[Disclaimer: This blog post doesn’t represent or reflect the views and works of USAID.]

“Condom has no acceptance among Afar. Handling condoms is a taboo, let alone with your wife. It is a taboo to carry condoms, even with another woman”. This quote is from an Afar man interviewed for a participatory qualitative action research study on HIV/AIDS awareness and health service access in the Afar region. The Afar region is one of 9 regions of Ethiopia, inhabited by nomadic and pastoralist communities and has an HIV prevalence rate of 3.7% (41/1097), more than 40% higher than rates in areas like Addis Ababa, the capital city. The research study sought to better understand underlying reasons for high HIV rates in the Afar region and was conducted by University of Amsterdam’s Institute for Social Science Research (AISSR) and the National Network of Positive Ethiopian Women (NNPWE), an umbrella organization of 23 associations.

Through Begna Yibika, an association of HIV positive people, and the local traditional community leaders, the research team was able to reach the Afar community to conduct the study and to implement an evidence-based HIV/AIDS education program. The results of the study revealed that Afar people living in the study areas had never received culturally or linguistically appropriate education on HIV/AIDS prevention. According to the research findings, respondents noted that their main sources of information on HIV/AIDS prevention came through informal channels, for instance from other people in their community or people in nearby towns, or from local radio stations serving the Afar region or Djibouti. When attempts were made to communicate information on HIV/AIDS more directly, the Afar communities were generally very resistant. For example, a leader of the Begna Yibika association for HIV positive people said “there were incidents when the Afar people took out their guns on us when we tried to teach them about HIV/AIDS”.

The research study also revealed that most of the people interviewed lacked knowledge about condoms and as such had never used or seen them before. Like with HIV, there were deep misconceptions about condoms and their use. For instance, several respondents referred to condoms as something that comes from distant towns and used by “Habesha ' people” (none-Afar Ethiopians). A 30-year-old female respondent stated “A condom is a rubber that Habesha people carry. I have heard that Habesha people bring condoms here”. The few respondents with knowledge about condoms and their use said that Afar people do not use condoms and do not approve of them. Both HIV and condoms were thus described in a similar way, essentially as foreign and as being brought to Afar land with the arrival of migrants from other parts of the country.

Using the results of the study, the research team designed and tailored an intervention to address the gaps in HIV/AIDS education among the Afar community. The package of interventions included a presentation of the findings of the study to local stakeholders, a culturally and linguistically appropriate dialogue with the community on HIV/AIDS and HIV/AIDS prevention, an HIV/AIDS education program targeting youth from the three villages where the research was conducted, and lastly, an evaluation of the intervention. The intervention was implemented in partnership with Zembaba and Begna Yibika- local associations of people living with HIV, NNPWE, local Afar community leaders, and other local stakeholders.

Engaging Local Community Leaders to Access Rural Afar Communities

The approach and method applied to build strong relationships with the local traditional community leaders was innovative and helped to reach around 500 nomadic pastoralists with a culturally and linguistically appropriate HIV/AIDS health intervention program. Through the leader of Begna Yibika association of HIV positive people, who is Afar by tribe, the research team was able to build trust with the community members and establish a partnership with community leaders from the three villages. Without buy-in from community leaders, who have the authority to allow outsiders access to their community, the research team would have been unable to engage with community members, let alone deliver any type of health intervention. In order to gain the trust of community leaders, the research team, together with the leader of Begna Yibika association of HIV positive people, engaged in a series of dialogues, negotiations, and discussions with them to answer their questions and allay their concerns. The discussions mainly focused on sharing with community leaders the main findings of the study and informing them of the vulnerability of their community to HIV infection and the need to provide culturally and linguistically appropriate HIV/AIDS education. This innovative approach of partnership and consensus building was effective in informing the community leaders about HIV infection risks faced by their community and allowed research teams to access these communities and deliver the appropriate education.

Culturally and Linguistically Appropriate HIV Education in the Form of Community Dialogue: “By Our People, in our language, and in our place”

“We need the HIV/AIDS education to be given by our people, in our place and by our language” was a common remark made by respondents in the study. Based on this on other research findings, the intervention team engaged the community in dialogue under a shadow of a tree, where they usually gather. The dialogue was facilitated in their language by an Afar female nurse who works at the health facility in the nearby town and was presided over by the community leaders. The content of the dialogue was focused on basic information about HIV/AIDS, its transmission and prevention methods, ARV drugs, condom use demonstration, and available HIV services in the area. The dialogue was supported by illustrative posters and flyers, and accompanied by Afar music, resulting in the community being actively engaged, participants asking many questions, and the training being effective. An average of 50 people, both men and women, attended each session, which was a greater number compared with the number of attendees for other community activities, as stated by one of the community leaders.

Introducing Condoms and Increasing its Acceptance in Afar Communities

Since the study revealed that talking about condoms or handling condoms was taboo among Afars, a key emphasis of the community HIV education program was the introduction of condoms and teaching people how to apply them. Once the nurse who facilitated the HIV/AIDS community dialogue ensured participants were well informed about HIV/AIDS and comfortable speaking about it, she educated them on condoms and demonstrated how to apply them. The demonstration was supported by flyers and posters with a step-by-step illustration of condom use. At first, participants were shy to give their full attention, but after the community leaders intervened and encouraged them to be open by explaining the importance of condoms to prevent HIV/AIDS, participants gradually became more willing to listen and follow the demonstration. In one of the villages, a female participant even voluntarily demonstrated condom use to other participants. The presence and full participation of the community leaders in each session played a big role in keeping the participants open and comfortable with the condom education. By the end of each session a total of 200 condoms were distributed to the participants.

Scaling up the Health Intervention Across LMICs

The approach and methods applied in this evidence-based HIV/AIDS intervention were innovative, and successfully led to Afar nomadic pastoralist communities, typically labeled as “resistant to HIV intervention” by existing local partners, being reached. This approach that was used is adaptable and can be scaled up for use in other low- and middle-income countries to reach isolated rural communities with health interventions targeted towards lesser known and or stigmatized diseases. This approach can also be leveraged to introduce and increase acceptance of health commodities associated with stigmatized diseases, such as PrEP (pre-exposure prophylaxis), antiretroviral drugs (ARVs), and condoms.

One key takeaway from this work was that it is often ineffective to apply health interventions designed for the general population to rural settings. Before attempting to implement general health interventions in isolated rural communities, it is vital to test whether the approach is applicable to targeted communities. In order to design an effective health intervention to address the specific problems and needs of a rural community, in addition to consulting national data, it is vital to go to the community, live there for a certain period of time, and conduct intensive needs assessments. These assessments can include studying their ways of life, their relationships with local governments and outsiders, their culture, and their history. Furthermore, it will require analyzing and assessing the available health services, interventions, local institutions, and community resources in the area to identify the gaps that may hinder rural communities to access those services. The findings of the needs assessments are critical and will lay the foundation for the innovative approaches and methods required to address the needs identified. Sharing the results of the assessment with the wider stakeholders in the area will also be important to build a common understanding of the problem and to develop collaborations needed to design evidence-based and tailored interventions. Without the full engagement and participation by the local community and religious leaders, local support groups, and community members along the entire process of the intervention, it may not be possible to bring about even the most essential health outcomes in rural communities.