1. Mainstreaming HIV into CIDA’s Ethiopia Programme: A Toolkit - Workshop - Paul Sunga and Marian Casey June 1-2, 2004 Addis Ababa

2. Objective of Workshop Goal: To enable a coherent response to the HIV epidemic in Ethiopia Purpose: 1.Launch HIV Mainstreaming Toolkit 2. Facilitate the mainstreaming of HIV components into food security programmes

3. Workshop Agenda 9:00Welcome - CIDA Country Director-– M-A Fredette Keynote - Minister of Agriculture – Ato Belay 9:50HIV situation analysis and projections 10:10HIV and food security 10:30COFFEE BREAK 11:00Six Steps to HIV Mainstreaming – the Toolkit 11:15Group exercise 1– Knowing about taboos 11 11:50Group exercise 2 – Knowing about HIV impacts 12:30LUNCH 1:30Group exercise 3 – Assessing a FS project through an HIV lens 2:30Group exercise 4 and 5– Using the mainstreaming toolkit 4:45Conclusions

4. Take the HIV Test 1.What do the terms HIV and AIDS stand for? 2.Name three ways that HIV can be transmitted? 3.How can HIV transmission be prevented? 4.How many Ethiopians are living with HIV? 5.What is the most common infection that kills HIV infected people in Ethiopia? 6.Which group has the highest number of infections each year? Male or female? Age- 15-24 / 20-49 / 30-49 7.What percentage of commercial sex workers are HIV infected in Addis? 8.What percentage of rural people are affected by HIV? 9.Name three ways that HIV is affecting development in Ethiopia? 10.Can people be cured of HIV?

5. Situation Analysis HIV epidemic in Ethiopia at a glance Forecasts and impacts Interactions between HIV and food security

6. Key Features of the HIV Epidemic in Ethiopia ‘generalized’ epidemic at 6.6% nationally transmission - mainly heterosexual and mother to child peak prevalence - women 15-24 yr urban concentration of 13.7% (1 in 7 adults) Has it reached a plateau? national rural prevalence estimated at 3.7% (1 in 27) based on weak rural surveillance NOTE: likelihood of higher prev. in some areas 50% of hospital beds are AIDS patients lack of studies in Ethiopia in rural areas

7. HIV Prevalence in Pregnant Women - Bahir Dar - Ministry of Health,GoE

8. Features of Response to the Epidemic emphasis on public health response responses are urban and in selected regions emerging rural surveillance data emerging sector-specific strategies

9. Forecasts and Impacts

10. HIV prevalence in adults in sub-Saharan Africa, 1986-2001 20 – 39% 10 – 20% 5 – 10% 1 – 5% 0 – 1% trend data unavailable outside region 1986 1991 19962001

11. Projected HIV positive population in Ethiopia Ministry of Health, 2002

12. Projected number of deaths from AIDS in Ethiopia Ministry of Health, 2002

13. Projected Number of AIDS Orphans Ministry of Health, 2002

14. Leading causes of disease burden in Africa, 2000 Source: The World Health Report 2001, WHO * Unintentional injuries aside from traffic accidents, poisoning, falls, fires and drowning 20.6 10.1 8.6 6.3 6.1 4.5 3.6 2.8 1.9 1.8 0.0 5.0 10.0 15.0 20.0 25.0 HIV/AIDS Malaria Lower respiratory infections Perinatal conditions Diarrhoeal diseases Measles Maternal conditions Tuberculosis Other unintentional injuries* Pertussis % of Total

15. 0 10 20 30 40 50 60 70 80 Tanzania 1996 Malawi 1992 Zimbabwe 1994 Uganda 1995 Zambia 1996-97 Probability of dying from all causes estimated for 6 years before survey estimated for year of survey Source: Timaeus I, AIDS 1998, 12 (suppl): S15-S27 Increase in mortality among men between 15 and 60, selected African countries

16. Changes in life expectancy in selected African countries with high and low HIV prevalence: 1950-2005 with high HIV prevalence: Zimbabwe South Africa Botswana with low HIV prevalence: Madagascar Senegal Mali Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision 30 35 40 45 50 55 60 65 Life expectancy (years) 1950– 1955 1955- 1960 1960- 1965 1965- 1970 1970- 1975 1975- 1980 1980- 1985 1985- 1990 1990- 1995 1995- 2000 2000- 2005

17. Percentage of workforce lost to AIDS by 2005 and 2020 in selected African countries 0 10 20 30 40 50 % 2005 2020 Botswana Cameroon CAR Côte d’Ivoire Ethiopia Guinea-Bissau Mozambique Nigeria South Africa Togo UR Tanzania Zimbabwe Sources: ILO (2000) POPILO population and labour force projection; UN Department of Economic and Social Affairs, Population Division (1998) World Population Prospects: the 1998 Revision 01 July 2002 slide number SSA-17

18. Interactions between HIV and Food Security

19. Impact of HIV/AIDS on urban households, Côte d’Ivoire General population Families living with AIDS Monthly income per capita Monthly income per capita Monthly consumption per capita Monthly consumption per capita 0 0 5 000 10 000 15 000 20 000 25 000 – 5 000 30 000 Francs CFA Savings/Disavin gs Source: Simulation-based on data from Bechu, Delcroix and Guillaume, 1997

20. Reduction in production in a household with an AIDS death, Zimbabwe Source: Stover & Bollinger, 1999 Reduction in output Maize Cotton Vegetables Groundnuts Cattle owned 49% 37% 29% 47% 61%

21. Newly diagnosed AIDS cases and medical expenditure on an agricultural estate in Kenya, 1989 to 1997 0 20 40 60 80 100 120 899091929394959697 Number of newly diagnosed AIDS cases 0 5 10 15 20 25 Medical expenditure (KSh millions) new AIDS cases medical spending Source: Rugalema et al. HIV/AIDS and the commercial agricultural sector of Ken UNDP/FAO, 1999

22. Broad Features of Ethiopian Food Security Situation roughly 5 million Ethiopians are chronically food insecure 95% of arable land is farmed by small holder farms that produce less than subsistence levels of food, fuel and fodder small holder farms are based upon an intimate relationship between farm production and domestic family life

23. Vulnerability to HIV Vulnerability factors increase the risk of HIV infection in a population Food insecurity is a major vulnerability factor

24. Some major factors that increase the vulnerability of Ethiopians to HIV infection Poverty Governance factors – lack of capacity, low civil society input into governance weakened social fabric due to famine and conflict status of women limited community and institutional capacity to respond to wide-spread epidemic

25. What is known MalnutritionFood insecurity Poverty New HIV infection

26. What is not known... how severe the epidemic will become in rural Ethiopia how the shift in demography of Ethiopia will affect food security how rural people in diverse ethnic and ecological settings will cope with the epidemic

27. What is ‘HIV mainstreaming’? HIV mainstreaming is the process of identifying and mitigating the effects of: development programmes or projects on the vulnerability of Ethiopians to HIV the HIV epidemic on the outcomes of development programmes and projects

28. Six Steps to HIV Mainstreaming in Food Security Programming 1.Knowing HIV and the epidemic 2.Assessing the situation and the impact 3.Planning to reduce or mitigate the impact 4.Implementing the plan 5.Monitoring 6.Evaluation of the effectiveness of mainstreaming HIV

29. HIV Mainstreaming Toolkit Features 3 modules –Module 1 is general and for everyone –Module 2 contains HIV mainstreaming tools for food security programmes –Module 3 contains HIV mainstreaming tools for democracy and governance programmes – The ‘tools’ are organized according to the Six Steps.

30. You are the experts….

31. Group exercise 1. Knowing about social taboos as barriers to communication Discuss your earliest sexual experience. How old were you? Were there things you should have known or would have liked to know? Who did you tell about it at the time? Why is it difficult to talk about this? Explain what you understand of the term ‘taboo’. How do social taboos make the HIV epidemic worse in rural Ethiopia?

32. Group exercise 2: Knowing the impact of the HIV epidemic Discuss with your group one person you know who has HIV or AIDS, or who has died of AIDS? What were the impacts of that person’s illness? On family and friends? Workplace? Community? Other. Identify three things that might have been done to lessen the impact.

33. Group exercise 3. Knowing about stigma Are HIV infected persons and their families treated differently by the community? How can social stigma make the spread of HIV worse in rural communities?

34. Key interaction points between HIV and Food Security social cohesion rural women institutional capacity to address HIV ( institutional HIV competence) rural resources technology and information

35. Social Cohesion Factors stability of families stability of communities stability of markets Key issues displacement of families migration of farmers for work or training economic pressure following illness or death of adult farmer loss of community support structures reduction in markets

36. Rural Women Factors poverty gender perceptions lack of voice illiteracy weak social and legal support poor health status Key Issues weak negotiating position weak political representation reduced income due to loss of family member unequal educational opportunities for women increased workload due to loss discriminatory traditional norms and laws poor access to health care

37. Institutional capacity (HIV competence) Factors discrimination against HIV+ persons unsupportive financial and social response mechanisms weak governance Key issues HIV stigma lack HIV awareness and understanding among leaders lack of local evidence re: HIV impacts of FS incapability of developing HIV strategy for the institution no institutional code of ethics regarding HIV positive employees, clients

38. Rural Resources Factors loss of labour loss of financial assets loss of credit loss of agricultural inputs reduction in land under till below subsistence yield Key Issues lack of sufficient prevention, care and treatment illness and funeral expenditures male-oriented credit system lack of safety nets for provision of agric input lack of technology options lack of diverse crop selection

39. Technology/ Information Factors reduced water saving increase in soil erosion increased pests reduced farm production livestock loss/switching Key Issues loss of know-how loss of information traditional lack of sharing of know-how and information lack of dissemination of appropriate know- how

40. Group exercise 4: Assessing an FS programme through an HIV lens Using the assessment tools, outline how you would carry out an HIV assessment of the example provided of a food security programme. Three sample programmes or programme components will be provided. NOTE that the assessment information is the basis for planning

41. Mainstreaming Considerations: Food Security displacement of families migration of farmers for work or training economic shock on farming household following illness or death loss of community support structures loss of access to markets weak political representation reduced income due over long term - loss of family member increased workload due to loss discriminatory traditional norms and laws unequal access to health care HIV stigma lack of HIV awareness among leaders

42. Mainstreaming Considerations - Food Security lack of local evidence re: HIV impacts of FS inability to develop HIV strategy for the institution lack of institutional code of ethics re: HIV positive employees, clients lack of sufficient prevention, care and treatment illness and funeral expenditures male-oriented credit system lack of safety nets for provision of agric input lack of technology options lack of diverse crop selection loss of know-how loss of information traditional lack of sharing of know-how and information lack of dissemination of appropriate know-how

43. Mainstreaming Intervention Points for Food Security programming analysis and means to reduce displacement of families analysis of impact of HIV on Ethiopian farms minimize migration of farmers for work or training support rural community-based prevention strategies support rural community-based care strategies support safety nets to reduce periodic economic catastrophe at time of illness or death of adult farmer support for HIV and gender advocacy in rural communities understanding women and child headed farms advocacy for legal framework protecting farming assets of survivors gender-focused agric extension training programmes gender-focused credit for farmers gender-focused micro-enterprise development

44. Mainstreaming Intervention Points for Food Security Programming understanding division of farm labour understanding labour reducing technology shifts understanding capacity loss training of agric ext cadre promote HIV awareness and understanding among leaders support development of capability of devising HIV strategy for the institution advocate for institutional code of ethics re: HIV positive employees, clients

45. Group exercise 5: Planning to mainstream HIV in an FS programme Using the planning tools, identify the areas that are most likely to require addressing in the example provided of a food security programme. Be as specific as possible, given that the assessment has not been carried out. Collect and collate your plan for a round table discussion.

46. Thanks for participating. Facilitators: Dr. Paul S.Sunga Langara College Vancouver, Canada psunga@langara.bc.ca Marian Casey PSU/CIDA Addis Ababa humanitarian@psu…