The HIV/AIDS pandemic is currently the most challenging public health matter that faces third world countries, especially those in Sub-Saharan Africa. Ethiopia, in East Africa, with a generalised and highly heterogeneous epidemic, is no exception, with HIV/AIDS affecting most sectors of the economy. The first case of HIV in Ethiopia was reported in 1984. Since then, HIV/AIDS has become a major public health con cern, leading the Government of Ethiopia to declare a public health emergency in 2002. In 2011, the adult HIV/AIDS prevalence in Ethiopia was estimated at 1.5%. Approximately 1.2 million Ethiopians were living with HIV/AIDS in 2010. Surveys are an important and popular tool for collecting data. Analytical use of survey data especially health survey data has become very common, with a focus on the association of particular outcome variables with explanatory variables at the population level. In this study we used the data from the 2005 Ethiopian Demographic and Health Survey, (EDHS 2005), and identified key demographic, socioeconomic, sociocultural, behavioral and proximate determinants of HIV/AIDS risk factor. Usually most survey analysts ignore the complex survey design issues like clustering, stratification and unequal probability of selection (weights). This study deals with complex survey design and takes the design aspect into account, because failure to do so leads to bias parameters estimates and standard error, wide confidence intervals and statistical tests will be incorrect. In this study, three statistical approaches were used to analyse the complex survey data. The first approach was a survey logistic regression used to model the binary outcome (HIV serostatus) and set of explanatory variables (the dependence of the HIV risk factors). The difference between survey logistic regression and the ordinary logistic regression is that survey logistic regression approach takes the study design into account during analysis. The second approach was a multilevel logistic regression model, that assumed that the data structure in the population was hierarchical, and that individual within household was selected from clusters that were randomly selected from a national sampling frame. We considered a three-level model for our analysis. This second approach considered the results from Frequentist and a Bayesian multilevel models. Bayesian methods can provide accurate estimates of the parameters and the uncertainty associated with them. The third approach used was a Spatial models approach where model parameters were estimated under the Integrated Nested Laplace Approximation (INLA) paradigm. / Thesis (Ph.D.)-University of KwaZulu-Natal, Pietermaritzburg, 2013.

According to the 2005 Ethiopian Demographic Health Survey, HIV prevalence in Gambella region where Fugnido refugee camp is located is 6%, which is the highest prevalence data recorded in the country. Similarly, the United Nations High Commissioner for Refugees (UNHCR) Health Information System (HIS) demonstrates that Fugnido has the highest HIV prevalence compared to other refugee camps in Ethiopia and furthermore shows variation in prevalence among the two main ethnic groups in the camp, namely Agnuak and Nuer (about 8.5% and 2.3% respectively). The study seeks to investigate why a significant difference exists in the number of people with known HIV positive status among the Agnuak community compared to the Nuer community in the Fugnido refugee camp in Ethiopia. It does this by investigating factors that are presumed to explain HIV high risk-behaviour and vulnerability. This was a cross-sectional study of Agnuak and Nuer tribes living at the Fugnido refugee camp. The sampled population involved men and women refugees from the ages of 15 to 49 years. The study used a mixed method approach or methodological triangulation. Cluster sampling technique was used for the quantitative data collection. The sample size was 831 refugees (439 Agnuak and 390 Nuer). Seven (7) Focus Group Discussions (FGDs) and 3 Key Informant (KI) interviews was used for the qualitative data collection. Findings show that the Agnuak were almost 4 times (OR=3.8, 95% CI [1.9-7.4] p < 0.05) more likely to practice risky behaviour compared to 0.3 times (OR=0.3, 95% CI [0.1- 0.9] p < 0.05) likelihood among the Nuer refugees. Factors associated with differences in risky behaviour for both Agnuak and Nuer included, inter alia, primary education as the highest level of education attained, 50% among the Agnuak (OR=0.5, 95% CI [0.3-0.8] p < 0.05), compared to Nuer community’s 30% (OR=0.3, 95% CI [0.2-0.6] p < 0.05). Access to HIV and voluntary counselling and testing (VCT) services was lower for the Agnuak (OR=1.8, 95% CI [1.1-2.9] p < 0.05) compared to the Nuer (OR=2.9, 95% CI [1.6-5.1] p < 0.05). Unlike the Nuer refugees, the Agnuak refugees who had experienced forced sex (OR=7.3, 95% CI [2.9-18.8] p < 0.05) and had a positive attitude (lack of or reduced stigma) towards HIV (OR=2.1, 95% CI [1.3-3.7] p < 0.05) were more positively associated with risky 6 behaviour (than the Nuer). The Nuer had no factor associated with risky behaviour that was different from that of the Agnuak. The study revealed more Agnuak refugees than Nuer refugees had been engaged in risky sexual behaviour by having multiple sex partners and being involved in transactional sex. The Nuer was more closed and reserved to having sexual relations outside of their group than the Agnuak were which contributed to their relatively lower HIV prevalence. Furthermore, there was very low condom use among the Nuer community compared to the Agnuak community, which was based on differential attitudes between the two communities concerning trust of partner and monogamous relations. The study findings recommend that humanitarian workers and community partners need to collaborate to develop congruent HIV interventions that go beyond traditional strategies of distributing condoms and focus on correct and consistent use of condoms in the camp. Humanitarian and community workers’ understanding the socioeconomic context of the communities and the influence of cultural and other factors, including behaviour with intervention strategies,could also curb the epidemic. / Sociology / M.A. (Sociology)

According to the 2005 Ethiopian Demographic Health Survey, HIV prevalence in Gambella region where Fugnido refugee camp is located is 6%, which is the highest prevalence data recorded in the country. Similarly, the United Nations High Commissioner for Refugees (UNHCR) Health Information System (HIS) demonstrates that Fugnido has the highest HIV prevalence compared to other refugee camps in Ethiopia and furthermore shows variation in prevalence among the two main ethnic groups in the camp, namely Agnuak and Nuer (about 8.5% and 2.3% respectively). The study seeks to investigate why a significant difference exists in the number of people with known HIV positive status among the Agnuak community compared to the Nuer community in the Fugnido refugee camp in Ethiopia. It does this by investigating factors that are presumed to explain HIV high risk-behaviour and vulnerability. This was a cross-sectional study of Agnuak and Nuer tribes living at the Fugnido refugee camp. The sampled population involved men and women refugees from the ages of 15 to 49 years. The study used a mixed method approach or methodological triangulation. Cluster sampling technique was used for the quantitative data collection. The sample size was 831 refugees (439 Agnuak and 390 Nuer). Seven (7) Focus Group Discussions (FGDs) and 3 Key Informant (KI) interviews was used for the qualitative data collection. Findings show that the Agnuak were almost 4 times (OR=3.8, 95% CI [1.9-7.4] p < 0.05) more likely to practice risky behaviour compared to 0.3 times (OR=0.3, 95% CI [0.1- 0.9] p < 0.05) likelihood among the Nuer refugees. Factors associated with differences in risky behaviour for both Agnuak and Nuer included, inter alia, primary education as the highest level of education attained, 50% among the Agnuak (OR=0.5, 95% CI [0.3-0.8] p < 0.05), compared to Nuer community’s 30% (OR=0.3, 95% CI [0.2-0.6] p < 0.05). Access to HIV and voluntary counselling and testing (VCT) services was lower for the Agnuak (OR=1.8, 95% CI [1.1-2.9] p < 0.05) compared to the Nuer (OR=2.9, 95% CI [1.6-5.1] p < 0.05). Unlike the Nuer refugees, the Agnuak refugees who had experienced forced sex (OR=7.3, 95% CI [2.9-18.8] p < 0.05) and had a positive attitude (lack of or reduced stigma) towards HIV (OR=2.1, 95% CI [1.3-3.7] p < 0.05) were more positively associated with risky 6 behaviour (than the Nuer). The Nuer had no factor associated with risky behaviour that was different from that of the Agnuak. The study revealed more Agnuak refugees than Nuer refugees had been engaged in risky sexual behaviour by having multiple sex partners and being involved in transactional sex. The Nuer was more closed and reserved to having sexual relations outside of their group than the Agnuak were which contributed to their relatively lower HIV prevalence. Furthermore, there was very low condom use among the Nuer community compared to the Agnuak community, which was based on differential attitudes between the two communities concerning trust of partner and monogamous relations. The study findings recommend that humanitarian workers and community partners need to collaborate to develop congruent HIV interventions that go beyond traditional strategies of distributing condoms and focus on correct and consistent use of condoms in the camp. Humanitarian and community workers’ understanding the socioeconomic context of the communities and the influence of cultural and other factors, including behaviour with intervention strategies,could also curb the epidemic. / Sociology / M.A. (Sociology)

Background AIDS remains one of the world’s most serious health challenges affecting more females than men. The differences in the spread of Human Immunodeficiency Virus (HIV) among gender groups stem from biology, sexual behaviour and socially constructed gender differences between women and men in roles and responsibilities, access to resources and decision-making power. It could also be due to the females’ status in society which could be justified by lower economic and decision making ability. Purpose The purpose of this study was to explore and describe the role of gender in the spread of HIV among women of reproductive age in Ethiopia; with the view of developing gender sensitive HIV and AIDS prevention strategies. Methods The study used sequential mixed method with quantitative and qualitative paradigm. During first phase of the study, health facility based descriptive cross-sectional study design was used. Data was collected from 422 respondents using a structured questionnaire. Forty participants were recruited by purposive sampling from representatives working in reproductive health or related fields. Results About 83.2% of respondents reported that sexual intercourse discussion should be initiated by male partners. This showed that majority of respondents were dependent on their male partners in decision-making regarding sexual matters in their relationship. Multiple sexual partners were common among the respondents. One third of the respondents reported to have had intercourse with more than one partner during the past twelve months of the study period. Higher proportion of respondents (61.4%, n=259) had never used condom during sexual intercourse with their partner/s. As a result these risky sexual practices are a potential threat for spread of HIV and AIDS among women. Thus developed guidelines would alleviate the existing problems through implementation of strategies of HIV and AIDS prevention to enhance women’s status at household and different administrative structure level. Conclusion Gender disparities in relation to negotiating sexual relations among the study respondents were found to be still relevant. The culture that has placed men at the helm of leadership in sexual matters is strongly upheld and that includes who recommends use of preventive measures and who regulates when and how to enter into a sexual relationship. Guidelines for gender sensitive prevention strategies if applied appropriately would educate women and men to make decision about what directly affects their health / Health Studies / D. Litt. et Phil. (Health Studies)

Background AIDS remains one of the world’s most serious health challenges affecting more females than men. The differences in the spread of Human Immunodeficiency Virus (HIV) among gender groups stem from biology, sexual behaviour and socially constructed gender differences between women and men in roles and responsibilities, access to resources and decision-making power. It could also be due to the females’ status in society which could be justified by lower economic and decision making ability. Purpose The purpose of this study was to explore and describe the role of gender in the spread of HIV among women of reproductive age in Ethiopia; with the view of developing gender sensitive HIV and AIDS prevention strategies. Methods The study used sequential mixed method with quantitative and qualitative paradigm. During first phase of the study, health facility based descriptive cross-sectional study design was used. Data was collected from 422 respondents using a structured questionnaire. Forty participants were recruited by purposive sampling from representatives working in reproductive health or related fields. Results About 83.2% of respondents reported that sexual intercourse discussion should be initiated by male partners. This showed that majority of respondents were dependent on their male partners in decision-making regarding sexual matters in their relationship. Multiple sexual partners were common among the respondents. One third of the respondents reported to have had intercourse with more than one partner during the past twelve months of the study period. Higher proportion of respondents (61.4%, n=259) had never used condom during sexual intercourse with their partner/s. As a result these risky sexual practices are a potential threat for spread of HIV and AIDS among women. Thus developed guidelines would alleviate the existing problems through implementation of strategies of HIV and AIDS prevention to enhance women’s status at household and different administrative structure level. Conclusion Gender disparities in relation to negotiating sexual relations among the study respondents were found to be still relevant. The culture that has placed men at the helm of leadership in sexual matters is strongly upheld and that includes who recommends use of preventive measures and who regulates when and how to enter into a sexual relationship. Guidelines for gender sensitive prevention strategies if applied appropriately would educate women and men to make decision about what directly affects their health / Health Studies / D. Litt. et Phil. (Health Studies)

Voluntary HIV counselling and testing (VHCT) is one of the key strategies in the prevention of HIV in Ethiopia. However, utilization of the VHCT services among adolescents has been reported as low by previous studies. The purpose of this study was to investigate adolescents’ knowledge and attitudes towards VHCT services among adolescents attending high school in Addis Ababa, the capital city of Ethiopia. A cross-sectional school-based design using quantitative methods was employed to attain the objectives of the study. Data collection was done using self-administered structured questionnaires among 378 adolescent high school students. Data was analysed using the Statistical Package for Social Sciences (SPSS). The findings revealed that 75.7% of students are aware of the voluntary HIV counselling and testing services; 62.2% use the services and suggested that VHCT services should be located in schools and youth clubs for better access by adolescents. Thirty-two percent of respondents rated themselves at risk of HIV infection and 35.2% were not willing to disclose their HIV positive status to anybody. The findings of the study clearly indicate a need for a more accessible voluntary HIV counselling and testing services for adolescents. / Health Studies / M.A. (Public Health)

This study aimed at assessing factors related to male participation in PMTCT in three public hospitals in Addis Ababa, Ethiopia. A quantitative, descriptive correlational design was used to assess correlation between male participation and socio-demographics, knowledge and awareness in HIV/PMTCT, socio-cultural belief, programmatic factors and reported risk. Male partners (n=216) were interviewed and reviews of HIV counselling and testing (HCT) acceptance formats were made. The major findings were 54.5% (n=156) males reported receiving HCT during their visit to partner’s antenatal care. Some 71.5 % (n=677) of women were accompanied to labour wards by male partners; 86.5% (n=208) of males accepted intra-partum HCT; 55.1% (n=216) scored above the mean score (10) on a 15-point scale for male participation. Male participation in PMTCT was found to have a statistically significant but weak correlation with educational level (r=0.193), income (r=0.167), PMTCT knowledge and awareness (r=0.172), socio-cultural belief (r=-0.164) and reported risk (r=-0.23). / Health Studies / M.A. (Public Health)

Given the lack of effective vaccine or medicine, changing an individual's risk behaviours has been crucial in preventing the spread of HIV. Consistent and correct condom use has been considered as the most effective form of HIV prevention among female sex workers. Despite coordinated national level interventions over the last decade, a consistent decline in condom use among female sex workers has been evidenced in the Ethiopian context, particularly with non-paying partners. Thus far, no study has been produced that has illustrated major determinants of consistent condom use among female sex workers which would help in developing effective intervention strategies for the prevention of HIV spread in the country. In other countries, the Information, Motivation and Behaviour (IMB) model has been used to identify individual level determents of condom use. However, the researcher postulated that behaviour emanating from the personality structure of individuals could be the fundamental individual level determents of adherence to condom use and chose to investigate this using the Enneagram theory of personality, which was acknowledged for its heuristic value in explaining and enhancing self-development of at-risk individuals. This cross-sectional study was conducted in Addis Ababa. With the Without Finite Population Correction of the Sample Size Estimation Formula, the sample size of 350 was set and participants were recruited using Respondent-Driven Sampling (RDS). Using trained female sex workers, the Essential Enneagram Test (EET) and an Information-Motivation-Behaviour (IMB) questionnaire were administered to collect data. General Linear Modeling (GLM) Multivariate analysis was carried out to assess the correlation between personality style and consistent condom use among participants in the last seven days before the interview. The finding of this study revealed that personality type, measured by the Essential Enneagram Test (EET), is able to predict adherence to condom use among female sex workers and provided a new dimension for policy makers and practitioners in behavioural intervention programmes, such as Information-Education-Communication, peer-to-peer approaches, as well as health and rehabilitation services by using the Enneagram principles and universal growth process. / Psychology / D. Litt. et Phil. (Psychology)

Stigma and discrimination (SAD) attached to Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) has been recognised as a major obstacle to HIV prevention, treatment, care and support throughout the world. SAD is more devastating when it occurs in health care settings where it is least expected. Health care providers (HCPs) are supposed to provide physical, social and psychological support to people living with HIV (PLWHA) but HIV and AIDS-related SAD has been extensively documented among the HCPs. Different studies have pointed out that there are three major actionable causes of HIV-related SAD in health care settings. These are lack of awareness among HCPs, fear of casual contacts and associating the SAD to immoral behaviour. The main objective of the current study is to determine the magnitude of HIV and AIDS-related SAD and its associated factors in hospitals and then to propose appropriate SAD reduction-intervention strategy in the health care settings. The study employed pre-test-post-test design with non-equivalent control group. Two paradigms were used in this study including quantitative and qualitative approaches. The sampling method for the quantitative part of the study was probability sampling in which the respondents were randomly selected using stratified sampling technique. The study was able to determine the magnitude of HIV and AIDS-related SAD among the HCPs. Moreover, the study has identified the factors that are attributed to the prevalence of SAD in the hospitals. The major factors identified for causing the SAD in the hospitals were sex, age, work experience, low level of knowledge, negative attitudes and percieved risk of HIV infection of some HCPs toward the PLWHA. The intervention made on the respondents in the treatment group was able to reduce the overall prevalence of the SAD among the HCPs. The study suggests that to reduce the SAD, HIV and AIDS-related trainings before and after graduation is critical to improve the knowledge, attitudes and practices of the HCPs. Besides, ensuring the availability of the protective supplies in hospitals is crucial in reducing the fear of HIV infection among the HCPs while providing care for HIV positive patients. Effective implementation of the hospital policies, strategies, guidelines and protocols along with good institutional support is also vital in creating safe and user-friendly hospitals for PLWHA / Health Studies / D.Litt. et Phil. (Health Studies)

Given the lack of effective vaccine or medicine, changing an individual's risk behaviours has been crucial in preventing the spread of HIV. Consistent and correct condom use has been considered as the most effective form of HIV prevention among female sex workers. Despite coordinated national level interventions over the last decade, a consistent decline in condom use among female sex workers has been evidenced in the Ethiopian context, particularly with non-paying partners. Thus far, no study has been produced that has illustrated major determinants of consistent condom use among female sex workers which would help in developing effective intervention strategies for the prevention of HIV spread in the country. In other countries, the Information, Motivation and Behaviour (IMB) model has been used to identify individual level determents of condom use. However, the researcher postulated that behaviour emanating from the personality structure of individuals could be the fundamental individual level determents of adherence to condom use and chose to investigate this using the Enneagram theory of personality, which was acknowledged for its heuristic value in explaining and enhancing self-development of at-risk individuals. This cross-sectional study was conducted in Addis Ababa. With the Without Finite Population Correction of the Sample Size Estimation Formula, the sample size of 350 was set and participants were recruited using Respondent-Driven Sampling (RDS). Using trained female sex workers, the Essential Enneagram Test (EET) and an Information-Motivation-Behaviour (IMB) questionnaire were administered to collect data. General Linear Modeling (GLM) Multivariate analysis was carried out to assess the correlation between personality style and consistent condom use among participants in the last seven days before the interview. The finding of this study revealed that personality type, measured by the Essential Enneagram Test (EET), is able to predict adherence to condom use among female sex workers and provided a new dimension for policy makers and practitioners in behavioural intervention programmes, such as Information-Education-Communication, peer-to-peer approaches, as well as health and rehabilitation services by using the Enneagram principles and universal growth process. / Psychology / D. Litt. et Phil. (Psychology)