Rewda Kedir works as a midwife in a rural area of the Oromia region in southwest Ethiopia. Only 14% of married women are using any method of contraception here.  The government hospital Rewda works in is supported to provide a full range of sexual and reproductive healthcare, which includes providing free contraceptives and comprehensive abortion care. In January 2017, the maternal healthcare clinic faced shortages of contraceptives after the US administration reactivated and expanded the Global Gag Rule, which does not allow any funding to go to organizations associated with providing abortion care. Fortunately in this case, the shortages only lasted a month due to the government of the Netherlands stepping in and matching lost funding. “Before, we had a shortage of contraceptive pills and emergency contraceptives. We would have to give people prescriptions and they would go to private clinics and where they had to pay," Rewda tells us. "When I first came to this clinic, there was a real shortage of people trained in family planning. I was the only one. Now there are many people trained on family planning, and when I’m not here, people can help." "There used to be a shortage of choice and alternatives, and now there are many. And the implant procedures are better because there are newer products that are much smaller so putting them in is less invasive.” Opening a dialogue on contraception  The hospital has been providing medical abortions for six years. “Before, there was no safe abortion," says Rewda. She explains how people would go to 'traditional' healers and then come to the clinic with complications like sepsis, bleeding, anaemia and toxic shock. If they had complications or infections above nine weeks, Rewda and her colleagues would send them to Jimma, the regional capital. "Before, it was very difficult to persuade them to use family planning, and we had to have a lot of conversations. Now, they come 45 days after delivery to speak to us about this and get their babies immunised," she explains. "They want contraceptives to space out their children. Sometimes their husbands don’t like them coming to get family planning so we have to lock their appointment cards away. Their husbands want more children and they think that women who do not keep having their children will go with other men." "More kids, more wealth" Rewda tells us that they've used family counselling to try and persuade men to reconsider their ideas about contraception, by explaining to them that continuously giving birth under unsafe circumstances can affect a woman's health and might lead to maternal death, damage the uterus and lead to long-term complications. "Here, people believe that more kids means more wealth, and religion restricts family planning services. Before, they did not have good training on family planning and abortion. Now, women that have abortions get proper care and the counseling and education has improved. There are still unsafe abortions but they have really reduced. We used to see about 40 a year and now it’s one or two." However, problems still exist. "There are some complications, like irregular bleeding from some contraceptives," Rewda says, and that "women still face conflict with their husbands over family planning and sometimes have to go to court to fight this or divorce them.”

In a room that is bare but for a few beds, Kuzema Abba Naga is resting after giving birth hours before to her tenth child, and now she thinks, her last. Before coming from her village to this remote and rural government health center in the Kebele district to give birth, Naga never knew it was possible to choose when or whether to have a baby. “I am 38 years old and I had my first baby at age 15,” she said. “This is my first baby for eight years.” Naga named the baby Nejat, which translates to ‘liberation’, after giving birth and discovering the contraception options available to her, she decides to have an IUD fitted immediately. Lack of access to contraception in rural areas This is the first time midwife Rewda Kedir has fitted a woman who has just had a baby with an IUD, though it is not uncommon to meet women coming from rural areas who have never heard about family planning. When they do, many are interested in it, even if they have to fight their husbands to use it or they are forced to hide it from them. “They want contraceptives to space out their children,” said Kedir. “Sometimes their husbands don’t like them coming in to get family planning, so we have to lock their appointment cards away. Their husbands want more children and some think that women who do not keep having their children will go with other men,” she said. Kedir says that most women prefer using the contraceptive implants because they feel few side effects, are long-lasting, easy and painless to have fitted and to conceal. “Here, people believe that more kids means more wealth, and religion restricts family planning services,” she said. “Only 28 percent of women aged 15 to 49 use modern contraceptives,” says Dessalegn Workineh, who manages the Family Guidance Association of Ethiopia’s south west area office in Jimma. Expanding contraceptive access in Ethiopia  With support from the Family Planning Association of Ethiopia (FGAE), who work with the Ethiopian government, clinics in remote rural areas like this one can now provide a full range of sexual and reproductive health (SRH) services for free.  Having all the products and services available and under one roof makes it easier to reach people who might really benefit from help with family planning.  In Oromia, 43 percent of women give birth at a health facility. Kedir finds a lot of women coming in for maternal and post-natal health services who she speaks to about family planning, end up staying or returning to get family planning services.   “Before, it was very difficult to persuade people to use family planning and we had to have a lot of conversations. Now, they come 45 days after delivery to speak to us about this when they get their babies immunised,” she said.  Staff at the clinic also provide family counselling to try and encourage men that contraception is a good idea for the whole family. “We tell them that continuously giving birth can affect the mother’s health and might lead to maternal death, damage the uterus and lead to long-term complications,” said Kedir. A number of staff at the clinic have been trained on family planning and can answer queries and deliver services, “So when I’m not here, people can help.” “The implant procedures are better because there are newer products,” said Kedir, who sits next to a handmade poster with the options for contraception glued on that still has the older, match-sized implants and the new, thinner implants. Providing comprehensive abortion care The clinic also provides comprehensive abortion care and for the past six years, medical abortions. This involves taking a pill rather than having vacuum aspiration or surgery, and is helping to stop women turning to unsafe abortion methods. “Before, there was no safe abortion. People would go to traditional healers and then come here with complications like sepsis, bleeding, anaemia and toxic shock,” said Kedir.  “The good thing is that the women that have [safe] abortions get proper care and the counselling and education has improved,” said Kedir. In Ethiopia, these services are vital “to save mothers from dying due to cases of unsafe abortion,” says Workineh. “Working on comprehensive abortion care reduces complications and therefore maternal mortality,” he added. Kedir says women still have to fight their husbands to get access to family planning and cases can end up in court or divorce. But the cases of complications resulting from unsafe abortion have plummeted.  “We used to see about 40 a year. Now it’s one or two,” she said.

At a small clinic in a quiet, residential neighborhood, ten women are preparing to hit the streets for a day of potentially life-saving work; by donning white coats and filling their handbags with condoms. These peer educators are former or current sex workers who teach others how to protect themselves from sexually-transmitted infections (STIs) and unintended pregnancy. Their mission is to educate sex workers about STIs, HIV and contraceptives, distribute condoms and persuade people to access the full range of services at a confidential clinic in Jimma, the capital of Ethiopia’s Oromia region. “It’s very difficult to convince sex workers to come to the clinic,” said Meseret Girma*, a 25-year-old peer educator. “Some sex workers tend to have no knowledge, even about how to use a condom,” she said. A safe space for underserved populations The Jimma confidential clinic was set up in 2014 to help at-risk and underserved populations like sex workers receive free and bespoke services that include HIV and STI testing, treatment and counselling, contraceptives and comprehensive abortion care. The peer educators work as volunteers and receive 2,000 Ethiopian Birr (about USD 60) per month for travel costs.  Their work is challenging, and they travel in pairs for safety because some people do not welcome their messages. “When we try to tell people about HIV we can be insulted and told: ‘You are just working for yourself and earn money if you bring us in.’ They sometimes throw stones and sticks at us,” said 25-year-old Melat Tesfaye*.  They also have a hard time persuading women that the staff at the confidential clinic are friendly towards sex workers and will keep their information private. “They have had bad experiences at other clinics so they fear coming in, or they are scared about being tested for HIV,” said Gueba. “In other clinics, they don’t keep people’s HIV status confidential. Doctors and nurses discuss it in public,” she said. But a lot of sex workers ask questions about HIV and what to do if they test positive. Working with people living with HIV The Oromia region ranks sixth out of eleven regions for HIV prevalence rates but has the greatest number of people living with HIV due to its large population, says Dessalegn Workineh, who manages the Family Guidance Association of Ethiopia’s (FGAE) south west area office in Jimma. “There is a need to work on awareness raising on HIV and AIDS,” he said, particularly among women. Another confidential clinic operates in the nearby region of Gambella, where HIV prevalence is high. “A 2016 study shows that only 17 percent of women in Oromia were aware of HIV, compared to 35 percent men,” and in the capital Addis Ababa where 42 percent of women and 52 percent of men knew about HIV, he said. Reaching sex workers Getting information to women often involves going out to find them. “I once found a woman who did not know her status who came in and found out she was positive. She had a young child and blessed me afterwards. It really saves lives,” says Gueba.  Peer educators focus on areas with a lot of hotels and bars and also broker's houses, where sex workers find clients. At one broker’s office in Jimma, Gueba and Tesfaye speak to half a dozen sex workers about staying safe by using contraceptives. It’s the first time 21-year-old Jamila has heard about condoms. “I never used a condom before and it’s interesting to hear that,” she said. “Now I think I can keep myself from getting diseases.” Eighteen-year-old Ameya had left her family and village 100km away for the first time to find a job cooking, cleaning or waitressing, and had arrived at the broker’s house a day before. “I’m interested in the family planning methods and I think I might use them now. Maybe the Depo-Provera [contraceptive injection],” she said. Lydia, 22, met the peer educators when she turned to sex work a year ago. She knew nothing about condoms or family planning and returned for further counselling.   “I never tested for HIV and did not use contraception and now I test every three months and use Depo-Provera and condoms,” she said. “We are happy when we meet these people and we tell them our stories, the difficulties sex workers face and how they can protect themselves,” says Tesfaye. Men will offer to pay double or triple to not use a condom and brokers routinely take new girls’ virginity and have sex with them, often without using condoms, until they get clients. In Jimma and other regions, budget issues and reallocations mean that outreach services to sex workers have been cut in recent years.  “We had to decrease our catchment area and services by around 30 percent,” said the clinic’s manager Eremiah Getachew, who used to have 20 peer educators but had to let ten of them go.  The Global Gag Rule This followed fears that Ethiopia’s ten confidential clinics would have to close after Donald Trump re-instated the Global Gag Rule in 2017, which does not allow any US funding to go to organizations with links to abortion care.  Emergency funding from the Netherlands kept the clinics open, but some services changed.  “We have 61 clients in Gambella on ART [anti-retroviral treatment for HIV] and we could have lost them. In Jimma, we could have lost 120 clients on ART,” said Workineh. The Jimma clinic was also forced to stop giving sex workers sanitary products, soap and water purification tablets. It currently serves about 400 sex workers per month, rising to 600 during coffee harvesting, when more people come to the city. Gueba sees the effect that outreach has and wishes there was more funding for it. “I do this because it saves other people’s lives. Even if we didn’t get paid transport costs, I would still go and do it,” she said. “This is a really important job. And we need the world to know about it.”

Emebet Bekele is a former sex worker turned counsellor, who works at the Family Guidance Association of Ethiopia (FGAE) run, confidential clinic in Jimma, Oromia. The clinic was set up in 2014 to help at-risk and underserved populations such as sex workers. The clinic provides free and bespoke services that include HIV and STI testing, treatment and counselling, contraceptives and comprehensive abortion care.  Counselling sex workers In her new role, Emebet counsels others about HIV and treatment with anti-retroviral drugs, follows up with them and monitors their treatment. Emebet tries to be a role model for other girls and women who are sex workers to adopt a healthier lifestyle “The nature of the sex work business is very mobile, and they often go to other places when the coffee harvest is good, so I tell them about referrals and take their phone numbers so I can keep counselling them”. “The difficult thing is sex workers using alcohol and drugs with ARVs [anti-retrovirals], which is not good and also means that they forget to take their medication. The best thing is that I know and understand them because I passed through that life. I know where they live so I can call them and drop medicine at their homes.” Bekele regularly tests sex workers and every month, “a minimum of five out of a hundred, maximum ten” test positive for HIV.  An increase in HIV cases Over the last five years, her reports show an increase in the number of HIV cases due to more sex workers coming in or changing clinics to attend the confidential clinic. Partly because the staff are friendly towards sex workers, who often report facing stigma in other public hospitals or being turned away when staff hear what they do. At the confidential clinic, people can walk-in any time, which better suits the sex worker lifestyle, but crucially, the service is confidential. “The ARV clinics in government hospitals are separate so everyone knows you have HIV. Also, people will see others crying and say that they have HIV,” says Bekele. A shared experience  “I used to be a sex worker, so I have a shared experience with them. When I came to this clinic I taught people about this place and the services and I counsel and train them. I didn’t have any knowledge about sex work so I also got infected. When I got knowledge, I decided I wanted to do something to help others.” “Sometimes clients add extra money for sex without condoms and sometimes sex workers have been drinking and don’t notice their clients have not used condoms. To have sex using a condom usually costs about 300 Ethiopian Birr [roughly USD 7] but it can go as low as 50 Birr [USD 1.20] or 20 Birr [USD 0.50], whereas sex without using a condom costs 200 to 300 Birr more or even up to 1000 Birr [USD 24].” When Bekele was a sex worker, she would take home about 7,000 to 8,000 Birr per month [roughly USD 170 to 190], after paying job-related expenses such as hotels, as well as for substances like alcohol to get through it. As a counsellor, she now gets 2,000 Birr to cover her travel costs.  “I have already stopped and I’m now a model for these girls. I have financial problems but life is much more than money.” “I see girls aged 10, 13 and 15 who live on the streets and take drugs. Sometimes we bring them from the streets and test them. Most of them are pregnant and I help them.” “This project is useful for our country because there aren’t any others helping sex workers and if there are ways to help them, we save many lives and young people. If you teach one sex worker, you teach everyone, from government to university staff and anyone who goes to see them, so I save many lives doing this job.”

Ethiopia is the second most populous country in Africa and the tenth most populous in the world. It is estimated that two-thirds of women do not have access to sexual and reproductive healthcare services. Our member association - Family Guidance Association of Ethiopia (FGAE) is bridging the gap between the need for healthcare and women by bringing services into the heart of the workplace across Ethiopia, a country where 47% of the workforce is female. FGAE currently provides services to over 125,000 people at sixteen large-scale workplaces across Ethiopia, from coffee plantations to textile factories.

This publication shares the experiences of people living with HIV. Men and women from Ethiopia, Mozambique and Swaziland talk about HIV-related stigma and describe their courage, inspirations, suffering, resilience and determination to trigger change. Their stories demonstrate how stigma and discrimination can hinder access to vital support and care and the prevention, testing and treatment of HIV. National and international organizations working on HIV-related issues have an immense responsibility towards people living with HIV, to change the unjust reality revealed by these personal stories into a better one. We must increase our efforts towards ensuring everyone enjoys a dignified, stigma-free life – one where every human being is valued and free of discrimination.