1. Overview of HIV/AIDS in Ethiopia
Unit 1
HIV Care and ART: A Course for Healthcare Providers
Unit 1 should take approximately 1 hour 45 minutes to implement.
Step 1: Opening Addresses by Coordinating Sponsors of Training (Slide 1) – 15 minutes
Step 2: Introduction to HIV Care and ART Training Workshop Overview of Unit 1 Learning Objectives (Slide 2-3) – 5 minutes
Step 3: Global and National Summary of HIV/AIDS Epidemic (Slides 4 – 35) – 60 minutes
Step 4: Policy of ARV Supply and Use in Ethiopia (Slides 36 – 45) – 20 minutes
Step 5: Key Points (Slides 46 – 47) – 5 minutes

2. Learning Objectives
Describe the national HIV/AIDS epidemiological profile
Describe the Ethiopian national AIDS strategies, guideline for implementation of ART, and roadmap to accelerate care and treatment for PLWHA
List the major achievements, challenges and opportunities during the implementation of the ART program in Ethiopia
Step 2: Introduction to HIV Care and ART Training Workshop Overview of Unit 1 Learning Objectives (Slide 2-3) – 5 minutes
Explain that this session provides an opportunity to discuss the broader picture of HIV/AIDS in Ethiopia, including national policies and guidelines. Some of the information may be a review, while some may be new. This information will be key to the ongoing discussion of structural challenges and implementation strategies. Discussion of clinical and technical information begins in the next unit.
Review the unit aim and objectives.
The aim of this unit is to review the status of HIV/AIDS in Ethiopia and national policy responses to antiretroviral therapy (ART). The unit discusses the global HIV/AIDS epidemic, HIV prevalence rates and trends in Ethiopia, and government responses to HIV.
Ask if participants have any questions before continuing.

3. Learning Objectives (2)
Explain the Ethiopian National Policy on ARV drugs, supply and use
Convey the current status of the ART program in Ethiopia
List prevention strategies to reduce the spread of HIV infection in the country

4. Global and Ethiopian Summary of HIV/AIDS Epidemic
Step 3: Global and National Summary of HIV/AIDS Epidemic (Slides 4 – 35) – 60 minutes

5. Global Summary of the AIDS Epidemic, December 2005
PLWHA 40.3 million
(36.7 – 45.3)
Adults 38.0 Million
( )
Women 17.5 Million
( )
Children <15 yrs 2.3
Million ( )
New infections 4.9 million
(4.3–6.6)
Adults 4.2 Million ( )
Children <15 yrs 700,000 (630,000 – 820,000)
AIDS Deaths 3.1 million (2.8 – 3.6)
Adults 2.6 Million (2.3 – 2.9 million)
Children <15 yrs (570, ,000)
Source: WHO/UNAIDS AIDS Epidemic Update, December 2005.

6. Global Picture of HIV/AIDS
Source: UNAIDS Report on the global AIDS epidemic. May Available at
Source: UNAIDS, 2006

7. Est. Number Newly Infected With HIV During 2005: 4.9 Million
Western
Europe
21,000
Eastern Europe & Central Asia
210,000
North America
44,000
East Asia & Pacific
290,000
North Africa
& Middle East
92,000
South
& South-East
Asia
890,000
Caribbean
53,000
Sub-Saharan Africa
3.1 million
Latin America
240,000
Australia
& New Zealand
5,000
This slide shows the global distribution of new HIV infections.
Source: UNAIDS/WHO

8. Est. Adult and Child Deaths From HIV/AIDS During 2005: 3.1 Million
Western Europe
65,000
Eastern Europe & Central Asia
60,000
North America
16,000
North Africa
& Middle East
28,000
East Asia & Pacific
51,000
Caribbean
36,000
South
& South-East Asia
490,000
Sub-Saharan Africa
2.3 million
Australia
& New Zealand
700
Latin America
95,000
Source: UNAIDS/WHO

9. More than three quarters of all young people living with HIV are women (WHO Regional Office for Africa, 2003; Reproductive Health Research Unit and Medical Research Council, 2004).
Source: UNAIDS/WHO 2004

10. Ethiopian Prevalence National prevalence for 2003 ......... 4.4%
Women….5.0%
Men….3.8%
Urban prevalence in %
Urban prevalence in %
Rural prevalence in %
Rural prevalence in %
Addis Ababa prevalence in %
Addis Ababa prevalence in %
Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

11. HIV/AIDS Indicators in Ethiopia (2005)
Number of PLWHA million
Estimated AIDS cases 143,129
PLWHA requiring ARVs 286,258
Annual AIDS deaths 134,124
Adults and Children on ART 20,477
Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

12. HIV/AIDS Indicators in Ethiopia (2005) (2)
AIDS orphans ,936
Total orphans 4,801,219
Children living with HIV/AIDS ,903
New HIV infections………39,886
New AIDS cases…………29,359
Annual AIDS deaths in children 28,693
Children newly needing ART 58,718
Children on ART
Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

13. Age & Sex Distribution of Reported AIDS Cases (1986 - June 2003, Ethiopia)
Source: AIDS in Ethiopia, 5th ed., MOH, July, 2004

14. Pregnant Women Testing HIV Positive: Urban, 2001
Source: Aids in Ethiopia, 4th ed., MOH, October 2002

15. Pregnant Women Testing HIV Positive: Rural, 2001
Source: Aids in Ethiopia, 4th ed., MOH, October 2002

16. HIV Prevalence Among Pregnant Women by Age, Urban 2001
Source: Aids in Ethiopia, 4th ed., MOH, October 2002

17. Impact on Rural Households
Loss of income (50% or more)
Loss of labor
Loss of skilled manpower and knowledge
Loss of land
Loss of remittances
Reduction in savings and investment
Expenses for treatment, funeral, teskar
Need to sell livestock to meet expenses

18. Impact on Industry Loss of workers
Expenses for recruiting and training replacements
Reduced productivity in cases of skilled workers or managers
Lost work days due to sickness and funeral leave
Increased health care costs
50% illness due to AIDS
Loss of skilled professionals

19. HIV/AIDS Treatment in Ethiopia
Step 4: HIV/AIDS Treatment in Ethiopia (Slides 19-35) - Time

20. Historical Overview of HIV/AIDS in Ethiopia
1984: The first evidence of HIV infection in Ethiopia
1986: The first two AIDS cases reported to the Ministry of Health
1989: HIV/AIDS surveillance started
March, 2005: Free ART program started
Currently, approximately:
129 surveillance sites
73 ART sites
658 VCT sites
Source: HAPCO

21. VCT Site Distribution by Region, 2005
Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

22. ART Site Distribution by Region
Total =73
Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

23. Regional Distribution of ART

24. PMTCT Site Distribution, by Region
Total site = 129
Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

25. National Response
HIV/AIDS Policy formulated by MOH and adopted by the Council of Ministers in 1998
Enabled HIV/AIDS prevention and control
Supplemented existing health, women’s, and education and training policy
Called for a multisectoral response
Guaranteed rights of PLWHA
ARV Drugs Supply & Use Policy formulated July 2002

26. National Response (2)
HIV/AIDS Prevention & Control Office (HAPCO) established June 2002
Restructured from NACS (April 2000)
Sits under Prime Minister’s Office
Established at all levels of government
Runs the daily activities of NAC
Resource mobilization
Advocacy
Coordination of the sectoral responses

27. National Response (3) HIV/AIDS Strategic plan for five years
Social mobilization & community involvement
Community ownership
Scaled up ART program
AIDS fund was initiated
Free ART program was scaled up

28. HIV/AIDS Intervention Strategies
Prevention
Social mobilization
IEC/BCC
HIV counseling and testing
Voluntary (VCT)
Provider initiated (PIHCT)
STI prevention and control
Condom promotion
Infection prevention
Prevention of mother to child transmission (PMTCT)
Post exposure prophylaxis

29. HIV/AIDS Intervention Strategies (2)
Care and Treatment
Palliative care
Community home based care
Opportunistic infection treatment
Tuberculosis treatment
Treatment of AIDS patients
Support for
Orphans and vulnerable children (OVC)
People living with HIV/AIDS (PLWHA)

30. Major Achievements National HIV/AIDS Policy
National AIDS Council Secretariat
Five editions of “AIDS in Ethiopia”
National ARV Policy (revised and published in January 2005)
Roadmap to accelerate access to HIV/AIDS care and treatment
M&E framework

31. Major Achievements (2) Five-year strategic plan revised & updated
Used as main input for the National Strategic Framework adopted by NAC
Contains strategic outline of interventions at federal and regional levels
Key guidelines developed:
HIV Surveillance Guideline
HIV Surveillance Training Manual
Voluntary Counseling & Testing Guideline

32. Major Achievements (3) Key guidelines (continued):
AIDS Case Management Guideline
STI Management Guideline
Home-Based Care Guideline
Private HIV Labs Licensing Guideline
PMTCT Guideline
Home Care Training Manual
Counseling Training Manual
ARV Guideline
Universal Precautions & Post Exposure Prophylaxis

33. Major Achievements (4) 658 VCT sites established
129 sentinel surveillance sites established
MOH has been the primary advocate for a multi-sectoral response to HIV/AIDS:
Formulated and disseminated HIV/AIDS and ARV Drugs Supply & Use Policies
Acts as a catalyst for several multi-sectoral HIV/AIDS committees that pre-dated the NAC

34. Major Achievements (5) Integrating HIV/AIDS into health programs:
Reproductive health
Mother and child health
Hospital hygiene
Health education
Integrated disease surveillance
TB/HIV Initiative

35. Limitations Synchronizing pharmacy & patients reports
Absence of laboratory reports
Inadequate Pre and ART registers
Employing ART coordinators and Data managers
Sending reports to RHBs and MOH
AIDS patients on waiting lists

36. Policy of ARV Supply and Use in Ethiopia
Step 4: Policy of ARV Supply and Use in Ethiopia (Slides 36 – 45) – 20 minutes

37. Introduction
Care and support of PLWHA plays an important role in preventing the spread of HIV/AIDS
ART is an important component of care for PLWHA
ARVs also have an important place in PMTCT and PEP
ARVs have enormous benefits, but affordability, toxicity, adherence and resistance are challenging

38. National ARV Policy Policy approved in July 2002
Objectives of the policy:
Reduce MTCT
Prolong and improve the quality of lives of PLWHA
Reduce accidental HIV infection within health institutions

39. General Policy
Determines type of ARVs that will be used in health care services
The Government of Ethiopia:
Coordinates & facilitates the supply of ARVs
Builds capacity for making available safe, effective and quality antiretroviral drugs, and for ensuring proper use of these drugs
Ensures sustainable supply of ARVs by encouraging involvement of all stakeholders

40. General Policy (2) The Government of Ethiopia (cont):
Nurtures international partnerships to strengthen sustainable supply and use of ARVs
Encourages research on modern and traditional HIV/AIDS treatment
Establishes strong systems to monitor ARV supply and use

41. General Strategies Selection of ARVs
Determine the type of ARVs to be used in Ethiopia
Incorporate selected ARVs into the national drug list
Permit the import of ARVs that are not included in the national drug list

42. General Strategies (2) Supply of ARVs ARVs for ART:
Exempted from taxation
Supplied at reduced prices through government negotiation with manufacturers, importers and distributors
Purchased by a system of bulk and generic substitution
Local production of ARVs encouraged
Benefaction of ARVs facilitated by the Ethiopian Government
Ethiopian Government supplies ARVs for PMTCT
Supply of ARVs:
Encourage the establishment of international drug initiatives
Create an enabling environment for drug research
Encourage the private sector to produce generic drugs locally
Encourage all stakeholders to supply drugs to the community

43. General Strategies (3) Drug Use
Prepare and implement standardized prescription paper
Prepare and implement national guidelines for safe and effective use of ARVs
Sustainable public education on ARV drugs
 ARVs
Prescribe in authorized health institutions by trained physicians using the national treatment guideline
Dispense in authorized retail outlets by trained pharmacists or pharmacy personnel
Establish a system of ensuring patient adherence

44. General Strategies (4) Research and Development
Government of Ethiopia encourages research on modern and traditional HIV/AIDS treatment
Government of Ethiopia shall make efforts to strengthen the capacity of research institutions
Rights and benefits of citizens that enroll in research studies shall be respected
National and international ethical norms and values in human experimentations shall be observed

45. Scaling up ART Uptake Need capacity development to:
Initiate treatment
Help patients adhere to their treatment regimens
Monitor the efficacy and toxicity of the regimens
Diagnose treatment failure
Monitor overall resistance in society
ART program must be implemented at Health Center level
Nursing initiative to prescribe ARVs is being piloted

46. Key Points AIDS is a global, regional, and national crisis
The national HIV seroprevalence rate in Ethiopia is 4.7%
Urban rate is 12.5%
Rate in Addis Ababa is 14.5%
Approximately 20,500 people in Ethiopia are currently receiving ART
Step 5: Key Points (Slides 46 – 47) – 5 minutes
Summarize the presentation, review the Key Points presented in this unit and answer final questions.

47. Key Points (2)
ARV guidelines have been written, policies have been adopted, and training is being conducted in Ethiopia
ARVs have enormous benefits and challenges. The challenges include:
Developing capacity to initiate treatment
Supporting adherence
Monitoring efficacy and toxicity
Diagnosing treatment failure
Monitoring resistance