Recent results from three Population Council projects in Ethiopia demonstrate that HIV prevention programs shaped by evidence and designed for replication and scale-up can reach large numbers of the girls and young women at greatest risk and increase their ability to avoid infection.
HIV is the leading cause of death among girls aged 15–19 in Eastern and Southern Africa. Despite decades of investment and substantial progress against HIV, adolescent girls remain disproportionately at risk of infection. Few programs have taken a "whole girl" approach to addressing the multiple vulnerabilities to HIV infection—social isolation, economic insecurity, lack of access to services, and sexual and gender-based violence—experienced by the most marginalized adolescent girls in the poorest communities in Africa.
Building the Assets to Thrive: Addressing the HIV-related Vulnerabilities of Adolescent Girls in Ethiopia is a comprehensive review of three programs conducted and evaluated by the Population Council and the Ethiopian government: Biruh Tesfa, Meseret Hiwott, and Addis Birhan. These programs seek to reduce Ethiopian girls’ HIV risk by using similar methods to engage girls—and, in the case of one program, the males who play a role in their health and well-being.
These programs enroll socially isolated girls (or their husbands) using recruitment strategies that account for girls’ limited movement outside the household and their relative lack of power in decisionmaking. Girls meet in small groups, in safe public spaces, where they receive social support, information, and services. The programs focus on building sustainable individual protective assets such as self-esteem, problem solving abilities, confidence, and social networks supporting increased education and economic participation. They also link socially isolated girls both to higher-status adult female mentors who can serve as their advocates and to community institutions and services.
The foundation of the Population Council’s work in Ethiopia began in the early 2000s with extensive formative research: quantitative, population-based surveys among adolescents in the urban slums of Addis Ababa and remote, rural Amhara Region to understand the circumstances of the most vulnerable populations.
The Council and the Ethiopian Ministry of Youth and Sports (now the Ethiopian Ministry of Women, Children, and Youth Affairs) found that adolescent girls who were married or were rural-to-urban migrants/domestic workers were most vulnerable. In response, we developed programs for these populations: Biruh Tesfa, Meseret Hiwott, and Addis Birhan. These programs reach different participants in different geographic areas, but they share many similarities adaptable to the design, implementation, and evaluation of programs to benefit adolescent girls elsewhere.
Biruh Tesfa (Bright Future)
Biruh Tesfa began in 2007 and is ongoing. It serves out-of-school adolescent girls and young women aged 7–24 in urban slums, reaching 63,000 extremely vulnerable girls in 18 cities as of 2013. The program improves girls’ ability to protect themselves by reducing their social isolation and providing them with assets, such as a safe space to gather, caring and trustworthy adult mentors, friends, health information, services to reduce sexual exploitation and abuse, and functional literacy skills. Girls gather in mentor-led groups according to age and educational level. In the meetings, mentors offer education on HIV and AIDS and related issues, as well as non-formal education and links to health services.
A Population Council evaluation found that girls in the program sites were twice as likely as girls in the control site to report having social support, to score highly on HIV knowledge questions, to know where to obtain voluntary HIV counseling and testing, and to want to be tested.
Meseret Hiwott (Base of Life) and Addis Birhan (New Light)
Meseret Hiwott was established in 2008 to support married adolescent girls and young women aged 10–24 in rural Amhara, the second largest region in Ethiopia and the one with the highest rate of early marriage. The program provided them with adult female mentors and a safe space to gather, as well as training in financial literacy, links to health services (including family planning and HIV and AIDS resources), and information on gender/power dynamics and spousal communication.
Addis Birhan, an offshoot launched shortly after Meseret Hiwott in response to community demand, was designed to support the goals of that program. Men and boys aged 10–85 married to adolescent girls were gathered into discussion groups focused on promoting caregiving to wives and children and addressing extramarital partnerships, alcohol abuse, and violence.
Both programs ran until 2013; Addis Birhan reached more than 135,000 boys and men and Meseret Hiwott reached more than 230,000 girls and young women. Girls in the program sites were significantly more likely than other girls to obtain voluntary HIV counseling and testing, use family planning, have their husbands accompany them to clinic visits, and receive assistance with domestic work from their husbands. Moreover, girls and young women from couples in which both the husband and wife participated in the groups benefitted more than girls and young women in couples in which the husband did not participate.
Six Steps to Effective Programs for Girls
The Population Council’s experience in Ethiopia and elsewhere suggests the following six strategies are essential to the success of programs aimed at reducing gender inequalities and vulnerabilities:
- Conduct and carefully link formative research findings to program design. Formative research, particularly population-based surveys, can be used to understand the circumstances and needs of local populations, identify those at highest risk of the worst outcomes, and shape program design to reach target groups. By developing programs that address the priorities and needs of target populations, program managers can increase the likelihood of program participation and effectiveness.
- Employ mentors. The mentorship model builds trust and inspiration among program participants, who often lack caring, protective adults in their lives. Mentors serve as trusted adults to participants and also as higher-status advocates for girls.
- Tailor recruitment and involve community gatekeepers. Because girls in many settings have far more limited mobility than boys, program mentors can reach and enroll them by going house to house—a method traditionally used by health extension workers. This method of recruitment not only results in reaching a higher proportion of a population in need of program services, but also allows mentors to negotiate with gatekeepers and observe and understand the home circumstances of girls in their groups.
- Measure girls’ protective assets as indicators of program success. Research has identified several types of protective assets, including: friendship networks, ID cards, and a shelter in which to spend the night in an emergency. These assets can and should be measured and documented.
- Monitor and evaluate programs. Monitoring and evaluation must be integral elements of any successful program in order to generate the evidence required to identify best practices, refine critical program elements, and eliminate ineffective approaches. Qualitative monitoring after programs are underway can provide important information for improving them—for example, to explore new areas for expansion or modification.
- Design for scale-up by encouraging local ownership. Collaborating closely with local partners, including government agencies, will foster program sustainability. The sharing of knowledge and ownership is critical, since local partners will ultimately be responsible for conducting programs. Engaging large numbers of local residents creates lasting, normative changes within a community.
Well-designed programs—based on thorough formative research, planned to be replicable and scalable, carefully monitored and adjusted, and taking a "whole girl" approach—are effective in reducing HIV risk and increasing girls’ prospects for a safe and more productive life. These programs successfully reached the most marginalized girls in the poorest areas, such as married girls in rural areas and child domestic workers and migrants in urban areas. The Population Council’s experience shows that there is an appetite for these programs not only among vulnerable adolescent girls but also among their husbands and, eventually, their employers. Persistence and political will in the face of skepticism are key to the success of these programs, both of which are engendered by close collaboration with local ministries and community groups.
Erulkar, Annabel. 2014. "Building the assets to thrive: Addressing the HIV-related vulnerabilities of adolescent girls in Ethiopia." New York: Population Council.
USAID/PEPFAR; UN Foundation; UNFPA; Nike Foundation; World Bank; Italian Trust Fund for Children and Youth in Africa; George and Patricia Ann Fisher Family