HIV/AIDS National Strategic Plan For Ethiopia 2021-2025

Executive SummaryThis HIV/AIDS National Strategic Plan (NSP) for Ethiopia 2021-2025 provides a uniqueopportunity to consolidate the steady decline in the HIV burden over the past decade andrefocus interventions for maximum public health impact. Enormous gains that Ethiopia hasachieved in addressing the HIV epidemic mean that epidemic control lies within reach.The Epidemic in PerspectiveThe Ethiopian HIV/AIDS epidemic is characterized as mixed, with wide regional variationsand concentrations in urban areas, including some distinct hotspot areas driven by key andpriority populations. The National adult (15-49) HIV prevalence is 0.93% in 2019; prevalencein women constitutes 61% of infections (women 1.22%, men 0.64%). There are wideregional variations ranging from a high in Gambella at 4.5%, Addis Ababa at 3.42% with thelowest in Somali region at 0.01%. In 2019, the national HIV incidence rate in the adultpopulation is estimated at 0.02% (0.03% in females and 0.02% in males) with an estimated15,000 (9,000 females and 6,000 males) new infections, the majority (67%) of theseoccurring in the age group below 30 years. About 265 out of more than 1000 Woredas(districts) in the country constitute nearly two thirds of all new infections annually. With anestimated 669,000 People living with HIV (PLHIV) of which 39,792 are 15 years of age, HIVremains a heavy burden on the country.Since the rapid expansion of the ART program in Ethiopia, the number of AIDS deaths hasshown dramatic decline from 117.7/100,000 in 2001, to 11.73/100,000 in 2019. At the peakof the death curve, an estimated 70,173 AIDS deaths occurred within one year. Comparedto the 2010 level, there is a 52% reduction in AIDS deaths in 2019. With declining mortalityrate the number of orphans due to AIDS has also decreased by more than half, from628,000 in 2010 to 309,000 in 2019. As of December 2019, a total of the 79% of estimatedPLHIVs who know their status, 90% were on ART while 91% were virally suppressed.What is New in this PlanThe thinking and rational behind the prioritized elements of this National Strategic Planrepresents a new way of doing business to achieve maximum public health impact within aresource constrained setting: It addresses the key drivers of the epidemic in a differentiated manner withevidence-based rationales and geographic prioritization It demonstrates a shift from an intervention-focus to a people-centered response It identifies the key drivers of the epidemic and prioritizes interventions with themaximum impact, specifically prevention among key and priority populations (KPPs) It is optimized to achieve maximum possible impact within a constrained fundingenvironment, and rigorously applies the investment case approach and value formoney principles (economy, efficiency, effectiveness, equity and sustainability). It sets a clear path to reach HIV epidemic control in all parts of the country by 2030 Lastly, but not least it engages country leadership at the highest levels and multiplestakeholders10

Strategic Framework Vision, Goal, and Guiding PrinciplesVision: An AIDS-Free EthiopiaGoal: The goal of the Ethiopia National Strategic Plan for HIV 2021-2025 (NSP) is to attainHIV epidemic control nationally by 2025, by reducing new HIV infections and AIDS mortalityto less than 1 per 10,000 population.The NSP has set the following impact targets to be achieved by the end of the 5-year period: Number of new HIV infections reduced to less than 1 per 10,000 population(Disaggregated by sex, age, region and population group)HIV related deaths reduced to less than 1 per 10,000 populationIncidence Mortality Ratio reduced to minus 1 (Target: From 1.08 to 0.9)Percentage of child HIV infections from HIV- positive women delivering in the past 12months reduced from 13.39% to less than 5% by 2025; and less than 2% by 2030.The Strategic Objectives, packages of interventions, and coverage levels in the NSP havebeen designed and modelled to ensure that the above goals can be realistically achievedwith the right enablers and levels of funding, whilst leaving no marginalized groups behind.Guiding Principles: The NSP will be implemented with adherence to the following guidingprinciples:a. Multisectoral: A multisectoral approach and partnership that builds on HIV being theresponsibility of all sectors and constituencies.b. Inclusiveness: An inclusive and people-centered approach that recognizes differentprevention options that individual may choose at different stages of their lives.c. Gender Responsiveness:- A gender-sensitive approach that caters for the differentneeds of women, girls, men and boys in accessing HIV information and relatedservices.d. Value for Money (VfM): All planning for and execution of activities in this NSP willaddress the multiple dimensions of VfM, including equity, economy, efficiency,effectiveness and sustainabilityPrioritization in the NSPThe NSP was informed by Investment Case modelling produced by Spectrum Goals toprioritize the most cost-effective interventions (those that promise the highest impact atleast cost) whilst investing in critical social and program enablers, including rights-basedprogramming to achieve this.Therefore, the NSP is a rights-based plan that was developed through considering the 5dimensions of the Value for Money (VfM) lens, that defines how to maximize and sustainequitable and quality health outcomes and impacts in a constrained economic and financial11

environment. Progress towards achieving VfM will be tracked against VfM indicatorsincluded in the NSP Results Framework.Geographic Prioritization: While HIV testing and treatment programs are neededeverywhere there are PLHIV, the investment case modelling demonstrates that preventionprograms will be more cost-effective in the high incidence woredas defined as an incidence 0.03%. These 265 woredas account for about two-thirds of all new infections and thusconstitute a geographic core where prevention interventions will be scaled up first toachieve maximum cost-effectiveness. The country has about 1076 woredas. Based on HIVincidence woredas are categorized into three geographic priority areas:1. High (265): Woredas with HIV incidence of 0.03% of people aged 15-49;2. Medium (326): Woredas with HIV incidence of 0.01- 0.029% of people aged 15-49;3. Low (485): Woredas with HIV incidence of 0.01% of people aged 15-491. Population Prioritization: The following populationgroups are defined as Key and Priority Populationstaking into consideration local epidemiology, HIVprevalence, high risk behaviors increased morbidityand mortality or higher vulnerabilities.The NSP has targeted achieving 90% coverage ofcombination prevention interventions for the Key andPriority Populations in high priority Woredas.KEY POPULATIONS: Female Sex Workers (FSW) andtheir clients Prisoners People with injecting drug use(PWID)PRIORITY POPULATIONS:2. Prioritization of Interventions Based on Cost- Widowed and divorced menEffectiveness: Interventions that demonstratedand women Long distanceevidence to be most cost effective, using thedriversSpectrum Goals model and other available evidence Workers in hot spot areasare prioritized for scale up. These interventions High risk adolescent girls andinclude female sex workers, PrEP, condoms, VMMC,young womenSBCC and differentiated ART. These core programs are PLHIV and their partnersshown in the investment case modelling for Ethiopiato avert substantial numbers of new infections andAIDS deaths if an appropriate enabling environment is in place. Modelling of the impact ofimplementing the NSP 2021-2025 as part of the Ethiopia Investment Case for HIV (2020)demonstrated that it could avert 30,000 new infections (compared to the current baselineinterventions and coverage) during the period at a cost per infection averted (undiscounted)of approximately 11,000.12

Cost-Effectiveness of PreventionNew HIV infections averted through implementing the NSP 2021-202520 00015 00010 0005 0000201920202021Base2022202320242025NSP TargetsTesting and treatment are the most cost-effective interventions since they are together costsaving over the period 2021-2025. As described above, prevention programs will be morecost-effective in the high incidence woredas defined as an incidence 0.03%.Strategic ObjectivesThere are six Strategic Objectives underpinned bycritical social and programmatic enablersStrategic Objective 1: Reach 90% of Key and Prioritypopulations with targeted combination HIV preventioninterventions by 2025During the strategic plan period (2021-2025) 90% ofthe estimated 3.75 million key and priority populationswill be reached with combination prevention(behavioral, bio-medical and structural) interventions.13Result 1: Comprehensive knowledgeabout HIV and AIDS reached 90% by2025 for key and prioritypopulationsResult 2: Condom use among keyand priority populations engaged inrisky sexual behavior reached 90%by 2025Result 3: 90% for key populationswill know their HIV status by 2025

The prevention program will be built on principle of population and geographic prioritizationfor maximum impact. Client centered, integrated and sustainable service delivery modelswill be used to deliver combination prevention services and interventions. While the focusof the program is on key and priority populations in 265 high incidence woredas, generalpopulation and KPPs in intermediate and low incidence woredas will be reached throughintegrated and sustainable prevention interventions within strategic sectors and communityinitiatives. ANC level services will be offered in all geographical areas.Strategic Objective 2: Enhance HIV case finding to attain 95% of PLHIV knowing their HIVstatus and linked to care by 2025Targeted case finding will enable 95% of PLHIV to know their status. High yield case findingmodalities include index case testing and partner notification, social network services andPITC using an HIV risk screening tool at both public and private health facilities. HIV selftesting (HIVST) will be expanded through social marketing outlets. Ninety-five per cent ofthose newly diagnosed with HIV will be linked to care and treatment.Strategic Objective 3: Attain virtual elimination of Mother to Child Transmission (MTCT) ofHIV and Syphilis by 2025The virtual elimination of mother to childtransmission (MTCT) presents significantchallenges which will be addressed in thisNSP. Strengthened primary prevention,optimized ART regimens, sustained supportfrom mothers support groups, strengthenedand scaled up Point of Care testing for HIVexposed infants with enhanced prophylaxis,supported by strengthened health workercapacities are among the interventions toreach expected results.Expected result 1 : Mother-to-childtransmission of HIV during pregnancy,childbirth and breastfeeding reduced toless than 5% by 2025Strategic Objective 4: Enroll 95% of PLHIVwho know their status into HIV care andtreatment and attain viral suppression to atleast 95% for those on antiretroviraltreatment.Expected Result 4 : Percentage of infantsborn to women living with HIV receiving avirological test for HIV within 2 months ofbirth increased from 64% to 95% by 2025Expected Result 2: Percentage of pregnantwomen who know their HIV statusincreased from 84% to 95% by 2025Expected result 3: At least 98% ofexpectant mothers living with HIV arevirally suppressed at labor and deliveryEthiopia has made excellent progress towards achieving the 2nd and 3rd 90s among adults.As of December 2019, of the 79% of estimated PLHIVs who know their status, 90% were onART and 91% were virally suppressed although there remain large regional variations in ARTcoverage. However special attention is warranted to increase access to treatment f

GBV Gender based violence GNI Gross National Income GTP Growth and Transformation Plan HAPCO HIV/AIDS Prevention and Control Office HCD Human Centered Design HCT HIV Counseling and Testing HDA Health Development Army HEI HIV exposed infants HEWs Health Extension Workers HDI Human Development Index HIV Human Immunodeficiency Virus