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Seventeen-year-old student Jumeya Mohammed Amin started educating other people about sexual and reproductive health when she was 14 years old. She trained as a ‘change agent’ for her community through the Family Guidance Association of Ethiopia’s south west office in Jimma, the capital of Oromia region. Amin comes from a small, conservative town about 20km outside the city. "I wanted to protect girls from violence – like early marriage – and I wanted to change people’s wrong perceptions about sex and sexuality, because they [men in her community] start having sex with girls at a young age, even with girls as young as nine years old, because of a lack of education." "They suddenly had to act like grown-up women" "Before I started this training I saw the majority of students having sex early and getting pregnant because of a lack of information, and they would have to leave home and school. Boys would be disciplined and if they were seen doing things on campus, expelled. Girls younger than me at the time were married. The youngest was only nine. They would have to go back home and could not play anymore or go to school. They suddenly had to act like grown-up women, like old ladies. They never go back to school after marriage. My teacher chose me for this training and told me about the programme. I like the truth so I was not afraid. I heard about a lot of problems out there during my training and I told myself I had to be strong and go and fight this." "I have a brother and four sisters and I practiced my training on my family first. They were so shocked by what I was saying they were silent. Even on the second day, they said nothing. On the third day, I told them I was going to teach people in schools this, so I asked them why they had stayed silent. They told me that because of cultural and religious issues, people would not accept these ideas and stories, but they gave me permission to go and do it. Because of my efforts, people in my school have not started having sex early and the girls get free sanitary pads through the clubs so they no longer need to stay home during periods." Training hundreds of her peers "I know people in my community who have unplanned pregnancies consult traditional healers [for abortions] and take drugs and they suffer. I know one girl from 10th grade who was 15 years old and died from this in 2017. The healers sometimes use tree leaves in their concoctions.  We tell them where they can go and get different [safe abortion] services. The first round of trainings I did was with 400 students over four months and eight sessions in 2017. Last year, I trained 600 people and this year in the first trimester of school I trained 400. When students finish the course, they want to do it again, and when we forget we have a session, they come and remind me. At school, they call me a teacher. I’d like to be a doctor and this training has really made me want to do that more."

Youth leader Nebiyu Ephirem, 26, has been staffing the phones at a hotline for young people who have questions about sexual and reproductive health (SRH) since it started in 2017 in Ethiopia’s Oromia region.  The helpline has two phones and is free, anonymous and open six days a week. The helpline is aimed at people aged 17-26 who are curious about SRH but are too shy or afraid to ask others about topics such as contraception, menstruation, and diseases.  The hotline also advises people dealing with emergencies following unprotected sex and issues such as unintended pregnancy and concerns over sexually transmitted infections (STIs), by referring people to their nearest clinic.  About 65 to 70 percent of the callers are female. Ephirem also trains other people about SRH and how to educate more young people about this. Being on call for his community  “Most days, I get about 30 to 40 calls and on a Saturday, around 50. People ask about contraceptive methods like pills and emergency contraceptives and depo provera [three-month injectable contraceptive], about the spread of STIs and HIV and how to prevent it, and about menstruation and sanitation. I give my suggestions and then they come and use Family Guidance Association of Ethiopia (FGAE) services, or I refer people to clinics all over the country. There are seven FGAE clinics in this area and dozens of private clinics. Young people need information about STIs before they come to the clinic, and when they want a service they can know where the clinics are. Most of them need information about menstruation and contraception. They fear discussing this openly with family and due to religious beliefs, so people like to call me. Culturally, people used to not want to discuss sexual issues. We took the information from IPPF documents and translated them into the two local languages of Oromia and Amharic, with the help of university lecturers. After four years, even the religious leaders did this training. We have trained university students, teachers and many more people to be trainers and 30 of them graduated. They [the people who dropped out] did not want to hear about the names in the local language of body parts. Most of the ones who stayed were boys and girls, but now we have women doing this. [At first], they were laughing and said: ‘How could you talk like this? It’s shameful. But slowly, they became aware. They now talk to me, they discuss things with their parents, families, even teachers at school and friends.” Lack of sex education  There is no sex education in Ethiopia’s national curriculum but youth groups and activists like Ephirem and his colleagues go into schools and teach people through school clubs. “This year [2019] up to June we trained 16,000 people and reached 517,725 adolescents and young people aged 10 to 24 through the helpline, social media – Facebook, Twitter and YouTube – workshops, radio talk shows and libraries.” A banner in Jimma town promotes the helpline and its number 8155, as does Jimma FM radio.  “The target for reaching people in school was 5,400. We achieved 11,658. The most effective way to reach people is at school. At the coffee plantation sites we reach a lot of people.”  The minimum family size around here is about five and the maximum we see is 10 to 12. In our culture, children are [considered as a sign of] wealth and people think they are blessed [if they have many]. When we go to schools to teach them, there are kids that already have kids. But after we teach them, they generally want to finish education and have kids at 20-25-years-old. We tell people they have to have kids related to the economy and to their incomes and we calculate the costs to feed and educate them. I’m a volunteer here, so it’s mental satisfaction I get from doing this. I get 1000 Ethiopian Birr [roughly USD 30] per month for transport costs. I am also studying marketing at university and want to become a business consultant.”

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.”

Meseret* and Melat*, volunteers Known in their local community as demand creators, Meseret and Melat, from the Family Guidance Association of Ethiopia’s (FGAE) confidential clinic head out to visit sex workers in Jimma town. This group of volunteers are former, or current, sex workers teaching others how to protect themselves from sexually transmitted infections (STIs) and unintended pregnancy. Their work is challenging, and they travel in pairs for safety - their messages are not always welcome. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Meseret* and Melat*, volunteers Meseret and Melat from the Jimma clinic talk to sex workers in their local community about sexual health concerns, as well as provide contraception. “It’s very difficult to convince sex workers to come to the clinic. Some sex workers tend to have no knowledge, even about how to use a condom.” says Meseret. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Melat, volunteer It can be challenging persuading women that the staff at the confidential clinic are friendly towards sex workers and will keep their information private. “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. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Fantaye, sex worker Getting information and contraception to women often involves going out to find them, such as Fantaye, a sex worker currently living in a rental space in Mekelle. Peer educators focus on areas populated with hotels and bars and broker's houses, where sex workers find clients. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Sister Mahader, FGAE Sister Mahader from FGAEs' youth centre talks to sex workers in Mekelle, about sexual health, wellbeing, and various methods of contraception. This outreach takes place weekly where information and advice is given to groups of women, and contraception is provided free of charge. Under threat from the loss of funding from the US Administration, the Jimma clinic has been forced to reduce the range of commodities available to its clients such as sanitary products, soap and water purification tablets. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Hiwot Abera*, sex worker Hiwot* after her appointment at FGAEs confidential clinic in Jimma. The clinic offers free and bespoke healthcare including HIV and STI testing, treatment and counselling, contraceptives and safe abortion care. Many sex workers have experienced stigma and discrimination at other clinics. In contrast, ensuring confidentiality and a safe environment for the women to talk openly is at the heart of FGAEs’ healthcare provision at its clinics.*pseudonymPhotos: ©IPPF/Zacharias Abubeker Share on Twitter Share on Facebook Share via WhatsApp Share via Email

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.”

19-year-old Joseph Ikatlholeng attends the Botswana Family Welfare Association (BOFWA) clinic in Gaborone every three months to receive antiretroviral treatment for HIV. He’s currently at university, studying for a degree in transport and logistics. “I hope to start my own transport business, maybe in the future an airline,” he says, laughing at the grandeur of his dreams.   Joseph first came to BOFWA when he and his boyfriend decided to start practicing safe sex in March 2017. “I had put myself in risky situations so thought I should get tested for HIV,” he says.   After learning he was HIV positive, Joseph tried out a few clinics to receive his treatment, but found BOFWA to be the most confidential and friendly. Sitting in the clinic behind the doctor’s desk, he says, “I never have any problems coming here. I feel comfortable here. At [the government clinic] there is no privacy; most of my friends are there. Sometimes if you go there you find them suspecting something, and everyone will be knowing your status. That’s why I prefer BOFWA.”     Feeling safe is important to Joseph, who regularly faces discrimination as a man who has sex with other men. “Last week I was walking along, and these guys came past in the car shouting “gay, gay, gay.” I experience that treatment a lot.”    Now, he and some LGBTI friends in Botswana are trying to work with their community to change the status quo about LGBTI people in the country. “We’re trying to tell the elders that we are here, we’re trying to change perceptions that LGBTI people are not just on drugs and having sex,” he says.  

“I’m a sex worker and peer outreach worker for the Nkaikela Youth Group. We reach the other sex workers because we are the ones that know them. We go to their houses, we go to the hotspots like clubs and the street; we reach them and encourage them to come here [to the Youth Group],” says Jackie Selelo, 34, sitting in one of the temporary office buildings at the Nkaikela Youth Group in Gaborone.   With the support of BOFWA nurses, the Nkaikela Youth Group provides a range of sexual health care to sex workers: “They need health services for STIs, smear tests, HIV tests, and to be enrolling onto antiretroviral treatment for HIV,” Jackie explains.   Female sex workers are in a particularly high-risk group for contracting HIV – the prevalence rate is 61.9% among the community – so having access to testing and treatment is vital. However, Jackie says many women don’t feel safe going to the government clinic. “They don’t accept us. It’s like we’re doing this because we want to, and just bringing disease. We’re not comfortable there and so sex workers are not [being tested and treated] in large numbers. Before BOFWA we were dying in large numbers because we were afraid of those clinics.”     The difference between being treated by the staff at BOFWA is huge, according to Jackie. “We get a good service with BOFWA, they’re helping us to come for tests and they’re treating us good. With BOFWA if you come for HIV testing and were positive they would initiate you on to treatment the same day. Any problem you could discuss with them without fear, like they are your brothers and sisters.”   She’s concerned that if funding continues to be cut, BOFWA nurses will stop coming to the Youth Group completely. “If they stop it will be difficult for us. We will die, we will be infected,” she says.  

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"I suspect I contracted HIV from my sex work. There were times I had to engage in risky sex, depending on the money on the table." Gabatswane used to go to the BOFWA clinic in Selebi Phikwe for treatment. “I enjoyed the confidentiality that they had there, compared to the government [clinic] where everyone knows everything. It was comfortable talking to the BOFWA providers.” Due to the Global Gag Rule’s funding cuts, the BOFWA clinic has been forced to close. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Goabaone, sex worker & peer outreach worker "I've been a female sex worker for 5 years and a peer outreach worker for the last two. I was looking at the problems that us sex workers encounter, and thought that this peer outreach system might be able to help,” says Goabaone, explaining how she came to work with MCDA. Since the Global Gag Rule funding cuts the scheme has ended, and she now has to refer them to the government clinic. BOFWA was different: “At BOFWA we felt free, there is no stigma. They didn’t ask [how you got the infection], they just treated you every time,” Goabaone says. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Jackie, sex worker & peer outreach worker “I’m a sex worker and peer outreach worker for the Nkaikela Youth Group. We reach the other sex workers because we are the ones that know them. We go to their houses, we go to the hotspots like clubs and the street; we reach them and encourage them to come here [to the Youth Group],” says Jackie, 34. “We get a good service with BOFWA, they’re helping us to come for tests and they’re treating us good. With BOFWA if you come for HIV testing and were positive they would initiate you on to treatment the same day. Any problem you could discuss with them without fear, like they are your brothers and sisters.” Read Jackie's full story here Share on Twitter Share on Facebook Share via WhatsApp Share via Email Joseph, university student Joseph, 19, first came to BOFWA in 2017 when he and his boyfriend decided to start practicing safe sex. “I had put myself in risky situations so thought I should get tested for HIV,” he says. After learning he was HIV positive, Joseph tried out a few clinics to receive his treatment but found BOFWA to be the most confidential and friendly. Sitting in the clinic behind the doctor’s desk, he says, “I never have any problems coming here. I feel comfortable here. At [the government clinic] there is no privacy; most of my friends are there. Sometimes if you go there you find them suspecting something, and everyone will be knowing your status. That’s why I prefer BOFWA.” Read Joseph's full story here Share on Twitter Share on Facebook Share via WhatsApp Share via Email Keanantswe, BOFWA client A few months after beginning her HIV treatment the BOFWA clinic was forced to close due to the Global Gag Rule funding cuts. “In April I received a call from my nurse telling me the clinic is being closed. She gave me tablets for two months up to June 2018. She told me I will get transferred to a government clinic," Keanantswe says. Although getting treatment is now much harder for her, she has to continue going every month or risks getting sick and even dying. “We have lost so much without BOFWA, not only me, but many women. I wish it would open again,” she says. Share on Twitter Share on Facebook Share via WhatsApp Share via Email