In 2005, Ethiopia rolled out its Anti-Retroviral Therapy (ART) program making AIDS treatment available to patients free of charge. With ART roll out came a great need to educate PLHA and providers on treatment options and to support ART uptake. ARC was tasked with the development of an overarching framework to guide all communication interventions to support the effective delivery and use of clinical care provided to HIV-positive adults. With quality of care as its centerpiece, the framework focused on increasing uptake and adherence to ART, engaging clients in their own care, enabling them to be more assertive and responsible for monitoring their health status and improving their well being. It also re-positioned HIV/AIDS as a chronic and manageable disease.
Audiences selected in the framework and targeted by the program include: adults living with HIV, caregivers of people living with HIV, service providers and community leaders.
- To -increase ART service uptake and adherence among PLHA
- To encourage positive living and improve quality of life of PLHA
- To improve the quality of care provided by ART service providers
ARC contributed to the first step in operationalizing the ART communication framework by producing various print materials dealing with healthy living, adherence, side-effects, management and treatment of opportunistic infections, nutrition and combination therapy for adults living with HIV, along with drug reference job aids for service providers. Materials were developed in the three major languages spoken in the country, namely: Amharic, Oromiffa and Tigrinya, and were distributed nationally through USG partners and associations.
Testament to the robustness and elasticity of the program is its progressive expansion to tackle many other vital and emerging issues including: patient-provider communication, pediatric care, stigma and discrimination, PLHA support, and social barriers to treatment and care.
The SMART Campaign
Research indicates that open client-provider communication can improve the quality of life of PLHA and their adherence to ART. To address communication gaps between providers and their HIV positive clients, ARC developed and implemented the SMART client/ SMART provider campaign (Astewai and Tagash). The SMART client/SMART provider approach focuses on encouraging clients to talk openly to their service providers and to take control and responsibility of their lives and health. It also encourages providers to be more attentive and responsive to their client’s needs and to promote patient involvement. To reach these audiences, the ART program mainly partnered with the Federal Ministry of Health, USG partners and PLHA associations.
For clients, the program developed a low literacy community conversation flip chart and accompanying facilitator discussion guide, a video and discussion guide, an adherence diary and a number of radio spots. ARC closely worked with Mekdim, a well-established PLHA association, to train association members on the effective use of these tools. Those trained facilitated conversations at associations, in various gatherings, health facilities and in waiting rooms.
For providers, a video and accompanying discussion guide was also developed. Discussions using these materials were undertaken in various service provider gatherings including meetings, conferences and trainings. Additionally, a pilot training in applied counseling and burn-out management skills was provided to service providers. Given the success of these trainings, the Ministry of Health is considering integrating SMART training into the national training curriculums for HIV/AIDS service providers.
Although scientific evidence may exist on the efficacy of a biomedical treatment of an illness, popular alternatives are also always available, sometimes in direct competition with biomedicine. Such is the case for ART in Ethiopia. For example, many followers of the Ethiopian Orthodox Church (EOC) believe that Holy Water has the power to cure HIV disease. Noting that many HIV-infected EOC believers were abandoning ART and opting for Holy Water instead, the ART communication team reached out to EOC clergy to address the problem. Rather than competing with the EOC’s alternative understanding of the illness and the power of faith to heal, ARC worked with clergy to find common ground and a mutually beneficial strategy that advocated patients to follow both treatments in tandem. ARC developed a special HIV/AIDS training curriculum, two documentaries and pocket guide specifically for clergy. Reaching the wider faith community, radio spots reinforced key messages of concurrent and complementary ART and Holy Water treatment seeking.
Addressing the second most common religion, Islam, various dialogues were undertaken with Muslim religious leaders from around the country. The dialogues were designed in such a way that unraveled common misconceptions regarding HIV and its treatment shared amongst religious leaders. These misconceptions were thoroughly analyzed and discussed with prominent religious scholars and service providers who explored each of the misconceptions raised in light of Islamic religious books and scientific understandings.
Children living with HIV are a special population with unique needs - clinical, psychological, and social. To ensure a strategic and synergistic approach, ARC worked with other stakeholders to develop a strategic communication framework solely focusing on pediatric HIV. As a follow-on, ARC developed materials to educate low literate caregivers about the needs of HIV-positive children in line with the framework.
Therapy, Stigma and Discrimination
To decrease stigma and focus on empowering people living with HIV/AIDS, ARC developed the “Lives in Color” activity to promote positive living and increase tolerance for people living with HIV/AIDS in the community. This innovative approach used full-length body maps of HIV positive adults and caretakers of HIV positive children, which provided an outlet for individuals to express and understand themselves while educating the general public about the lives of people affected by HIV and related challenges. The body mapping workshops were accompanied by experienced counselors from ARC’s Wegen AIDS Talkline who supported participants during emotional moments of reflection. Body mapping is a therapeutic tool and for most of the participants, was a very emotional experience. Whilst developing beautiful art works of their bodies, participants were able to reflect on major incidents in their lives, answer questions about their pasts and futures, and ultimately made hopeful plans for their futures. These maps were put on display in the National Museum where they garnered widespread attention. Volunteer body-mappers talked audiences through their life journeys, and spoke about what it means to be positive.
Promoting the Care of Self and Other
Mekonen Alemu is a member of Mekdim Ethiopia National Association of PLHA. For both his own use, and for educating fellow Association members, Mekonen has been utilizing ART communication materials since their first release. Mekonen says that with all of the important information about living with HIV and being on ART easily available, “I have learnt a lot about how to live whilst being HIV positive … I also feel more confident to talk to my doctor and ask questions about things I do not understand.” With the help of the adherence diary and the drug information booklets, Mekonen is also better able to do his part in keeping up with his treatment, while recognizing signs of adverse effects.
The materials have additionally enabled Mekonen to be a counselor and active PLHA Association member. “All the materials help me teach our members about HIV easily. “ Mekonnen especially appreciates the materials developed for the SMART campaign, “….the SMART flipchart is very useful … topics raised and the images used help me have very valuable discussions with our members that address adherence, healthy living and above all being responsible for one’s own life.”
Mekonen applauds the ARC for abundantly distributing ART communication materials to PLHA associations; “our members like it when we give them materials to take home ... thankfully, ARC has always provided us with ART materials to distribute to our members.”
Materials and Resources
- Print materials
- Mass media triggers
- Consolidation of activities – distribution and outreach
- Roll-out SMART campaign to other regions
- Development of pediatrics materials and activities
- Development of mental health materials and activities
The ART Communication program is managed by the Johns Hopkins Center for Communication Programs/AIDS Resource Center (CCP/ARC). It is funded by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC), Ethiopia's HIV/AIDS Prevention and Control Office (HAPCO), and in partnership with its University Partners, the Ethiopian Ministry of Health (MOH), CCP/ARC's Wegen AIDS Talkline, Fitun Warmline and Betengna PLHA Radio Diaries program.
Anthoula Assimacopoulou, ART Program Officer
AIDS Resource Center
Telephone: +251-115 503584 (Ext.1126)
Fax: +251-115 503749