How MSH Is Using Gender Awareness and a Family-Focused Approach  to  Respond to HIV & AIDS in Ethiopia

[Dr. Belkis Giordis. Photo Credit: MSH Staff.]Dr. Belkis Giordis. Photo Credit: MSH Staff.The HIV/AIDS Care and Support Program (HCSP), funded by the US Agency for International Development, represents the largest national expansion of HIV & AIDS services at the community and health center levels in Africa. Dr. Belkis Giorgis, the program’s NGO Capacity Building/Gender Advisor, discusses how gender awareness, a focus on the family, and community involvement are essential when responding to HIV & AIDS in Ethiopia.

Why is gender awareness necessary in the context of HIV & AIDS and Ethiopia?
Issues of gender fuel the HIV & AIDS epidemic in Ethiopia.  Women are disproportionately infected by HIV here because they are more vulnerable to the virus than men and also due to their lower social status and lack of knowledge or control in sexual situations. In 2007, 2.9 out of every 100 women were affected with AIDS in comparison to 1.9 out of every 100 men.*

At the same time, women have a central role in their families—and communities.  In Ethiopia women carry the major responsibilities for family health and welfare. Women take care of the elderly, the sick, and children in addition to their own health, and they have largely carried the burden of caring for those affected by HIV. Women in Ethiopia are also the transmitters of social values—both positive and negative—regarding sexuality, femininity, masculinity, fatherhood, and motherhood.  So the culture that is subordinating women is also the source of their strength and identity.
Yet when addressing gender issues, these realities, as well as the creativity and resourcefulness of women to find solutions to difficult problems are often not acknowledged. For example, due in large part to the efforts of women, there are ceremonial, religious, and mutual support associations already in place that are helping communities to meet the challenges of HIV & AIDS.

Why is focusing on the family so important?
Focusing on the family has multiple benefits. Remember that gender includes both men and women and issues related to male involvement should demonstrate benefits for both men and women.  By focusing on the family, men and women are brought together as a social unit and we are able to increase participation in voluntary HIV counseling and testing (VCT), antiretroviral therapy, and the promotion of prevention of mother-to-child transmission (PMTCT) of HIV services. Issues around gender violence also become more apparent and can be dealt with more effectively when working with a family unit.

The social, cultural, and psychological dimensions of HIV & AIDS affect not only the individual but also the whole family. Stigma and discrimination can alienate men and women from their families, so it’s important to educate and support the whole family unit. And, a family with an HIV-positive member can often be ostracized by the community and left without means to support themselves. In this case, families need additional support, such as links to food, shelter, and income.

Why do you need to involve the community when addressing gender?
As individuals, women in many African societies, including Ethiopia, find it difficult or even impossible to change or adopt new behavior without the sanction of their immediate grouping, which ranges from their extended families, to community and religious leaders and kinship systems groups. Since religion is so critical in Ethiopia, HCSP has worked with Ethiopian Interfaith Forum for Development Dialogue and Action to train religious leaders of all faiths who have daily contact with the community on stigma and how to counsel individuals, families, and communities. Traditional ceremonial and religious events where women predominately participate—such as coffee ceremonies— are used to provide information and link them to services.

At the same time, outreach workers, nongovernmental organizations, and other groups are used to take HIV & AIDS services outside the clinic walls to where women live and work.  Underutilization of health services plagues many countries in sub-Saharan African countries for many reasons, including transportation and cost. HCSP has trained  kebele-oriented outreach workers—a “kebele” is an urban area, similar to a neighborhood—who operate in the communities, as well as supported 600 outreach workers from local nongovernmental organizations who are mostly women.  A majority of the outreach workers are women who go house-to-house supporting individuals and families infected and affected by HIV & AIDs, serving as advocates and connecting them to health centers for HIV and other primary care services.   Since many outreach workers are also HIV-positive, other women and the entire community can see that it is possible to be HIV-positive and a productive member of society.

How do you ensure that gender concerns are integrated into all program activities?
HCSP is a project where even if you tried you cannot fail to address gender. The question is to what degree and how effective it is.  We started by using a family-focused approach and then took care to clearly articulate gender issues and outcomes expected in other components of the project.  For example, 50 percent of the case managers we hired and trained at the health center level are women with the goal of increasing use of services by women. Having a female case worker can increases a woman’s comfort with discussing health issues and can encourage her to access the services she needs.

We also sensitize HCSP staff to recognize gender issues and find entry points to address gender that may come up along the way.  For example, if the project is aware that one of the problems women face is lack of privacy in the health center where they seek treatment, even though HCSP does not have the mandate to change the set up of the health center, we can work with the health center staff to see how this can be changed.

How do you know this approach is working?

Progress in addressing gender issues can be difficult to measure because many of the outcomes—such as a change in cultural and social values—will be felt years after a project ends and can be affected by other factors. However, many gender issues are easily observable. I believe that there is a tremendous opportunity for HCSP to analyze the data and show trends which may be important in addressing gender.  For example, on the health services side, we see the numbers of VTC increasing for women as well as PMTCT. Linkages to other services—particularly food, income, shelter—which the outreach workers implement are also showing increases.  

What have you learned from this project that can be applied elsewhere?

Mainstreaming gender—integrating gender awareness and gender sensitivity into project programming— is not difficult.  The key to mainstreaming gender is not only to overcome challenges but to find opportunities and build on what is already there. It is a long-term process but can be accelerated through interventions that have a positive impact for everyone—such as happens in a family-focused approach.  Also, in particular for HIV & AIDS, ownership of the gender agenda needs to be taken up by everyone on the project—and gender literacy taught to all staff—so it will be possible to take advantage of unforeseen opportunities and see tangible outcomes.

*Ethiopia's Federal Ministry of Health and the National HIV/AIDS Control Board


Related Links:

Ethiopia: A Community Response to HIV & AIDS (Video)

"Strengthening the Response to HIV & AIDS in Ethiopia," article from Monday Developments

HIV-Positive Women Start "Mothers Support Groups," Preventing Transmission of HIV to Children in Ethiopia


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