inventory management
management which cause delays in parameters and distribution system already in
deliveries place considering the case load/needs of
vii. Limited access to HIV/AIDS medicines facilities
and related health technologies in j. Device client cantered product redistribution
the private sector system
k. Support cross docking of bulk HIV commodities
l. Ensure the distribution of supplies to address
the need of the targeted population at
downstream supply chain levels.
m. Strengthen a system for implementing of
reverse logistics
n. Revision of LMIS tools
o. Decentralized ARV drugs distribution to
community pharmacies
p. Open the market of HIV/AIDS medicines and
related health technologies to the private
sector

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Issues/ Challenges/Gaps Strategic interventions
ART PHARMACY
i. Pharmacy professionals in the ART a. Enforce ART pharmacies to ensure rational
pharmacy do not monitor patients’ drug use is in place including good dispensing
adherence to medications using and counseling, and adherence monitoring
pharmacy record and pill count and support.
ii. Poor recording and reporting at ART b. Integrate ART pharmacy regimen data
pharmacy recording and reporting system including drug
iii. Absence of timely recording and safety monitoring with the overall information
reporting for regimen data (both system such as e-APTS
paper and electronic) c. Address human resource gaps:
iv. Data quality issue in terms of i. Train and provide mentorship to ART
timeliness, accuracy, and Pharmacy staff
completeness ii. Ensure all ART pharmacies have full time
v. Weak system in place for pharmacy professional
pharmacovigilance Weak structure d. Strengthen Pharmacy service supportive
from federal to RHBs that supports supervision
ART pharmacies and link with the
program e. Engage Pharmacies in different program
platforms (catchment area meeting, program
performance reviews…)
f. Support EFDA in addressing existing gaps
related to adverse drug events monitoring and
reporting
g. Enforce ART pharmacies to implement
strategies in prevention, management and
reporting of medication errors and adverse
drug reactions
h. Ensure all RHBs have ART pharmacy services
focal person in in the supply /pharmaceutical
management core process/team

OTHER HIV RELATED COMMODITIES

i. Problem of defining clear budget a. Design sustainable financing model for such
source for HIV health commodities commodities in collaboration with partners
(OI, STI and haematology, chemistry,
CD4, Nutrition, hepatitis, etc..)

RTKs

i. Not properly integrated in to IPLS a. Enforce and follow the implementation of RTK
ii. Facilities are not using RRF that integration in to IPLS
integrated service and logistics data b. Rationalize distribution channels
iii. Poor data quality of RRF: timeliness, c. Establish a standard regulatory capacity to
accuracy, and completeness conduct or evaluate test kits quality at
iv. Pack size for RTK: Existing pack size national level
of RTKs not suitable for d. Consider supply chain implication of test kit
decentralized distribution to all pack size in the algorithm development

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 Issues/ Challenges/Gaps Strategic interventions
testing units process
v. Shortage of RTKs due to poor e. Align RTK pack size with the number of testing
targeting (Risk screening tool is not sites
used fully and/or consistently) f. Ensure implementation of targeted testing
vi. Lack of guidance and through regular use of Risk screening tool
implementation modalities for fee g. Engage the private sector: Establish system for
based RTK access for general fee based access of RTK and HTS for general
population population

CONDOMS
i. National Condom strategy not yet a. Speed up implementation of national condom
implemented strategy
ii. Existing procurement and i. Develop implementation guide
distribution system not addressing ii. Ensure private sector engagement and
condom shortage issues (the public total market approach
source)
b. Install proactive condom market authorization
iii. Repeated product quality problems Improve procurement and distribution of
within public source procurement public sector condoms
affecting also utilization of allocated
budget from government sources

Other proposed measures include:

• Streamline procurement procedures that EPSA has to follow

• Effective coordination between EPSA, EFDA, FHAPCO and partners to expedite

procurement

• EFDA’s quality assurance laboratory, advocate for improvement and ? accreditation

• Supply Chain Policy: There is a need to draft clear guidance on supply chain functions
of private sector engagement

• Streamline and increase capacity of EFDA’s quality assurance procedures which

currently result in lengthy delays in market authorization for HIV testing commodities.
Developing policy to cost value of supply chain functions of private sector with
ultimate goal of offloading public pharmacies by engaging private sector in the
distribution of ARVs.

• Implementing fast track market authorization for priority commodities

• Design and implement community led monitoring of supply chain need of ART clients

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7.5.2 Laboratory System

The Ethiopian Pubic Health Institute is an autonomous institution overseeing laboratory

systems, surveillance, research, public health emergencies, nutrition and vaccine
production. Key functions in support of the HIV/AIDS response include HIV research,
developing/validating the national testing algorithm at regular intervals, EID, viral load,
biochemistry, and hematology tests associated with HIV treatment, quality assurance and
ARV drug resistance surveillance. ARV drug resistance surveillance is part of a regular
program implemented in 13 sites and linked with VL testing labs.

There are 26 labs currently measuring VL. Machines are purchased through long term
framework service agreements. VL samples are collected as plasma and require cold chain
transportation which is undertaken by the post office. Once VL tests done, the results are
transferred back to these ART sites via the Electronic Test Ordering and Result Reporting
System (ETORRS).

Strategic Interventions:

 Rationalize placement of multiplex platforms and consider alternate POC

technologies for low volume health facilities with limited laboratory staff. here are
340 GeneXpert machines which can be used for EID and VL. There are 190 PCR
machines for EID with a 40% utilization rate.
 Viral load and EID reagents are procured through PEPFAR and Global Fund. HIV RTKs
are procured exclusively by the Global Fund whereas CD4, hematology, and
chemistry reagents are purchased by MOH through SDG pooled fund.
 ARV drug resistance surveillance is part of a regular program including early warning
indicators (EWI) of HIV drug resistance is implemented in 13 sites and linked with VL
testing labs.
 Integrated Sample Transport System: There is an integrated specimen collection
and transport system for specimens for HIV and TB laboratory including VL, CD4,
DBS, hematology, chemistry, specimen for culture tests. Transport is based on the
Ethiopian Postal system with specimens transferred to the nearest referral
laboratory using a trans-regional approach; a referral laboratory may service
facilities in one or more regions. Test results sent back to health facilities.

There are delays and inefficiencies at different points of this system.

1. At the site of collection, those health facilities with high volume have pre-
scheduled sample collection twice per week by postal service while samples from
low volume health facilities use call based specimen collection by postal services.

2. The postal service uses public transport system which not only experiences
delays but may affect the safety and integrity of the specimen as it gets
transported with passenger goods.

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 3. At the referral laboratory level there are delays by waiting until the specimen
reach batch size to run the test, frequent power supply interruptions and
shortage of fuel to put on the generators, shortage of reagents, delayed
maintenance of laboratory equipment and lack of back up equipment, high
turnover of trained staff, and engaging the laboratory staff in training and other
assignments can result in delay in carrying out the tests.

4. There is delay in communicating the test results to the health facilities due to
poor communication infrastructure including internet connectivity.

A well-functioning sample referral system is important especially for EID, VL and TB

diagnosis. The ways to reduce the delays is by optimizing the transport system,
enhancing testing activities at referral laboratories including working at off office hours
and weekends and expanding the Electronic Test Ordering and Result Reporting System
(ETORRS).

The following specific measures that improve HIVAIDS outcomes will be considered in
this NSP but other inputs also need to be addressed through the HSTP II:

1. Strengthening the framework contracts with suppliers specifically for PCR and
GeneXpert machines as well as strategically purchasing more laboratory
equipment where it can eb demonstrated that there is a need.

2. Strengthen IPLS for lab commodities with end to end visibility of stocks for lab
supplies and reagents from EPSA to hubs and health facilities with dashboards to
EPHI, regional health bureaus, and referral laboratories.

3. Alternatives to the sample transport system by the postal service need to be

explored, specifically engaging the private sector.

4. Strengthen performance monitoring of laboratory referral system by using

scorecard at each level

5. Training of laboratory staff and postal service workers on maintaining sample

safety and quality as well as reviewing staff deployment based on workload,
including extending workhours; Install a staff motivation mechanism

6. Expand electronic test ordering and result reporting system by building (ETORRS).

• Establish a proper monitoring mechanism for decentralized laboratory

services

• Engaging more facilities for HIV laboratory accreditation

• Develop laboratory test menu and train supply chain cadres at all levels

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  Enforce bundled procurement of laboratory commodities

 Design and implement bundled storage and distribution

• Review and enforce relevant inventory management model for lab

commodities

• Strengthen the laboratory quality control system

• ARV Drug resistance study

7.6 Human resources for health/ HIV response

7.6.1 Context

The HIV governance structure is inadequate, varies across regions and lacks human
resources jeopardizing the HIV response leading to weak coordination at federal and
regional levels This is especially evident at zonal and woreda levels. Additionally staffing
does not take into consideration the HIV burden across woredas. There is no clear
documentation regarding the optimal structure and staffing at various levels.

Trainings are provided to HIV experts at program management and service delivery areas,
but there is no proper documentation which enables tracking and use of trained staff as well
as the planning and implementation of trainings and capacity building efforts.

7.6.2 Strategic interventions

• Conduct a study to understand the current HIV related HR capacity at program

management and service delivery levels

• Develop and implement an HR strategy, tailored to current strategic directions and

HIV burden, aligning with the HR development strategy of MOH and in line with the
country’s goal of attaining sustained HIV epidemic control

• Design strategies for Human resource capacity building efforts including in-service
trainings

• Design and Scale up cost efficient training approaches including modular on line
trainings, and on job trainings

7.7 Governance, leadership, coordination and accountability

Ethiopia’s success over the past fifteen years in addressing the HIV/AIDS epidemic has
paradoxically resulted in decreased attention by political leadership as other priorities are
raised higher on the political agenda. However, the progress made to date remains fragile
and gains can be easily reversed.

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During the strategic period the HIV governance, policy and coordination structure will be
strengthened to ensure effective multisectoral and community HIV response.

The National AIDS Council (NAC), chaired by the President, has a multi-sectoral membership
and is the highest national body overseeing the country’s response to HIV/AIDS. The
mandate and oversight function of the NAC will be revised to not only engage leadership
but also to ensure accountability at all levels. Within a federalized system, Regional AIDS
Councils will be reactivated to galvanize local efforts, engage communities and also oversee
accountability at regional level.

Federal HIV Prevention and Control Office will continue to lead the multi-sectoral response.
Federal and Regional HAPCOS structure and mandate will be revised to effectively respond
for the epidemic. FHAPCO will be strengthened with human resources and its capacity will
be built to implement the strategy and realize sustained epidemic control..

Required human resources will be deployed within the Federal Ministry of Health, Regional
and Woreda Health Offices to effectively lead and coordinate the HIV response. The Woreda
Health Offices will assign at least one full time HIV Program Coordinator and two additional
experts (one for KPP program and one for Planning, M&E) to effectively coordinate the HIV
response in the woreda. The Woreda HIV Program coordinator based in the woreda health
office will be responsible to coordinate the sectors and community HIV response including
peer service providers program, DIC and outreach programs. The Health Extension Workers
role in HIV response will be strengthened with revision of the HIV module and strengthened
accountability mechanisms.

Strategic sectors will revise the structure, staffing and budget for HIV mainstreaming to
effectively implement HIV programs targeting KPP within their mandates.

MOH/RHBs and FHAPCO/RHAPCOs will have regular meetings to coordinate the HIV
response between health and non-health sector actors. The clinical and non-clinical teams,
including the pharmacy sector, under RHBs will have at least a monthly meeting to ensure
communication and coordination of the HIV response. The woreda based and multi sectoral
planning and review process will be integrated to ensure on plan and monitoring
framework.

The National Prevention Advisory Group and Technical Working Groups established for
different components of the HIV programs will be strengthened to ensure optimizing the
quality of programing and coordination among the government, CSOs and development
partners.

Partnership forums for government, CSOs, NGOs, Media and other actors will be
strengthened to ensure coordination and synergy among different actors at all levels.

Policy directives with accountability frameworks need to be developed to clearly define

sectoral involvement in the AIDS response.

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At community levels, civil society, KPPs, community based organizations; PLHIV Associations
will be involved in the monitoring of the HIV/AIDS response.

7.8 Policy
7.8.1 Context

Ethiopia’s apparent success in mitigating the Some Relevant Policies and Guidelines
impact of HIV is made possible by a political • National HIV/AIDS Policy 1998
commitment of the highest level. Such
commitments were expressed, among others, • Health Sector Transformation Plan
(HSTP II) draft 2020
by way of issuing an AIDS policy, establishing a
national organ to coordinate the response to • Policy on Ethiopian Women 1993
the epidemic and setting up governance and • Condom Strategy 2019
coordination mechanisms at national,
subnational and community levels. However, • Domestic Resource Mobilization
Strategy 2020 – to be endorsed and
despite changes in the dynamics of the legal framework established by
epidemic and the periodic introduction of a Parliament
variety of arsenals for HIV prevention, care and
• Multisectoral Policy on Illicit Drig Use
treatment, there is very little or no progress to (to be developed)
appropriately tailor the policy and governance
• Supply Chain Policy (to be developed)
arrangements. Many are of the opinion that
this may be have resulted from the program’s • There are multiple guidelines reflecting
heavy dependence on external funding and the the various components of HIV testing
care and treatment
fact that ART has transformed the face of AIDS.

The national polices and guidelines for HIV care and treatment encompass a broad range of
protocols that include HIV testing services, linkage to treatment and care, the initiation,
monitoring and follow up of patients on ART, and management of opportunistic infections
affecting PLHIV and the guidance for service delivery.

Ethiopia issued its AIDS Policy in 1998, nearly 12 years after the first case of AIDS was
reported in the country. Whereas relevant policies and laws have direct impact on the lives
of, PLHIV including stigma and discrimination, social and legal protection, efforts to address
such challenges are fragmented.

One singular example that demonstrates the gaps in HIV policies and laws is the
disproportionate burden of HIV among women. The government of Ethiopia has issued the
national policy on women (1993), revised the family law (2000) and the penal code (2006) as
part of measures to address gender inequities, provide legal protection and enhance
women’s access to services. The current family law (revised in 2000) raised girls’ minimum
age of marriage to 18 years, while the Penal Code (revised in 2005) criminalizes acts of
violence against women, including child marriage and abduction.

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Although advocates for women’s rights raise a number of arguments to prove that these
polices and laws are incomplete, changes in the laws alone could only improve women’s
lives when they are fully enforced. Violence against women abound in family circles, in the
streets, schools and workplaces. Few women are able to access the legal system. Gender
disparity in education, employment and income levels compound to disadvantage women in
every aspect of life, including exposure to HIV, STI and other health conditions and health
care seeking behavior.

A number of other issues related with HIV services that may require a policy framework
include, discrimination in employment and workplaces, age at consent for HIV test and
disclosure of status, parental refusal to disclose children’s HIV status and initiate treatment,
and a regulation on assignment of university entrant youth on ART.

7.8.2 Strategic Interventions

• The AIDS Policy was developed twenty years ago and does not currently reflect the
nature of the HIV/AIDS epidemic. Policy updates related to KPP groups, human
rights, gender and stigma and discrimination, drug policy, public private
partnership, age of consent for testing, HIV mainstreaming, domestic and external
resource mobilization, roles of communities, are among the areas to be addressed
at the revision of the policy. Revision of the AIDS Policy should include a gender
perspective and be in line with international conventions.

• Undertake HIV policy analyses to address policy related barriers to HIV services and
inform corrective measures

• Examine gaps in enforcement of relevant laws affecting gender and advocate for
improved enforcement and legal reform as deemed fit.

7.9 Partnership, Multisectoral Collaboration, Civil society and the

Private Sector
7.9.1 Multisectoral Collaboration

In line with the current nature of the epidemic and with the focus of this NSP to address the
key drivers of the epidemic, it is essential that key sectors and their regional counterparts
are involved in the response. The priority sectors will be:

• Ministry of Education and Regional Bureau of Education

• Ministry of Science and higher education
• Ministry of Women, Children and Youth Affairs and Regional counterparts.
• Uniformed forces
• Ministry of Water, irrigation and and Energy and regional counterparts
• Sugar Corporation

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 • Ministry of Mining and regional counter parts
• Ministry of Transport and regional counter parts.
• Ministry of urban, housing and construction
• Prison administration
• Jobs Creation Commission
• Ministry of Finance and Economic Cooperation
• Ministry of Labor and Social Affairs
• Ministry of Agriculture and regional counterparts
• Privatization and public enterprises supervising Agency
• National and Regional media

The key sectors Ethiopia are selected by the comparative advantages they have to address
HIV prevention interventions across segments of the general population or key and priority
population groups. They can be divided into four groups:

1. Sectors which primarily serve populations considered priorities for the HIV response
e.g.,., Ministry of education, Ministry of science and higher education, Ministry of
Women, children and youth, Ministry of Defense, the media sector

2. Sectors which by design have the access to routinely reach populations e.g. the
media sector, Job Creation Commission

3. Sectors which by virtue of doing development activities deploy workers in various

hot spot areas. Ministry of mining, transport, road authority, sugar corporation,
Ministry of Water Resources and Energy, Ministry of urban, housing and
construction, Ministry of Agriculture

4. Sectors which coordinate and oversight key sectors e.g. Privatization and
public enterprises supervising Agency, MoFEC

Sectors which have mainstreamed HIV are required to include meaningful planning on HIV,
allocate budget for execution of the HIV plan, assign structure and staffing to carry out the
HIV plan, conduct risk assessment, and monitor and evaluate implementation of their HIV
response.

Lack of ownership and commitment by the leadership, poor planning, monitoring and
evaluation, investment of the allocated budget for interventions limited only to the
permanent staff of the sectors, leaving out the populations which they deploy for
development activities are among the gaps of implementation of HIV mainstreaming.

Key strategies and interventions

• Reposition HIV mainstreaming to ensure strong ownership by the highest leadership

as well as by the leadership of respective sectors

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 • Build capacity of Key sectors in the planning, implementation and monitoring and
evaluation of their HIV interventions

• Enhance HIV mainstreaming across key sectors aiming to reach key and priority
populations

• Integrate HIV indicators in the routing information systems of key sector

7.9.2 CSOs, FBOs and CBOs

Civil society and community based organizations, including PLHIV Associations have an
essential role to play in the response at all levels: involvement in planning at all levels,
implementation of programs among various populations, supporting linkage and adherence
to treatment, resource mobilization and monitoring of the response.

There is also a specific and important role for faith based organizations to support evidence
based interventions outlined in the NSP and work in partnership with the health sector to
ensure that their congregations adhere to treatment.

Through this NSP, civil society organizations will play a role in supporting key and priority
populations and vulnerable groups such as orphans and KPP groups with a basket of
targeted interventions through building the capacity for possible social contracting
arrangements.

Key and priority populations will be empowered and supported to be organized through
clubs, saving groups, and peer groups based on the country’s legal context so that they can
be meaningfully engaged in the response and they contribute to the response. KPPs will
engage in peer education, life skills, risk reduction, reduction of stigma & discrimination, use
and promote use of HIV services by their peers, undertake community led monitoring,
partake in design, monitoring & evaluation of the response.

7.9.3 Strategic interventions

• Build capacity of CSOs across high burden geographic areas

• Standardize a set of activities which CBO. CSO, FBOs can undertake which include:
demand creation, linkage to health facilities, support adherence and trace LTFU

• Link the CSOs HIV response activities for KPPs with the health program management
and general population

• Engage in stigma reduction campaigns

• Undertake community led monitoring (service access, quality, stock outs, user
friendliness of services)

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 • Engage in creating community support system for care & support of needy OVCs
• Engage CSOs, CBOs and FBOs in the planning, implementation, monitoring and
evaluation of the HIV response

• Strengthen coordination platform for community based response

7.9.4 Community-Led Monitoring (CLM)

Community-led monitoring describes a technique initiated and implemented by community-

based organizations and other civil society groups; networks of key populations, people
living with HIV and other affected groups; or other entities that gathers quantitative and
qualitative data and observations about components of HIV services, with a focus on getting
input from recipients of treatment services.

This NSP will support community level groups to undertake CLM that will diagnose and
pinpoint persistent problems, challenges, and barriers to effective service and client
outcomes at the site level. Most importantly this collaboration can identify workable
solutions that overcome barriers and ensure beneficiaries have access to optimal HIV/AIDS
services.

Specifically:

CSOs:

• Will play key roles in supporting KPPs to be organized either as formal or informal
groups

• Engage in training members of KPPs on SBCC such as peer education, life skills

• Mobilize KPPs to utilize HIV services

• Enhance linkage between community and facility based services

• Support in case finding processes through targeted testing approaches,

• Support in building capacities for community care coalition

• Support in undertaking community led monitoring by KPPs

• Engage in creating community support for care & support of needy OVCs and PLHIVs

PLHIV associations

• PLHIVs and PLHIV Networks of Associations will be involved in supporting program

interventions ( e.g. through peer support groups, adherence supporters).

• As case managers and adherence supporters engage in adherence counseling and

tracing of LTFU;

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 • Advocate and communicate on treatment literacy and viral suppression;

• Engage in stigma reduction campaigns and lead study on stigma index;

• Address gender based violence and the promotion of human rights;

• Take part in awareness creation campaigns for KPPs and general population;

• Promote use of PrEP by KPPs and discordant couples;

• Engage in creating community support system for care & support of needy OVCs and
PLHIVs and economic empowerment

• Take part in joint planning and M&E of the HIV response, engage in program
management and governance.

Faith Based Organizations (FBOs):

• FBOs will work with CSOs and HIV implementing partners to be engaged in the
combating misconceptions around treatment adherence and retention to care that
undermines impact of HIV response and viral load suppression

• FBOs will work with and PLHIV associations and peer groups to pass standardized
and consistent messaging to combat misconceptions around faith and treatment
adherence and support the gains for improved viral load suppression.

• FBOs will engage in and contribute positively in fighting stigma reduction, ART
adherence and retention.

• Religious groups and FBOs use appropriate media outlets, provide psychosocial
support and create awareness for clients who are fighting self-stigma and
discrimination, have discontinued ART to attend religious cure services and help
them to re-engage on ART

• Integrate HIV program into health extension program performance monitoring

scorecard.

• Sensitize leadership on strengthening community systems for improved HIV

response.

• Create digital platform to enhance community led monitoring by PLHIVs and KPPs.

Professional Associations will support the technical aspects of the response

• Creating opportunities for economic empowerment of vulnerable population groups

as structural HIV prevention intervention,

• Take part in planning, implementation, monitoring, and evaluation of the health

systems

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7.10 Private for Profit Sector Strategic Interventions

To gain a better understanding of increased roles for the private sector and identify
potential contributions that can be made.

• Assess and map the private sectors which have the potential to meaningfully
contribute to the HIV response

• Strengthen the coordination platforms of private sectors for more effective

involvement of private for profit organizations

Private health facilities are involved in the prevention and delivery of HIV care and
treatment services and can serve as alternative option for provision of HTS to general
population on fee basis. They will also provide HTS and STIs service to KPPs, PMTCT and ART
services, and TB diagnosis and treatment through public private partnership arrangements.

Other private companies in key sectors should be actively involved in protecting their
workforce as well as the KPPs around the project areas. These sectors include: construction,
flower farms, textile and other factories, companies operating in emerging industrial zones
etc. The Privatization and Public Enterprises Supervising Agency will be involved for any
policy setting in the implementation of HIV mainstreaming across key private sectors.

Social marketing programs will be involved in the promotion and distribution of condoms
and lubricants through retail outlets, bars and shops. They will engage in harm reduction for
PWID through provision of needle and syringe exchange services through social marketing.

All private entities can engage in initiatives for reduction of stigma and gender based
violence and be involved in domestic resource mobilization.

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8. Monitoring and Evaluation Framework
National HIV Strategy M&E Plan 2021 -2025 accompanies this plan. It includes the following:

• The Results Framework

• Description of data management processes through the routine data reporting

system

• Outlines purposes, strategies and plans for the collection, management, analysis and
use of non-routine information from the joint AIDS/TB Program Reviews;
Evaluations, Surveys such as EPHIA and DHS; IBBS and Size Estimation of FSW, LDTD
and other key and priority populations; HIV Recency Testing, community
participatory reviews at federal, regional and Woreda level, and partner reviews,
among others.

• Guides on Data Quality Assurance Mechanisms and Related Supportive Supervision

and Mentoring

• Outlines how M&E systems will be coordinated, within each strategic objective,
accountability for results at each level and data flow

• Outlines which and how monthly, quarterly, semi-annual, annual and multi-year
information products (reports, newsletters; dashboards, and other) / newsletters
and reports will be disseminated, and their intended purpose and use at community,
Woreda and national level to improve the HIV and other health Program
Performance.

• Describes the multisectoral review mechanisms at each level of the health system,
that will assess sector and program performance against coverage and outcomes
annually, and impact at the end of the strategy period

• Outlines how progress and performance will be assessed and how information will
be used to improve policies and future implementation

• Describes processes to identify corrective measures and feed back to communities,

facilities, Woredas, sectors and funders

• Describes and costs a framework for strengthening Ethiopia’s M&E / Strategic

Information System

• Estimates a budget for M&E and outlines how it will be funded.

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Annexes

Annex 1: Results Matrix: Indicators and annual targets

Annex 2: Resource Needs Estimation Model

Annex 3: References

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Annex 1: Results Matrix: Indicators and annual targets

ETHIOPIA HIV NSP 2021-2025 RESULTS FRAMEWORK

Key
Represents absolute number
Represents strategic objective
Core indicator (Global)
Priority indicator (Global)

Results Indicators Disaggregation Baseline Data Target Target Target Target Target
Level Source 2021 2022 2023 2024 2025
Impact Number of new (Further 14,843 Spectrum 11132 9462 8043 6837 5811
HIV infections disaggregation by Estimates
Woreda - see (2019)
incidence baselines
Mapping)
0.016%
Female 0.019% Spectrum 0.0136 0.0124 0.0112 0.009 0.008
(8830)
Male 0.013% 0.009 0.008 0.007 0.006 0.005
(6013)
Children (0-14) 3,230 Spectrum (0- 2746 2496 2246 1747 1248
4)
Incidence by ‘’
Region (adults)
Amhara 5023 ‘’ 3767 3202 2722 2313 1966

Oromiya 3970 ‘’ 2977 2531 2151 1829 1554

SNNP 1662 ‘’ 1247 1060 901 766 651

Tigray 1308 ‘’ 981 834 709 603 512

Addis Abeba 950 ‘’ 713 606 515 438 372

Affar 499 ‘’ 374 318 270 230 195

Gambela 491 ‘’ 368 313 266 226 192

Dire Dawa 327 ‘’ 245 208 177 151 128
Somali 240 ‘’ 180 153 130 110 94
Benis Gumz 221 ‘’ 166 141 120 102 87
Harari 152 ‘’ 114 97 82 70 60
Percentage of Disaggregated by 0.93 (2019) Spectrum 0.83 0.78 0.74 0.7 0.66
people living age, gender, Adults 15-49 Estimates
with HIV location and KPs
(Prevalence) (FSW, PWID)
669,236 Spectrum 664,926 662,958 660,678 657,971 654,712
Estimates

FSW 23% IBBS 2013, 21% 19% 18% 17% 16%

EPHI
TB/HIV mortality All 22 WHO Global 17 15 13 11 7
rate per 100,000 TB Report
population 2018

148
 Number of All 11,546 Spectrum 8,974 8,003 7,545 7,157 6,843
AIDS-related Estimates
deaths Male 4,976 Spectrum 3868 3449 3252 3084 2949
Estimates

Female 6,570 Spectrum 5106 4554 4293 4073 3894

Estimates
Children (0-14) 2055 1845 1636 1426 1217 1007
Incidence All 1.286 Spectrum 1.241 1.182 1.066 0.955 0.849
Mortality Ratio Estimates
(IMR)
% of people Adults (15-64) 71.70% EPHIA 75% 80% 85% 90% 90%
living with HIV in Population
the reporting survey 2018
period with (Urban)
suppressed viral
loads (≤1000
copies/mL)
Percentage of All 91% Program 90% 91% 93% 95% 95%
people living Data/
with HIV and on surveys
ART who are
virologically
suppressed
Adolescents 15-24 81.80% Program 84% 87% 90% 93% 95%
Data/
surveys
Children 0-14 74.00% Program 79% 85% 90% 93% 95%
Data/
surveys
Percent MTCT All 13.39% Spectrum 10% 9% 7% 7% 5%
past 12 months Estimates

Strategic Objective 1: Reach 90% of Key and Priority populations with targeted combination HIV
prevention interventions by 2025

SBCC Result: Comprehensive knowledge about HIV and AIDS reached at least 50% by 2025
Outcome Percentage of Adults (15 – 38% DHS 2016 40% 45% 50% 55% 60%
women and men 49):Male
aged 15-49 who Adults (15 – 49): 20% DHS 2016 25% 30% 35% 40% 60%
both correctly Female
identify ways of Young People (15 – 39% DHS 2016 45% 50% 55% 65% 70%
preventing the 24): Male
sexual Young People (15 – 24% DHS 2016 35% 45% 55% 65% 70%
transmission of 24): Female
HIV and who
reject major
misconceptions
about HIV
transmission
Outcome Percentage of Males 1% DHS 2016 0.95% 0.85% 0.75% 0.65% 0.50%
15-24 who have
Females 9% DHS 2016 8.50% 8% 7% 6% 5%
sex before age
15
Coverage % 15 – 24 Sex 31% FHAPCO 35% 42% 50% 60% 70%
reached with Annual
HIV prevention Report 2018
programmes
during the last
12 months (e.g.
school and out
of school Peer or
life skills
education )

149
 Adolescents and 7.57M 9.27M 11.2M 13.7M 16.3M
youth reached
with school and
out of school
prevention
programmes
(Millions)
Coverage % 10-14 Sex 35% FHAPCO 40% 45% 57% 64% 70%
reached with Annual
prevention Report 2018
programmes
during the last
12 months (In
school
programmes)
Voluntary Medical Male Circumcision (VMMC)
Result: Quality Male Medical Circumcision Scaled Up and 50% of medically males circumcised by 2025
Coverage % of males aged Young men 15 - 29 72% DHS 75% 78% 80% 85% 90%
15-49
circumcised at Adult men 15-49 (- 72% DHS 75% 78% 80% 85% 90%
Gambella and 21% medically, rest
Selected traditionally)
woredas of
SNNP region
Coverage Number of Infants (90% 72% DHS 75% (4511) 78% (80%) of 85% 90%
VMMCs per circumcised and circumcised circumcised of which 50 (5662) of
annum 50% medically [2]) of these these 30% , medically which
21% 1353 circ. 60%
medically 2469 medically
circumcized- circ. 3397
898
Number of 10+ Years 23,776 COP 18 20,000 6,000 6,000 6,000 6,000
medically (2019) APR/ MRIS
circumcised Men
10+ years
Number and % 0.36% PEPFAR 0.30% 0.25% 0.20% 0.15% 0.10%
of circumcised Program
males data
experiencing
adverse events
Condoms and Lubricants- Utilization and distribution
Result: Condom use at last sex with non-regular sexual partner among general population reached at 90% % by 2025
Outcome % of people who Adults (15-49): 20% DHS 2016 30% 35% 40% 45% 55%
used condoms Females
during their last Adults (15-49): Male 51% Population 55% 60% 65% 70% 70%
high-risk sex act -Av both sexes 41% Survey
the last 12
months[3]
Coverage Number of male Male Condoms 164.1 M DHIS2 186.3 M 220.5 248 M 278 M 299 M
and female Baseline
condoms from MRIS + M
distributed Female
annually Condom Use
and
preference /
need study
Female Condoms 2M 2M 2M 2M 2M

Pre-exposure prophylaxis (PrEP)

Percent of eligible people on PrEP by 2025

150
Coverage % of eligible All 1% ART 10% 20% 40% 65% 80%
people who Program
initiated oral Data
PrEP during the
reporting period
Coverage % and Number Discordant couple 1% 10% 20% 40% 65% 80%
of eligible people (%)
who received Discordant couple 200 DHIS2 1,380 2,760 5,521 8,972 11,043
oral PrEP at (number)
least once FSWs (%) 2% Program 10% 30% 50% 70% 90%
during the last Data
12 months FSWs (number) 800 DHIS2 4,158 12,474 20,790 29,106 37,422
Coverage % of PrEP users New core indicator 80% 85% 90% 95% 95%
who continued to measure loss to
oral PrEP for 3 follow up
consecutive
months after
having initiated
PrEP during the
reporting period
Key and priority populations Results
Result 1: Comprehensive knowledge about HIV and AIDS reached 90% by 2025 for key and priority populations
Result 2: Condom use among key and priority populations engaged in risky sexual behavior reached 90% by 2025
Result 3: 90% for key populations will know their HIV status by 2025
Outcome % KPP FSW 70 IBBS 2013 70% 80% 85% 90% 90%
Members ([Denominators:
reached with a 216,000 in 2020 151,200 193,800 210,600 216,000
defined and 240,000 in 177,600
packages of HIV 2025])
prevention Prisoners *(Prison 58% Prison 70% 80% 90% 90% 90%
services Administration) Survey
60550 69200 77850 77850 77850

PWID N/A 40% 50% 70% 80% 90%

[Denominators is
4,320 5,200 7,000 7,680 8,280
11000 in 2020 and
9200 in 2025,
0.13% of adults in
Spectrum pop
projection]
Long distance 55% IBBS 60% 70% 80% 85% 90%
drivers
[Denominators: 35750 41,400 51,100 61,600 68,850 76,500
65000 in 2020;
85,000 in 2025]
Widowed and 28% DHS 15-49 30% 50% 70% 80% 90%
divorced men and both sexes
women [ 295,800 732,200 860,800
Denominators: 508,000 1,003,438
956475 in 2020 and
1111493 by 2025)
Workers in hot spot N/A 50% 60% 70% 80% 90%
areas [Estimated at
840,000 in 2020 441,000 673,400 801,600 945,000
and 1,050,000 in 553,200
2025]
High risk adolescent 24% DHS 2016 50% 60% 70% 80% 90%
girls and young
women
[Denominators: 68479 83745 99534 115847 132683
134341 in 2020 and
147426 by 2025)

151
Outcome Percentage of FSW condom use Paying 98% IBBS 99% 99% 99% 99% 99%
key populations at last sex with
reporting use of Paying and Non Paying IBBS 45% 50% 55% 70% 90%
a condom with nonpaying clients 37%
their most recent
partner LDD condom use at 84% IBBS 88% 90% 93% 95% 95%
last sex with non-
regular partner
Widowed and 31% DHS 40% 55% 70% 80% 90%
divorced men and
women condom use
at last sex (15-49)
Workers at hot spot 41% DHS 55% 70% 75% 80% 90%
areas condom use
at last sex with non-
regular partner (15-
24 men and
women)
High risk 24% DHS 35% 45% 60% 75% 90%
adolescents and
young women
condom use at last
sex with non-regular
partner
Coverage % of PWID PWID NA Program 0 25% 50% 75% 90%
benefiting from Data
needle
exchange
programs
Number of PWID PWID NA Program 0 2,600 5,000 7,200 8,280
benefiting from Data
needle
exchange
programs
% PWID PWID 0% Program 25% 50% 75% 90%
receiving Data
OPIOID
Substitution
Therapy
Number of PWID 0 2600 5000 7200 8280
receiving
OPIOID
Substitution
Therapy
Coverage Percentage of KPP NA MRIS 40% 55% 75% 85% 90%
key and Priority
populations
reached with
Social Behaviour
Change
Communication
or peer
education
sessions (non-
cumulative)
% of AGYW New indicator N/A 60% 65% 75% 85% 90%
seeking monitoring
contraception/ integration of
family planning AGYW services
who received an
HIV test
Coverage Percent of Adults 15-49 32% DHS 2016 40% 45% 50% 55% 60%
people 15-49
years with STIs
treated

152
 Percent of FSWs Female sex 56% IBBS 2013 65% 70% 75% 80% 90%
with STIS
treated workers
Strategic Objective 2: Enhance HIV case finding to attain 95% of PLHIV knowing their HIV status and
linked to care by 2025
DIFFERENTIATED HTS
HTS Result: HIV testing, and counselling services scaled up and at least 95% people who know their HIV status by 2025
Coverage Number of Number 8,024,936 Program 7.08 M 7.04 M 7.36 M 7.46 M 7.57 M
women and men Report
who received an
HIV test in the
last 12 months
and who know
their results
Coverage % of women and Adults (15-59) 79% EPHIA, 87% 90% 93% 95% 95%
men aged 15-59 Spectrum
years living with
HIV who know
their HIV status
Young People (15 – 79% 87% 90% 93% 95% 95%
24):
Coverage Percentage and FSW 70% IBBS for 70% 80% 85% 90% 90%
Number of key baselines
populations who 151,200 193,800 210,600 216,000
received an HIV 177,600
test in the last 12 Prisoners 58% Prison 70% 80% 90% 90% 90%
months and who Survey
know the results 60550 69200 77850 77850 77850
PWID N/A IBBS 40% 50% 70% 80% 90%
4,320 5,200 7,000 7,680 8,280
Long distance 55% IBBS 2013 50% 60% 80% 90% 90%
drivers 34,500 43,800 61,600 72,900 76,500
Widowed divorced 24% DHS 2016 30% 50% 70% 80% 90%
men and women 295,800 732,200 860,800
508,000 1,003,438
Workers in hot spot 20% DHS 2016 50% 60% 70% 80% 90%
areas
441,000 673,400 801,600 945,000
553,200
High risk 18% DHS 2016 50% 60% 70% 80% 90%
adolescents and
68479 83745 99534 115847 132683
young women
Coverage Percentage of Age (U15, 15+); <0.6% 2019 / 0.80% 1.20% 1.50% 1.80% 2%
HIV-positive Gender, Community (48,781 / Annual
results among testing (mobile 8024936) Report DHIS
the total HIV testing, community 2
tests performed VCT) Facility testing
during the (ANC clinics, FP
reporting period clinics, TB clinics,
VCT centers, other)
Coverage Percentage of Age group, Gender, DHIS2/ 90% 95% 95% 99% 99%
people newly FSW, PWIDs, Program
diagnosed with prisoners, AGYW, Data
HIV initiated on ABYM,
ART
Strategic Objective 3: Attain virtual elimination of MTCT of HIV and Syphilis by 2025
Elimination of Mother to Child Transmission (eMTCT)

Result 1: Mother-to-child transmission of HIV during pregnancy, childbirth and breastfeeding reduced to less than 5% by 2025

153
 Result 2: Access to lifesaving treatment for HIV+ pregnant women increased to 100% by 2025 and AIDS-related maternal deaths
substantially reduced
Coverage Percentage of All 64% DHIS2 79% 83% 87% 91% 95%
infants born to
women living
with HIV
receiving a
virological test
for HIV within 2
months (and 12
months) of birth
Coverage Percentage of All 71% DHIS2 & 84% 87% 89% 92% 95%
HIV+ pregnant Spectrum
women who Estimates
received 2019
antiretroviral
therapy to
reduce the risk
of mother to
child
transmission
% of expectant NA 90% 93% 95% 95% 98%
mothers living
with HIV who are
virally
suppressed at
labour, delivery
and postpartum
Coverage Percentage of Disaggregated by 84% Spectrum 86% 89% 92% 94% 95%
pregnant women Woreda
who know their
HIV status
Coverage Percentage of Program 67% 74% 81% 88% 95%
women Data
accessing
antenatal care
services who
were tested for
syphilis
Coverage % of HIV+ All modern methods 41% Mini DHS 45% 50% 57% 65% 75%
women aged 15- (2019)
49 years who
have their need
for family
planning
satisfied with
modern methods
% of HEI 61% 65% 70% 75% 85% 95%
receiving
enhanced
postnatal (dual)
prophylaxis

Strategic Objective 4: Enroll 95% of PLHIV who know their status into HIV care and treatment and attain
viral suppression to at least 95% for those on antiretroviral treatment.
Result 1: At least 95% of Adult and Children living with HIV who know their status receiving antiretroviral treatment by 2025
Outcome 95-95-95 All 79-90-91 Spectrum 87-91-92 90-95- 93-95- 94-95-95 95-95-95
Estimates 95 95
% of all people Adults (15-64): 79-92-92 and EDHS 87-95-95 90-95- 90-95-95 94-95-95 95-95-95
living with HIV Female Triangulation 95
who know their
Male 78-95-92 87-95-95 90-95- 90-95-95 94-95-95 95-95-95
HIV status, % of
95
all people with
diagnosed HIV Children <15 65-67-74 75-80-85 80-85- 80-90-90 94-95-95 95-95-95
88

154
 infection who 26% for children 0-4 35-91-90 65-92- 75-95-95 90-95-95 95-95-95
received 93
antiretroviral 46% for those aged 60-91-90 70-92- 80-95-95 94-95-95 95-95-95
therapy and % of 5-10 years 93
all people 58% for those 11- 70-91-90 80-92- 90-95-95 94-95-95 95-95-95
receiving 14 93
antiretroviral
therapy who
have viral
suppression
Outcome Percentage of All 86% Spectrum 90% 91% 93% 95% 95%
adults and Estimates
children living
with HIV
infection
receiving
antiretroviral
therapy at the
end of the
reporting period
(To disaggregate
by region)
Number on Numbers on ART 476746 DHIS 2; 549,265 570,817 587,635 590,878
treatment (All ages) Treatment 560,041
Data
91% 92% 93% 95% 95%
Adults (15+) 452909 526,226 536,550 546,874 564,552 577,101
26% for children 0-4 26% 30% 40% 55% 75% 90%
Numbers, 1-4 3,428 2,528 1,880 1,183 986
46% for those aged 46% 55% 65% 75% 85% 95%
5-10 years

Numbers, 0-14 23,039 23,491 23,943 23,083 23,000

58% for those 11- 58% 65% 70% 75% 85% 95%
14
Outcome % and number New Indicator ART <15% <13% <10% <7% <5%
of ART patients (Disaggregate by Registers
(who were on age)
ART at the
beginning of the
quarterly
reporting period)
and then had no
clinical contact
since their last
expected
contact)
Outcome Percentage Gender, Age 89% Treatment 90% 91% 93% 95% 95%
PLHIV on ART Reports
who are
virologically
suppressed
492,368 534,585 558,253 569,602
505,139
Outcome % of all PLHIV Gender, Age 68% 75% 80% 85% 90% 90%
who are (Including not VL
virologically tested)
suppressed
% VL tests 70% (2019) 75% 80% 85% 90% 90%
Number VL tests 410,307 488,600 528,872 539,623
449,013
Tuberculosis and Hepatitis

155
 TB deaths in people living with HIV reduced by 75% by 2025
Outcome Percentage of Adults (15+): Male 91% (DHIS2) 95% 95% 95% 98% 98%
HIV-positive new and Female
and relapse TB
patients on ARV
therapy during
TB treatment
Coverage Percentage of All 97% TB Program 98% 99% 99% 99% 100%
estimated HIV-
positive incident
TB cases that
received
treatment for
both TB and HIV
Coverage Percentage of Adults (15+): Male (DHIS2) 95%
people living and Female;
with HIV newly Children under 15
enrolled in HIV
care started on
TB preventive
therapy
Coverage Percentage of All People (DHIS2) 100%
people living
with HIV who are
screened for TB
in HIV settings
% of PLHIV on All N/A Program 98% 98% 98% 98% 98%
ART who Reports;
completed a DHIS2
course of TB
preventive
treatment among
those who
initiated TPT
% people on All Program 5% 10% 20% 25% 30%
ART who were Reports
screened for
Hepatitis C
during the
reporting period
% people All Program 90% 92% 95% 97% 98%
diagnosed with Reports;
chronic HCV DHIS2
infection who
initiated
treatment during
the reporting
period
Strategic Objective 5: Mobilize resources and maximize efficiencies in allocation and utilization
Coverage % of HIV ALL 11% NASA / NHA 12% 14% 16% 19% 22%
Program (NSP) Annual
Budget funded National
by domestic Budget
sources

156
Coverage Proportion of All >20% NHA/ NASA 18% 17% <15% 12% <10%
population with
large household
expenditure
(over 20%) on
health as a
share of total
household
expenditure or
income
(catastrophic
spending on
health)
Outcome Percentage in- Disaggregated by 70 NHA/ 90% 90% 90% 90% 90%
country source of funding Program
utilization of and implementer Expenditure
disbursed funds type (public or Report
(i.e. in-country community)
disbursement
utilization)
Strategic Objective 6: Enhance generation and utilization of Strategic Information for an accelerated
evidence based response
Coverage Completeness of All DHIS2 75% 80% 85% 90% 90%
facility reporting:
Percentage of
expected facility
monthly reports
(for the reporting
period) that are
actually received
Coverage Percentage of All (DHIS2) 95% 95% 95% 95% 95%
health facilities
timely submitting
reports within
DHIS2
Coverage Percentage of All <80% Program 80% 85% 90% 95% 100%
planned surveys report
and (HAPCO/
surveillances EPHI)
conducted, and
reports released
on time (within 3
months of
finalization)
Coverage Percentage of High Burden, Program 75% 80% 85% 90% 90%
Woredas that Medium Burden, Reports;
produce periodic Low Burden DHIS2
analytical
report(s) as per
nationally
agreed plan and
reporting format
during the
reporting period

157
Coverage Percentage of All 89% DHIS2 90% 95% 95% 98% 98%
facilities which
record and
submit data
using the
electronic
information
system

Social and programmatic enablers to maximize the reach and impact of Ethiopia’s HIV/AIDS response
Structural Barriers (Gender and Human Rights Related Barriers to service delivery, accessibility and
utilization removed by 2025
Outcome % of key and Disaggregated for >30% EDHS; 30% 20% 15% 10% <5%
priority FSW, PWID and Stigma Index
population AGYM
members who
avoid health
care because of
stigma and
discrimination
Outcome % of women and Adults (15- 49): 65% EDHS 2016 70% 75% 80% 85% 90%
men aged 15-49
Male
with accepting
attitudes to Adults (15-49): 52% EDHS 2016 60% 70% 80% 85% 90%
PLHIV
Female
Outcome Proportion of Adults Females (15- 34% Gender link --- --- 26% --- 20%
women aged 15- 49) GBV
49 who reported Indicator -
experiencing DHS 2016
physical or
sexual violence
from a male
intimate partner
in the past 12
months
Outcome Ethiopia Gender 0.508 Human 0.3985 0.289 [5]
Inequality index Development
(value) Report 2019
75% of PLHIV, at risk of and affected by HIV and in need benefit from HIV-sensitive social protection by
2025
Outcome % Orphans and Target is Double Spectrum 13% 20% 29% 39% 43%
vulnerable Orphans; Modeling
children 0-17 Denominator is 32,733 47,408 61,413 74,960 73,536
years in need Total AIDS Orphans
who received
basic external
support
Coverage % PLHIV on Nutrition Status 26% BMC (2020) 15% 20% 25% 30% 35%
nutrition support (Severely) Alebel et al.
that are malnourished FMOH/
malnourished / children and adults - UNICEF
undernourished at risk of morbidity
or mortality;
medically defined
as 'Wasted'.
Targets are PLHIV
on ART
123954 21,421 28,562 35,702 42,843 49,983

158
Coverage AGYW High Risk AGYW Program 5% 10% 15% 20% 25%
economic and Reports
other
empowerment
programs
6717 13434 20151 26868 36857

Strategic Objective 7 : RSSH - Community Systems Strengthening: At least 80% of Community Care
Coalitions supported to deliver services and linked to health facilities by 2025
Number of --- --- (DHIS2)/ 90% 90% 90% 95% 95%
community CHIS/
indicators that FHAPCO/
can be PEPFAR
integrated into
DHIS2
Coverage Percentage of All NASA --- --- 20% --- 25%
HIV and TB resource
funding mapping and
channeled expenditure
through tracking
community-
based
organizations/
CCCs
Percentage of 0 40% 50% 65% 80% 90%
community care
coalitions that
integrated a
package of
prevention
interventions in
their service
Coverage Number of Woreda (At least 1 50 100 150 200 265
community- per highest
based incidence Woreda)
organizations
that received a
pre-defined
package of
training
Coverage % of NSP All 5% 6% 7% 9% 10%
budget funded
by communities
(including
prevention, OVC
and PLHIV care)
Number of Woreda (At least 1 CCME 50 100 150 200 265
community per highest Oversight
based incidence Woreda) Reports
organizations
engaged in
community led
monitoring in
high burden
woredas

Strategic Objective 8 : Resilient and Sustainable Systems for Health support program acceleration and
attainment of at least 90% of targets

159
Outcome Active health Differentiated by 10.6 per MOH 12 14 18 20 23 skilled
workers per cadre 10,000 health
10,000 population workers
population (does not per 10000
(Occupation count population
group
(Physicians,
Nurses and
Midwives,
Laboratory
technicians,
Pharmacists and
CHWs)
% of women All 48% EDHS 2016 - 65 70 75 80 85
giving birth at MOH/ ANC
health facilities,
or (ANC 4)
Outcome Percentage of --- MOH / --- --- 80% ---- 90%
antenatal clients UNICEF
with 1st visit
before 12 weeks
Coverage Proportion of Program 25% 45% 60% 75% 95%
community Data/
health workers HAPCO SRs.
who received at
least one
supportive
supervision
during the
reporting period
Proportion of 50% of MOH Health 50% 60% 70% 90%
community 70000 Extension
health workers (HEW, Programme
who are trained CHW,…)
on predefined
package of on
HIV prevention
and treatment
Coverage % Percentage of Main ARV Global 99% 100% 100% 100% 100%
health facilities regimens, AL, TB, Health
with tracer and Azithromycin, Supply Chain
medicines for COVID-19 Test Kits monitoring
the three HIV Test Kits report. 97% 99% 100% 100% 100%
diseases Health
available on the Viral Load facility, 80% 85% 96% 100% 100%
day of the visit or Reagents Hospital
day of reporting

160
Annex 2: Resource Needs Estimation Model
Introduction

We have used the Goals model in Spectrum to estimate the cost, impact and cost-
effectiveness of alternative HIV investment strategies in Ethiopia. This document describes
the methods, data, assumptions and results. The scenarios analyzed were defined through
discussions with stakeholders.

Methods

This analysis uses the Goals model, a module implemented in the Spectrum modeling
system that estimates the impact of future prevention and treatment interventions. The
model has been set up for Ethiopia using all available data sources to specify the distribution
of the population by age and risk group and the behaviors by age and risk group.

The Goals model also has an impact matrix that summarizes the impact literature to
describe changes in behavior by risk group as a result of exposure to behavior change
interventions 1.

The model calculates new HIV infections by sex and risk group as a function of behaviors
and epidemiological factors such as prevalence among partners and stage of infection. The
risk of transmission is determined by behaviors (number of partners, contacts per partners,
condom use) and biomedical factors (ART use, male circumcision, prevalence of other
sexually transmitted infections). Interventions can change any of these factors and, thus,
affect the future course of the epidemic.

The Goals model is linked to the AIM module in Spectrum that calculates the effects on
children (0-14) and those above the age of 49. The AIM module also includes the effects of
programs to prevent mother-to-child transmission on pediatric infections. Additional details
on the Goals and AIM models are available from several publications. 2,3

Data and assumptions

Epidemiological data are from the EDHS (2005, 2010, 2016), the EPHIA (2018) and the 2020
Spectrum/AIM file. This AIM estimate is based on surveillance, survey and routine ANC
testing data on HIV prevalence as well as program data on coverage of PMTCT and ART
programs.

1
Bollinger LA, How can we calculate the “E” in “CEA” AIDS 2008, 22(suppl 1): S51-S57.
2
Stover J, Hallett TB, Wu Z, Warren M, Gopalappa C, Pretorius, et al. How Can We Get Close to Zero? The
Potential Contribution of Biomedical Prevention and the Investment Framework towards an Effective Response
to HIV PLoS One 9(11):e111956. doi:10.1371/journal.pone.0111956.
3
Stover J, Andreev K, Slaymaker E, Gopalappa C, Sabin K, Velasquez C et al. Updates to the Spectrum model to
estimate key HIV indicators for adults and children AIDS 2014 28 (Suppl 4):S427-S434.

161
Behavioral data are drawn primarily from the EDHS and EPHIA. Size and prevalence
estimates for female sex workers are based on the National Road Map 4.

International studies are used to set values of the epidemiological parameters such as the
risk of HIV transmission per act and the variation in the risk of transmission by stage of
infection, type of sex act, presence of other STIs, use of condoms, etc 5.

Estimates of the current coverage of interventions were compiled by the NSP costing
consultant (Elias Asfaw) based on a variety of sources, relying mainly on program statistics
(DHIS-2), project data from PSI-Ethiopia, FHAPCO annual reports and the PEPFAR Country
Operational Plan, 2019.

The model is fit to the historical pattern of prevalence in order to replicate the epidemic
dynamics (Figure 1).

Figure 1. Model fit to survey data and AIM trends

Unit costs for key interventions (also collected by Elias Asfaw) are FHAPCO, PSI, Project
Hope, EPHI, Federal Ministry of Health, FPSA Medical Supplies, National AIDS Spending

4
FHAPCO, HIV Prevention in Ethiopia: National Road Map, 2018-2020, November 2018.
5
Marie-Claude Boily, Rebecca F Baggaley, Lei Wang, Benoit Masse, Richard G White, Richard J Hayes, Michel
Alary Heterosexual risk of HIV-1 infection per sexual act: Lancet Infect Dis 2009; 9: 118–29.

162
Assessment of 2011 (to be updated with the new NASA at the end of March) and PEPFAR
Expenditure Analysis and rely on regional estimates when national figures are not available.

We assume that unit costs remain constant for most interventions except treatment. Since
treatment accounts for the largest share of expenditures, it is important to consider the
costs of the treatment program in detail. Our current assumptions for unit costs are:

Table 1. ART unit costs

Component Cost per patient per year

First line ARVs: TDF+3TC+EFV $86

First line ARVs: TDF+3TC+DTG $84

Second line ARVs $266

Third line ARVs $838

Service delivery (current $50

model)

Service delivery (DSD) $50

Laboratory $37

Percent of patients on second 6.8%

line

Transition to TLD

According to FHAPCO the prices of TLE and TLD are quite similar in Ethiopia. So, there may
not be much savings once the switch to TLD is complete.

Differentiated service delivery

PEPFAR is scaling up differentiated service delivery models (DSD) including Appointment

spacing model (ASM), fast-track pharmacy refill and health worker managed community
refill groups. Cost savings could arise if DSD is less expensive than the full visit model.
However, at this time it appears that the costs of DSD may not be much different.

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Constant Coverage

The number of new HIV infections and AIDS deaths have declined substantially since 2010.
However, that decline will slow considerably If the current program effort remains constant
(constant coverage of ART, VMMC, condoms, etc.). Figure 2 shows the estimated trend from
2010 to 2019 and the projected future trend to 2030 under the assumption of constant
coverage of all interventions.

Figure 2. New infections and AIDS deaths with constant intervention coverage

Under this scenario new infections decline by 58% from 2010-2020 (less than the global
target of 75% decline) and by 52% from 2010-2030 (less than the global target of 90%. HIV-
related deaths decline by 64% by 2020 and by 59% by 2030.

Another measure of progress is the incidence – mortality ratio. This is the number of new
HIV infections divided by the number of deaths to PLHIV. When the indicator crosses 1.0 it
means that a tipping point has been reached, after which the number of PLHIV will decline.
This ratio has dropped to just below one in 2020 but, as Figure 3 shows the, it would remain
at about one through 2030 with constant coverage.

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Figure 3. Incidence – prevalence ratio

Funding Scenarios

Ethiopia current spends about $240 million on the HIV program. The estimated distribution
of expenditures is shown in Figure 4. Treatment accounts for about 50% of total
expenditures.

Figure 4. Estimated distribution of expenditures in 2019

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To continue progress in reducing new infections and AIDS deaths key prevention and
treatment services will need to be scaled-up to reach more people. The ability of the
program to do that will depend, to a large extent, on the financing available. We
constructed four funding scenarios, Figure 5, to examine the impact of funding on impact.

 Base: Coverage of all interventions remains constant

 NSP: Funding from the Global Fund and PEPFAR remains constant through 2030.
Domestic government resources increase according to the draft National Resource
Mobilization Plan.
 Optimistic: Funding from the Global Fund remains constant but PEPFAR funding falls
by about 20% by 2030. Domestic government resources increase according to the
draft National Resource Mobilization Plan.
 Pessimistic: Similar to the Optimistic scenario but Government of Ethiopia funding
remains constant through 2025.
Figure 5. Available Funding by Scenario

Coverage Targets for 2025

These funding levels are not enough to achieve full coverage of all interventions (which
requires about $330 million per year by 2025). Even the Optimistic scenarios falls short of
needs under full coverage. We have constructed coverage targets for 2025 to match the
funding available. These are shown in Table 2.

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Table 2. Coverage targets by scenario (percent of target population reached with services)

Intervention 2019 2025

Testing 13 12
Adult ART 75 90
Pediatric ART 48 89
PMTCT 74 95
Condoms 53 90
SBCC Campaigns 8 12
STI treatment 34 60
Sex workers 50 90
Priority populations 28 90
AGYW 0 45-90
VMMC 89 90

To develop these targets, we first estimated the cost-effectiveness of each intervention

separately. The results are shown in Figure 6. ART clearly has the largest impact and also
prevents deaths, while VMMC and condom programs have the lowest cost per infection
averted. Not shown in Figure 3 are programs for priority populations (cost-effectiveness
varies by population) and mass media and programs for adolescent girls and young women
(AGYW) which more costly than the upper limit of the chart.

In constructing the targets, we first scaled-up treatment as much as possible and then, if
there were remaining resources, scaled-up VMMC, condoms and sex worker programs. The
model also includes programs to reduce stigma and prevent violence against women, but
those programs were too costly if implemented solely as HIV programs. We recognize that
progress on stigma and violence prevention may be necessary to reach the target coverage
levels for other interventions.

The testing coverage declines slightly as we have assumed the testing services transition
from the current situation with about 8 million tests per year (mostly provider-initiated
(PITC) and VCT) with a yield of about 0.3% to one with targeted testing based on index case
testing and expansion of self-tests to replace VCT. Even though PITC will still be required (for
pregnant women, TB patients, etc.) the higher yields of index case testing mean that 95%
knowledge of status can be achieved with a 70% reduction in the number of tests.

167
Figure 6. Cost per infection averted by intervention

For the Optimistic and Pessimistic scenarios, we used the Goals model to optimize available
funding. The optimization involves allocating funds first to the most cost-effective
interventions and removing funding from those that are least cost-effective in order to
match the total funding available. Changes in the coverage of key interventions due to the
optimization are shown in Figure 7.

Figure 7. Relative changes in coverage by scenario

168
Impact

Projections of new infections and AIDS deaths shown in Figures 8 and 9. New infections
decline substantially (65%) from 2019-2025 in NSP, dropping to 5200 new infections in
2025. This scenario averts 30,000 new infections from 2020-2025 compared to the Base
scenario.

In the Optimistic funding scenario, new infections drop 46% from 2019-2025, averting
24,000 new infections. In the Conservative Funding scenario new infections decline only
37% and 20,000 new infections are averted compared to the Base scenario.

In the NSP scenario the number of people on ART increases to 2.8 million by 2025 and
annual deaths decline to 6100. This averts almost 15,000 AIDS-related deaths. In the
Optimistic and Conservative Funding scenarios ART still expands, since ART is prioritized for
funding, but fewer AIDS deaths are averted.

Figure 8. New HIV infections by scenario, 2019-2025

Figure 9. HIV-related deaths by scenario, 2019-2025

169
Costs

The costs for each intervention are estimated as the population in need of the service
multiplied by the coverage (the percentage actually using the service) multiplied by the unit
costs. We assume that the unit costs of most interventions remain constant

Total funding required for the NSP scenario is shown in Figure 10. Total funding needs to
reach the NSP targets increase from about $225 million in 2020 to $277 million in 2025. The
largest amounts are needed for ART (46%), testing, (20%), condoms (5%) and health system
strengthening (7%).

Significant additional resources would be needed to scale up programs to reduce stigma

($64 million in 2025) and address violence against women ($18 million) so scaling-up these
programs is not included in any of the scenarios.

Figure 10. Total Resources Required under the NSP Scenario

Cost-effectiveness

Since the core programs (testing, treatment, VMMC, condoms, services for key populations)
can avert substantial numbers of new infections and AIDS deaths, they are clearly cost-
effective. However, it may not be possible to reach those ambitious targets without also
addressing the social enablers.

For the period 2021-2025 the incremental cost of the NSP scenario is $185 million, and it
averts 47,000 new infections during that period. The cost per infection averted
(undiscounted) is about $400.

Testing and treatment are the most cost-effective interventions since they are cost savings
over the period 2021-2025.

170
Figure 9 shows the distribution of woredas by HIV incidence in the population aged 15-49.
While treatment programs are needed everywhere there are PLHIV, prevention programs
will be more cost-effective in the high incidence zones. At the national level incidence
among the population 15-49 is estimated at 0.029%. Incidence is more than three times as
high in 14% of woredas. These woredas account for about one-third of all new infections
and thus constitute a geographic core where prevention interventions might be scaled up
first to achieve maximum cost-effectiveness.

PEPFAR assistance in provide in 5 priority regions (Addis Ababa, Oromiya, Amhara, Gambella
and SNNP) that together account for 85% of all new infections. Targeting interventions to
the highest incidence woredas in these and other regions can ensure that resources are
used in the most cost-effective manner possible.

Productivity gains and return on investment

When people are sick with HIV, they may miss work or perform at reduced productivity. The
productivity gains from scaling-up treatment can be estimated from the number of people
living with HIV who are not on ART and have CD4 counts below 200 cell/ml 6. Applying these
calculations to the NSP scenario indicates a cumulative productivity gain of $87 million from
2021-2025.

The NSP scenario costs more than the Base scenario. Is it worth the extra cost? To answer
this question, economists have developed the full-income approach which estimates a value
on changes in income and mortality.7 Using a 3 percent annual discount rate the cumulative
incremental cost of the NSP scenario for 2020-2025 is $167 million. The cumulative
discounted benefits are $1.4 billion 8. Thus, the return on investment for the Optimistic
scenario is 8. This high return clearly demonstrates the value of the additional investment.

Figure 8. Distribution of Woredas by Incidence among 15-49

6
Resch S, Korenromp E, Stover J, Blakley M, Krubiner C, et al. (2011) Economic Returns to Investment in AIDS
Treatment in Low and Middle Income Countries. PLoS ONE 6(10): e25310. doi:10.1371/journal.pone.0025310
7
Lamontagne E, Over M, Stover J. The economic returns of ending the AIDS epidemic as a public health threat,
Health Policy 123 (2019) 104-108.
8
Benefits are calculated as the reduction in standard mortality units (SMUs) estimated as deaths per 100,000
population, multiplied by the value of a one-unit reduction in the SMU. This value (VSMU) is estimated as 1.8%
of GNP/capita.

171
Summary

This analysis shows clearly that efforts to control the epidemic in Ethiopia will depend on
some increase in funding. Substantial decreases in available funding would eliminate most
prevention services and provide no opportunity to achieve the 90-90-90 and 95-95-95
treatment targets.

The draft national resource mobilization plan envisions an increase in domestic resources of
$59 million annually by 2025. Cost savings from efficiency improvements in testing and
treatment could reduce testing and treatment costs while still increasing the number on
treatment by 77,000. If the domestic resource mobilization and improved efficiencies can be
achieved and resources from PEPFAR and the Global Fund do not decline, there will be
sufficient resources to reach the treatment targets and scale up primary prevention
activities.

If the government resources do not increase or PEPFAR and Global Fund resources decrease
then the targets could not be achieved resulting in a stagnant or a worsening of the
epidemic. Ethiopia has shown that it can implement a cost-effective program. The new NSP
can use this information to develop a cost-effective plan and make the case to government
and international donors to support the program financially.

172
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blockchain technology will provide comparatively safer and credible unique identifiers allowing patients to connect to
other hospitals and collect their medical data automatically and access commodities.

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