HIV among children in Ethiopia

Westerlund E, Jerene D, Mulissa Z, Hallström I and Lindtjørn B. Pre-ART retention in care and prevalence of tuberculosis among HIV-infected children at a district hospital in southern Ethiopia. BMC Pediatrics 2014, 14:250


Background  The Ethiopian epidemic is currently on the wane. However, the situation for infected children is in some ways lagging behind due to low treatment coverage and deficient prevention of mother-to-child transmission. Too few studies have examined HIV infected children presenting to care in low-income countries in general. Considering the presence of local variations in the nature of the epidemic a study in Ethiopia could be of special value for the continuing fight against HIV. The aim of this study is to describe the main characteristics of children with HIV presenting to care at a district hospital in a resource-limited area in southern Ethiopia. The aim was also to analyse factors affecting pre-ART loss to follow-up, time to ART-initiation and disease stage upon presentation.

Methods  This was a prospective cohort study. The data analysed were collected in 2009 for the period January 2003 through December 2008 at Arba Minch Hospital and additional data on the ART-need in the region were obtained from official reports.

Results   The pre-ART loss to follow-up rate was 29.7%. Older children (10-14 years) presented in a later stage of their disease than younger children (76.9% vs. 45.0% in 0-4 year olds, chi-square test, chi2 = 8.8, P = 0.01). Older girls presented later than boys (100.0% vs. 57.1%, Fisher’s exact test, P = 0.02). Children aged 0-4 years were more likely to be lost to follow-up (40.0 vs. 21.8%, chi-square test, chi2 = 5.4, P = 0.02) and had a longer time to initiate ART (Cox regression analysis, HR: 0.50, 95% CI: 0.25-0.97, P = 0.04, controlling for sex, place of residence, enrolment phase and WHO clinical stage upon presentation). Neither sex was overrepresented in the sample. Tuberculosis prevalence upon presentation and previous history of tubercolosis were 14.5% and 8% respectively.

Conclusions  The loss to follow-up is alarmingly high and children present too late. Further research is needed to explore specific causes and possible solutions.

Missing AIDS Patients

ResearchBlogging.orgIt is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not come for their antiretroviral medications. Such patients are labelled as “lost to follow-up.”

During the early years of antiretroviral treatment (ART) drug distribution in Africa, researchers reported high rates of adherence to treatment, often as high as in Europe or the United States. At the same time, studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. A reason for the high death rates was late presentation of patients to care.

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start to present at earlier stages of their illness, and death has decreased among adult HIV patients. Early treatment start contributed to improved survival (Mulissa, Jerene and Lindtjørn, 2010).

Unfortunately, 25 per cent were lost before that started treatment. This means they were diagnosed, but did not return for treatment, and this have increased during the recent years. We also found that 15% per cent of those who start treatment were lost to follow up. 40% of the latter group had died, and 20% had started treatment in another institution.

Some ART programmes in Africa are experimenting with different programmes to reduce loss to follow-up. Some organizations offer a two- or three-month supply of medication for each clinic visit, others deliver drugs to patients’ homes, and some have tried to refund patients for transport costs. None of these efforts have been evaluated.

Mulissa, Z., Jerene, D., & Lindtjørn, B. (2010). Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia PLoS ONE, 5 (10) DOI: 10.1371/journal.pone.0013268

New articles from EJHD

The latest issue of the Ethiopian Journal of Health Development contains many interesting articles.

Among these important public health articles, I would like to highlight one paper: Getnet Tadele from the Department of Sociology at Addis Ababa University writes about sexual abuse against male street children in Addis Ababa (1). He worked in the Merkato (main market) area in Addis Ababa, and found that sexual abuse against male children around Merkato area is widespread.

Male homosexuality makes up a major HIV transmission route in the Americas, Eastern Europe and parts of Asia but is rare in Africa. Although anthropologists have reported homosexual behaviour in Africa since the 17th century, it remains as a taboo subject. Recent information suggests that homosexuality is common in Ethiopia. This adds to increasing evidence that the HIV epidemic in Ethiopian towns is more complex that previously anticipated (2 – 4) .


1.         Tadele G. ‘Unrecognized victims’: Sexual abuse against male street children in Merkato area, Addis Ababa. Ethiop J Hlth Dev. 2009;23(3):174-82.

2.         Kloos H, Mariam D, Lindtjørn B. The AIDS Epidemic in a Low-Income Country: Ethiopia. Human Ecology Review. 2007 Jan 1;14(1):39-55.

3.         Tadele G. Bleak prospects: young men, sexuality and HIV/AIDS in an Ethiopian town. PhD Thesis. Amsterdam: University of Amsterdam; 2005.

4.         Gebreyesus SH, Mariam DH. Assessment of HIV/AIDS related risks among men having sex with men (MSM) in Addis Ababa, Ethiopia. J Public Health Policy. 2009 Sep;30(3):269-79.

Treating children with AIDS

We are reviewing the treatment results among patients receiving antiretroviral therapy at Arba Minch Hospital.

From Ethiopia there are few results published on treatment outcome in children with HIV infection. We have therefore reviewed the survival of children 14 years or younger.

The preliminary results (se Figure) show the five-year survival rate is about 90 %.

Most of the deaths occur during the first twelve months, and usually occurs among patients with advanced disease when we started treatment.

Long-term outcome of HIV treatment

We are reviewing the outcome of antiretroviral treatment at Arba Minch Hospital. We started treating patients in 2003, and since then about 1550 patients have received the antiviral drugs.

Our early papers showed the death rates among patients were high during the first months of treatment. We thought the reasons for these high death rates were the patients came late for treatment; that is, they presented themselves with late stage disease.

Our objective for the study is to see if the treatment results improve over time, and if patients present with earlier stage disease. Dr Zewdie Mulissa and Dr Degu Dare take part in this study.

Our preliminary findings confirm improved survival, and that patients come earlier for treatment. We are now also trying to find out what happens to patients after they are diagnosed with HIV until they start treatment.

Antiretroviral therapy is cost-effective

As the resource implications of expanding anti-retroviral therapy (ART) are likely to be large, there is a need to explore its cost-effectiveness. We therefore assessed the cost-effectiveness of ART for routine clinical practice in a district hospital setting in Ethiopia.

We estimated the unit cost of HIV-related care from the 2004/5 fiscal year expenses of Arba Minch Hospital in southern Ethiopia. We estimated outpatient and in-patient service use from HIV-infected patients who received care and treatment at the hospital between January 2003 and March 2006. We measured the health effect as life years gained (LYG) for patients receiving ART compared with those not receiving such treatment. The study adopted a health care provider perspective and included both direct and overhead costs. We used Markov model to estimate the lifetime costs, health benefits and cost-effectiveness of ART.

ART yielded an undiscounted 9.4 years expected survival, and resulted in 7.1 extra LYG compared to patients not receiving ART. The lifetime incremental cost is US$2,215 and the undiscounted incremental cost per LYG is US$314. When discounted at 3%, the additional LYG decreases to 5.5 years and the incremental cost per LYG increases to US$325.

The undiscounted and discounted incremental costs per LYG from introducing ART were less than the per capita GDP threshold at the base year. Thus, ART could be regarded as cost-effective in a district hospital setting in Ethiopia.


Bikilla AD, Jerene DS, Robberstad B and Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:13doi:10.1186/1478-7547-7-13

Also see [intlink id=”146″ type=”post”]previous post on cost of HIV treatment[/intlink]:

Bikilla AD , Jerene D, Robberstad B and Lindtjorn B. Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:6doi:10.1186/1478-7547-7-6

Preventing HIV among adolescents and youth in rural Ethiopia

Mitike Molla is on May 28, 2009 defending her PhD at the University of Bergen.

The title is: Preventing HIV among young people: A community based study from Butajira on traditional norms, sexual health and HIV associated deaths. 

The health needs of young adults in Ethiopia are often neglected.  HIV is one of the major health problems among young people in Ethiopia, where the transmission often starts to pick up at the age of 15-24 years.

She interviewed 3743 young adults about sexual behaviours and sexually transmitted infections. She also asked about the attitude, opinion and knowledge of health providers towards young adults reproductive health needs. She used data from the Butajira Rural Health Programme, Demographic Surveillance Site to assess mortality trends among young adults aged 10-24 years.

She found the traditional norm of keeping virginity until marriage is still followed among the youth in rural South Central Ethiopia. Only 3% of the never-married youth had premarital sex, while almost all married youth started their union as celibates. Young adults who used alcohol, chewed khat, and did not believe in the traditional norm were more likely to have premarital sex. However, the study also showed that married women are vulnerable to HIV and other sexually transmitted diseases because of risky sexual behaviours among their husbands.

4% had had a sexually transmitted disease during the year preceding the study. Most of these were married women. Half of them who had STI symptoms did not seek help, mainly because of shame of having the infection in marriage and taboos related to premarital sex. Lack of readiness of the health services for the youth, unfavourable attitude of health professionals, women’s subordinate position in the society, and lack of knowledge about STIs among youth are possible reasons for low health seeking behaviour among young people. Six out seven of the sexually active young adults never used condoms.

Among young adults, the deaths rates declined during the period 1987-2004, with only a few deaths caused by HIV.

Upholding the traditional norm of virginity, prevention programmes should encourage HIV counselling and testing (HCT) before marriage, and faithfulness in marriage. Condom use among non-users should be encouraged and strengthened among ever-users to bring about consistent use in all non-mutual monogamous relations. The health services should be reoriented towards young adults’ SRH to improve use.

Mitike Molla’s PhD publications:

Molla M, Byass, P: Berhane Y, Lindtjørn B. Mortality decreases among young adults in south-central Ethiopia. Ethiop J Hlth Dev 2008; 22: 218-225.

Molla M, Berhane Y, Lindtjørn B. Traditional values of virginity and sexual behaviour in rural Ethiopian youth: results from a cross-sectional study. BMC Public Health. 2008;8:9.

Mitike Molla, Maria Emmelin, Yemane Berhane, and Bernt Lindtjørn. Youth in rural Ethiopia hesitate to seek health services for sexually transmitted infections: A mixed method research in Butajira, Central Ethiopia. African Journal of AIDS Research 2009, 8(2): 135–146

M. Molla A. Nordrehaug Åstrøm , Y. Berhane Y: Applicability of the theory of planned behavior to intended and self reported condom use in a rural Ethiopian population. AIDS Care, 2007, 19 (3):425-431.