HIV AIDS and SRH Updated

WACHEMO UNIVERSITY
COLLEGE OF MEDICINE AND HEALTH
SCIENCES
DEPARTMENT OF PUBLIC HEALTH
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SRH, HIV/AIDS AND LIFE SKILL
FOR
WACHEMO UNIVERSITY STUDENTS
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CHAPTER ONE
Basics of HIV/AIDS
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Learning Objectives
At the end of this chapter, students will be able to:
 Describe the terms AIDS, HIV, people with HIV and AIDS
patients;
 Explain the differences between HIV and AIDS;
 Identify magnitude of HIV/AIDS in Ethiopia, Sub-Sahara and
in the world;
 Describe risk and vulnerability factors related to HIV/AIDS;
 Discuss the major impacts of HIV/AIDS on different
development sectors (education, health, family, economic,
social etc.) of HIV/AIDS;
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Learning Objectives……
 Explain HIV/AIDS transmission modes and prevention
methods;
 Describe stigma and discrimination that HIV/AID infected
people experience, and its consequences on the individuals and
the society at large;
 State the importance of HIV testing in the prevention,
treatment, care and other support services of HIV infected
people and AIDS patients, and;
 Participate in community based HIV/AIDS prevention, care
and support activities.
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Defining common terminologies
Brainstorming Questions
 Have you ever heard people talking about terms AIDS, HIV,
and people with HIV and AIDS patients?
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Defining common terminologies…….
 Many people see HIV and AIDS as they are the same; and
therefore make an assumption that someone who is HIV
positive is to die soon.
 HIV is an abbreviation of human immune deficiency

virus.
 It is a type of virus causes AIDS.
 H(human):Infects only human beings,I
(Immunodeficiency): that weakens the immune system
(infection protection capacity) and increases the risk of
infection, V (Virus): virus that attacks the body.
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 AIDS is the acronym for the term acquired immuno-
deficiency syndrome.
 Acquired means not inherited; Immune stands for
immune system;
 Deficiency refers to deficiency of CD4+ cells in the
immune system and syndrome represents a group of
signs and symptoms that occur together and
characterize a particular abnormality.
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 Accordingly, AIDS is an acquired (not inherited) disease

that weakens the immune system of an individual by
creating a deficiency of CD4+ cells in the immune system
and makes the individual to show the signs and symptoms
that characterize the disease.
 It is the disease of the immune system due to infection

with HIV.
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 AIDS syndrome represents the late clinical stage of

infection with the human immunodeficiency virus (HIV),
which most often results in progressive damage to the
immune and other organ systems, including the central
nervous system (CNS).
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 It occurs when infection with HIV destroys the
body’s natural protection ability from illness.
 HIV destroys the CD4 T lymphocytes (CD4 cells) of

the immune system, leaving the body vulnerable to
life-threatening infections and cancers.
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People infected with HIV
People with HIV, or who are HIV carriers, are those who are
infected with HIV but have no symptoms.
AIDS patients
AIDS patients are people whose resistance to diseases is severely

destroyed by HIV, to the extent that their bodies fail to resist
even mild disease and different manifestations of diseases
appear.
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Characteristics of People infected with HIV
 They do not fall ill on the very day HIV invades their
body because the virus needs some time to reproduce
itself in the human body.
 The immunity of the persons has not been severely

attacked so no remarkable symptoms are apparent.
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 During the second to fourth week after HIV has

enters their bodies, these people may have certain
clinical manifestations, similar to flu-like symptoms
such as a fever, muscular pain or a rash.
 They often look healthy and live and work just like
those who are not infected
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History of HIV /AIDS
• Do you have any information about the time

HIV/AIDS noticed around the globe and in world for
the first time?
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 According to FHAPCO (2011), a severe, life -
threatening clinical condition first recognized as a
distinct syndrome in 1981.
 Since its discovery in 1981 in a cluster of cases of

homosexual males, substantial advances in our
understanding of the acquired immune deficiency
syndrome (AIDS) have been achieved.
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• The identification of a cytopathic retrovirus in 1983
and development of a diagnostic serologic test for
HIV-1 in 1985 have served as the basis for
developing improvements in diagnosis.
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History of HIV /AIDS……
 In addition, therapy was dramatically altered with the
introduction of antiretroviral drugs in 1987 and
revolutionized by combination treatment, known as highly
active antiretroviral therapy (HAART), in 1996.
 The existence of HIV infection in Ethiopia was recognized
in the early 1980s with the first two AIDS cases reported in
1986.
 Since then, the epidemic has rapidly spread throughout the
country and the epidemic peaked in the mid-1990s
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History of HIV /AIDS……
 In the three years following the introduction of HAART,
mortality, AIDS, AIDS-defining diagnosis, and
hospitalizations all decreased 60 to 80 percent.
 Ethiopia is among the countries most affected by HIV and
AIDS.
 Even though since 2000 the epidemic has been declined in
major urban areas and stabilized in rural settings, there is a
significant variation in the epidemic among geographic
areas and population groups.
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Magnitude and Current status of HIV/AIDS
(Global, SSA , Ethiopia)
 HIV/AIDS is a leading cause of death worldwide.
 Since, the first cases were reported in 1981,approximately 30
million people have been died of AIDS-related illnesses.
 As to the report of FHAPCO (2014),Globbally in 2013:
 5.3 million people were living with HIV worldwide,
including 3.3 million children.
 The global prevalence rate of the pandemic among the
people aged 15 - 49 was 0.8 percent.
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Magnitude …….
 There were 2.3 million new HIV infections, including 260 000
children.
 Approximately 95 percent of the people are in low and middle
income countries .
 About 700 infections are in children less than 15 years of age .
 An estimated 5500 new HIV infections are in adults aged 15 years
and older, of whom almost 47 percent are among women; about 39
percent are among young people (15-24).
 A total of 1.6 million people died from AIDS-related illnesses.
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Magnitude …….
 A total of 1.6 million people died from AIDS-related

illnesses.
 HIV/AIDS is a major public health concern and cause

of death in many parts of Africa.
 Although the continent is home for about 15.2 percent

of the world's population, in 2011, Sub-Saharan Africa
alone accounted for about 69% of all people living with
HIV and 70% of all AIDS deaths.
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Magnitude …….
• According to 2014 Ethiopia progress reports on HIV
response, HIV/AIDS has been a major health issue in Sub-
Saharan Africa for more than two decades.
• Ethiopia has one of the lowest HIV prevalence rates in
East Africa, but it was estimated that in 2013 still 793,700
people were found to live with HIV out of which 200,300
were children (EPP/Spectrum modeling, 2014).
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Magnitude …….
 There were approximately 45,200 AIDS related deaths in 2013
and about 898,400 AIDS orphans in the same year.
HIV adult prevalence is estimated at 1.5% in 2011, the year in
which the last Ethiopian Demographic Health Survey (EDHS)
was conducted and reduced in to 1.1% in 2015.
 However prevalence varies according to age, sex, gender, and
geographical location.
 According to the 2011 EDHS report, adult prevalence was almost
twice as high among females compared to among males at 1.9%
versus 1.0% respectively
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Magnitude …….
 The distribution of HIV prevalence also varies by age,
peaking earlier in females in the 30-34 years age group
compared to 35-39 years in males.
 Looking at the younger age groups, it can be seen that
young women have a two to six fold higher HIV
prevalence than young men (ranging from 15-17 years:
0% males vs. 0.2% females to 20-22 years: 0.1% males
vs. 0.6% females).
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Magnitude …….
• Marked variation in urban rural prevalence is also
reported in the 2011 EDHS with urban areas showing
a seven fold higher HIV prevalence compared to rural
areas (4.2% versus 0.6%).
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Magnitude …….
Figure 1: Age and sex distribution of HIV prevalence (EDHS 2011)

Source: FHAPCO HIV/AIDS in Ethiopia. An epidemiological synthesis, 2014
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Magnitude …….
 The HIV epidemic in Ethiopia is becoming more
concentrated in urban areas and along major transport
corridors.
 DHS 2011 data showed high HIV prevalence in large towns
including Addis Ababa the regional capital increasing from
2005 to 2011.
 Moreover, DHS 2011 analysis showed HIV prevalence is
four times greater among populations that reside within
5km from a main asphalt road compared to those further
away.
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Magnitude …….
 Variations in HIV prevalence were also observed among regions.
 According to the 2011 DHS Gambella region and urban
administrations of Addis Ababa and Dire Dawa have the highest
prevalence while SNNPR and Oromia region have the lowest
prevalence.
 However, due to their large population size, Oromia, Amhara and
SNNPR regions have the largest people living with HIV (PLHIV)
population.
 Thus although these regions have a lower HIV prevalence they still
bear a significant proportion of the epidemic burden.
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Magnitude …….
Figure 2: HIV Prevalence by region (EDHS, 2011)

Source: EDHS, 2011
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Major Impacts of HIV/AIDS
• With one or two of your classmates, please discuss

the impacts that HIV/AIDS puts on people living
with HIV, AIDS patients and on the larger
community of particular location.
• Report your answers to the whole class.
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Major Impacts of HIV/AIDS…..
 HIV/AIDS is one of the most destructive diseases
humankind has ever faced.
 It brings profound social, economic and public health
consequences.
 It has become one of the world’s most serious health and
development challenges. It changes family composition and
the way communities operate, affecting food security and
destabilizing traditional support systems.
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 By eroding the knowledge base of society and weakening
production sectors, it destroys social capital.
 By inhibiting public and private sector development and

cutting across all sectors of society, it weakens national
institutions.
 By eventually impairing economic growth, the epidemic has

an impact on investment, trade and national security, leading to
still more widespread and extreme poverty.
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• The most devastating consequences of HIV infection arise
not simply because many people will die but because the
deaths will occur mainly among adults between the ages
of 25 and 45 years, the very people who work to support
families and make them the most productive
economically.
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Major Impacts of HIV/AIDS……
 Therefore HIV/AIDS is changing the contours and

dynamics of poverty through its demographic and socio-
economic impacts.
 Specifically, HIV/AIDS has the following socio-economic

impacts on the individual with HIV/AIDS in particular and
on society in general(EDHS, 2011).
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Impacts on an individual
 HIV-infected persons are often discriminated by society.
 Proper concern and care are seldom given by relatives and
friends.
 In addition, finding out about their HIV status can cause
great stress and can let the individuals feel like being given
a death sentence.
 They tend to limit their interaction with others
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Major Impacts of HIV/AIDS……
Impacts on a particular society
 Creates inter-generational poverty
 Alter the age structure and composition of the poor
 Result in irreversible survival mechanisms for the poorest
 Intensify discrimination and marginalization
 Increase the prevalence of poor female-headed households
 Exacerbate unequal asset distribution (land, livestock).
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National responses to HIV/AIDS(strategies & polices)
 In response to the HIV/AIDS epidemic, in Ethiopia

collective efforts have been made by the government,
communities, faith-based organizations, community-
based organizations, civil societies, associations of
PLHIV, national and international NGOs, the private
sector, and multilateral & bilateral donors and individuals.
 The major responses include the following.
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National responses……..
 A National HIV/AIDS taskforce was established in 1985 and
the National AIDS Control Program (NACP) was established at
a Department level at the Ministry of Health (MOH) in 1987.
 HIV/AIDS surveillance activities began in 1989: two
medium-term prevention and control plans were designed and
implemented in 1989 and 1996 respectively.
 HIV/AIDS Policy was formulated by MOH and adopted by
the Council of Ministers in 1998.
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 The National AIDS Council was established in 2000:
this was charged with directing and overseeing the multi-
sectorial response.
 In June 2002, the National HIV/AIDS Prevention and
Control Office (HAPCO) was established by
proclamation to coordinate and lead the multi-sectorial
response.
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 In July 2002 ARV Drugs Supply & Use Policy
formulated.
The government introduced its ART program in 2003,

with the goal of reducing HIV-related morbidity and
mortality; improving the quality of life of people living
with HIV; and mitigating some of the impacts of the
epidemic and launched free ART in 2005.
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 HIV/AIDS Strategic plan for five years (2004-2008)
focuses on the provision of preventive, care, support and
treatment services and stipulated ambitious targets.
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 As a student, what actions did you see/experience
taken by your school against the epidemic when you
were at high school?
 What actions do you think should be taken here by the

University and other higher learning institutions?
Mention as many as you can.
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Major Responses in Higher Education Institutions
(HEIs):
The HEIs have been implementing several anti-AIDS programs

such as:
 Peer education
 Life-skill education
 Community conversations
 Outreach programs
 Community radio
 Mass events
 Modeling and reinforcements, etc
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The Education Sector HIV and AIDS
Prevention Strategy
The Federal Ministry of Education in cooperation with the MoH
and other stakeholders will develop specific guidelines on HIV
and AIDS prevention and sex education, particularly
promoting options that are available to our youth that are
culturally acceptable, for protecting themselves and others
from HIV infection
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The Education Sector….
 All learning institutions need to ensure the mainstreaming of HIV
and AIDS prevention in their educational programs.
 The institutions are sensitive to socio-cultural contexts and other

special needs pertinent to HIV&AIDS prevention.
 All learning institutions will ensure that age appropriate HIV and
AIDS educational materials such as information, education and
communication (IEC) or behavior change communication (BCC) are
available and accessible to all members of the education system
throughout the country.
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 Learning institutions need to advocate and sensitize girls,
boys, men and women on the prevention of HIV and on the
risks arising from it through IEC or BCC activities.
 All learning institutions have to design and implement

creative extracurricular activities, to provide prevention
education and thereby mitigate the impact of HIV and AIDS
on people, within the education sector.
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 All learning institutions and workplaces in the
education sector will take precautionary measures
that reduce the exposure to HIV, by creating a
conducive environment that is safe and hygienic for
handling all forms of injuries in line with universal
precautions.
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Risk and vulnerability factors
Definition
Risk: is defined as the probability that a person may acquire HIV
infection.
 Certain behaviors create, enhance, and perpetuate risk.
Risk factors
The behavior related risk factors for the epidemic of HIV in
Ethiopia including in HEIs are:
 Multiple and concurrent sexual partnership
 Early sexual start and sexual experimentation
 Unsafe sexual practice
 Transactional and intergenerational sex
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Risk and vulnerability factors……
 Repeated episodes of sexually transmitted infection (STIs) and

low treatment seeking behaviors
 Mobility/migration of population
 Lack of adequate knowledge and skills to protect one-self
 Socio-cultural norms
 Inaccessible and inadequate basic HIV service coverage,

including information and education
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 Gender inequality
 Unintended pregnancy
 Substance use and abuse
 Sexually transmitted infections
 Inconsistent & incorrect condom use
 Coercion and sexual abuse
 Gender based violence
 Sexual harassment
 Poverty
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Discussion
 Which of these risk factors do you think is the most prevalent in your
locality/area?
 In groups of 3 or 4 people coming from different localities, please

discuss the issue by sharing your local experiences.
 One of the factors that accelerate HIV/AIDS spread is poverty. How

they are related?
 Please think individually first and then discuss with one of your
neighboring students.
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Relationship between Poverty and HIV spread
Existing literature (FHAPCO, 2011; Ramos, 2008; WHO

2004) reveals that poverty relates to the spread of HIV in
three interrelated ways.
Deep-rooted structural poverty: This usually arises from

such things as gender imbalance, land ownership
inequality, ethnic and geographical isolation, and lack of
access to services.
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Developmental poverty: this is created by unregulated
socio-economic and demographic changes such as rapid
population growth, environmental degradation, rural-
urban migration, community dislocation, and marginal
agriculture.
Poverty created by war: this is manifested in the form of
civil unrest, social disruption, and refugees.
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Vulnerability
 Is defined as a possibility of an individual to be exposed to
HIV/AIDS infection.
 It results from a range of factors that reduce the ability of
individuals and communities to avoid HIV infection.
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Example of factors that increase vulnerability to the infection
includes:
 Lack of knowledge and skills
 Inaccessibility of services
 social and cultural norms
 beliefs and laws that stigmatize and disempowering certain

populations and act as barriers to essential HIV prevention
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Vulnerable populations: are groups of people who are particularly
exposed to HIV infection in certain situations or contexts, such as:
 Adolescents (particularly adolescent girls)
 Orphans
 Street Children
 People in closed settings (such as prisons or detention centers),
people with disabilities
 Migrants and mobile workers
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Vulnerability Factors
Vulnerability factors in Ethiopia in general and HEI in
particular include:
1.Biological: Sex, age
2. Life styles
 Lack of parental guidance or support
 Lack of open communication with parents and peers
 Inadequate stress coping skills;
 Abusing the use of social media, availability of internet
pornographic sites, video houses which show porn films.
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Environmental Factors
 Inadequate life skills building programs
 Lack of youth friendly service and supplies
 Lack of information on service availability
 Inadequate income generation activities
 Lack of counseling services
 In tourist destinations: tourists use students as sex
workers through dealers etc.;
 Availability of big cities, constructions areas, etc.
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Societal Factors
 Peer pressure
 Harmful traditional practices like early marriage
 Surrounding environment like bars, “shisha” and ‘chat’
houses, dealers around university compounds
 Lack of comprehensive knowledge about HIV/AIDS, sexual
and reproductive health;
 Lack of awareness, concrete facts and knowledge related to
HIV and other SRH issues;
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Economic Factors
 Inappropriate use of money by students
 Economically/financially weak students who do sexual

activity for money
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Vulnerable and risk groups
High risk (or key) populations are defined as a group within a

community with a high risk for HIV as the result of the group
members engagement in some form of high-risk
behavior/activities.
 In some cases, the behaviors or HIV sero-status of their sexual

partner may put them at risk.
 High risk populations are diverse in Ethiopia and have not

been monitored over time or are not well defined..
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 However, some studies such as regional HIV synthesis have
been conducted and identified region specific high risk groups.
 Based on the current available information, the most-at-risk
populations (MARPs) in the country include the following
 Female sex workers
 Men who have sex with men (Gays)
 Injecting drug users
 Uniformed forces(police and armed forces)
 Young women (aged 15-24)
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 Long distance drivers
 Conflicting/disagreeing couples
 Prisoners
 University and college students
 Migrant laborers including cross-border and mobile
populations etc.
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Mode of transmission of HIV
1. Unprotected sexual contact with an infected partner
Through unprotected sexual intercourse a person infected

with HIV virus can pass it onto another person when his
or her body fluids (e.g. semen, vaginal fluids or blood)
enter the other person’s blood stream through
unprotected sexual intercourse.
2. Blood and blood products
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Mode of transmission…….
Through contaminated blood or blood products: such as
– injections/needles (sharing needles, jewelry, IV drugs,
or injury from contaminated needles or other sharp
objects)
– Cutting tools (using contaminated skin-piercing
instruments, such as scalpels, needles, razor blades,
circumcision instruments)
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Mode of transmission…….
 Transfusions (receiving infected blood or blood products) or
transplantation of an infected organ.
 Contact with broken skin (exposure to blood through cuts or

lesions)
3. Mother to child transmission (MTCT)
– During pregnancy
– During delivery
– During breastfeeding.
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Mode of transmission ……..
People do not get infected with HIV through:
 Everyday casual contact with people at school, university, work,
home, or anywhere else.
 However, contact with sweat, tears, or a casual kiss of an
infected person, and deep or French kiss are not advised
 Contact with forks, cups, clothes, phones, toilet seats, or other
things used by someone who is infected;
 Eating food prepared by an HIV-infected person;
 Insect bites.
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Misconceptions about HIV and AIDS
 What misconceptions about HIV and AIDS do you

think people have?
 What do you think are the causes of the

misconceptions?
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Misconceptions about HIV and AIDS…..
Many people have different misconceptions about HIV
and AIDS. The misconceptions arise from different
sources
 Simple ignorance
 Misunderstandings about scientific knowledge

regarding HIV infections
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List of some common misconceptions.
‾ HIV is the same as AIDS
‾ Sexual intercourse with a virgin will cure
AIDS
‾ HIV antibody testing is unreliable
‾ Sexual intercourse with an animal will
avoid or cure AIDS
‾ HIV can be spread through casual contact
with an HIV infected individual
‾ HIV-positive individuals can be detected
by their appearance
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-HIV cannot be transmitted through oral
sex
-HIV is transmitted by mosquitoes
-HIV can infect only homosexual men and
drug users
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Lists…..
− An HIV-infected mother cannot have children
− HIV cannot be the cause of AIDS because the body
develops a vigorous antibody response to the virus
− Only a small number of CD4+ T-cells are infected by
HIV, not enough to damage the immune system
− HIV/AIDS can be cured.
− People cannot get HIV from tattoos or body piercing
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Prevention methods
 What HIV/AIDS infection prevention methods do you

know?
 Which of the prevention method/s do you apply to

protect yourself and others from the infection of the
epidemic?
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Prevention methods……
 There's no vaccine to prevent HIV infection and no cure
for AIDS.
 But it's possible to protect yourself and others from
infection.
 Thus, acquiring knowledge about HIV and avoiding any
behavior that allows the entrance of HIV-infected fluids
such as blood, semen, vaginal secretions, and breast milk
into your body is a unique method of preventing the
infection of the epidemic.
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• On the top of that, the following strategies are applied
to prevent the transmission of HIV/AIDS.
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1. ABC strategy: abstinence, be faithful, use condom
– Abstain from sexual intercourse (only method that is

100% effective)
– Have only 1 mutually faithful uninfected sexual

partner
– Correct and consistent use of condoms: using male or

female condom can greatly lower the chances of
transmitting HIV through sex
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• The ABC strategy promotes safer sexual behavior,
reduces sexual partners and encourages loyalty to
them, and delays introduction of sexual activity.
• The implementation of ABC method differs a lot

among the people who use it.
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Prevention strategies …….
2.Avoiding of sharing sharp materials
3.Avoid risky sexual behaviours like alcohol and
other drugs
4.Screening Blood Transfusion
5.Voluntary Counseling and Testing
6.Prevention of mother to child HIV transmission
(PMTCT )
7.Avoidance of unwanted pregnancies among
infected mothers
8. Use of antiretroviral therapy
9. Provision of post exposure prophylaxis
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Stigma and discrimination
Definitions
HIV-related stigma refers to the negative beliefs, feelings, and
attitudes towards people living with HIV, groups associated
with people living with HIV (e.g. the families of people living
with HIV) and other key populations at higher risk of HIV
infection, such as:
 People Who inject drugs,
Sex workers,
Men who have sex with men
 Transgender People.
 Stigma and discrimination are often directed towards these
groups simply because others disapprove of their behaviors.
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Stigma and discrimination…..
 Stigma also varies depending on the dominant
transmission routes in a country or region.
 In sub-Saharan Africa, for example, heterosexual
relationship is the main route of infection;as result,
the HIV-related stigma in this region, is mainly
focused on sexual disloyalty and sex work.
 These people are increasingly marginalized, not only
from society, but from the services they need to
receive so as to protect themselves from HIV.
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HIV-related discrimination : refers to the unfair and unjust
treatment (act or omission) of an individual based on his or her
real or perceived HIV status.
 Discrimination in the context of HIV also includes the unfair

treatment of other key populations listed earlier
eg.sex workers, people who inject drugs, men who have sex with
men, transgender people, people in prisons and other closed
settings).
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• In some social contexts, it may be directed at women,
young people, migrants, refugees, and internally
displaced people.
• HIV-related discrimination is usually based on

stigmatizing attitudes and beliefs about populations,
behaviors, practices, sex, illness, and death.
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 Discrimination can be institutionalized through existing

laws, policies, and practices that negatively focus on
people living with HIV and marginalized groups,
including criminalized populations.
 In general, AIDS-related stigma and discrimination means
prejudice, negative attitudes, abuse and maltreatment
directed at people living with HIV and AIDS.
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 Many people with HIV and Aids are rejected by family,

friends and community.
 They are treated poorly at the hospital and school. Even

at places of worship, worshippers refuse to sit by them
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Common Causes of Stigma and Discrimination
 What do you think are the causes of stigma and

discrimination against people living with HIV/AIDS
and their relatives such as families?
 What different forms of stigma and discrimination do

you know?
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 Stigma against PLHIV remains a significant issue
in Ethiopia.
 EDHS routinely include four attitudinal issues
determining stigmatizing attitudes among the
general population. These include:
Needing to keep HIV in the family a secret
 Unwillingness to care for an HIV-infected
relative
Unwillingness to accept female PLHIV to serve
as teachers, and
 Unwillingness to purchase vegetables from a
PLHIV shopkeeper or other people infected with
the virus.
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Forms of HIV stigma and discrimination

 Self-stigma/internalized stigma
 Governmental stigma
 Healthcare stigma
 Employment stigma
 Community and household level stigma
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 From your practical experience, which of the discussed types of

stigmas have you ever seen people experiencing?
 Please share your experience to your classmates by explaining
exactly what happened to the people you observed.
 Do you think that the stigmatizing and discriminating practices

had any consequences on the victims?
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Consequences of stigma and discrimination
 The WHO(2004)cites fear of stigma and discrimination has

been the main reason for people to become reluctant to get
tested, disclose their HIV status and take antiretroviral drugs.
 The epidemic of fear, stigmatization and discrimination has

undermined the ability of individuals, families and societies to
protect themselves and provide support and reassurance to
those affected.
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• This hinders, in no small way, efforts at stemming the epidemic.
It complicates decisions about testing, disclosure of status, and
ability to negotiate prevention behaviors, including use of family
planning services.
 The consequences of stigma and discrimination are wide-ranging.
 Some people are avoided by family, peers and the wider

community, while others face poor treatment in healthcare and
educational settings, erosion of their human rights, and
psychological damage.
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Consequences……
These all limit access to HIV testing, treatment and related services.
 The people living with HIV stigma index indicates that
roughly one in every eight people living with HIV is denied
health services because of stigma and discrimination.
 HIV-related stigma and discrimination exist worldwide,
although they manifest themselves differently across
countries, communities, religious groups, and individuals.
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Consequences……
Research by the International Centre for Research on Women
(ICRW, 2012)found the possible consequences of HIV-
related stigma to be the following.
 Loss of income and livelihood
 Loss of marriage and childbearing options
 Poor care within the health sector
 Withdrawal of care giving in the home
 Loss of hope and feelings of worthlessness
 Loss of reputation/respect
To overcome or at least to minimize the consequences, there
were certain national responses to the stigma and
discrimination.
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Major National Responses for Stigma and Discrimination
against PLHIV
 Public awareness campaign including community conversations
 Workplace discussions, mass media and peer education.
 Establishment of National Network of PLHIV programs (found

in all regions of Ethiopia) to build capacity to address stigma
and discrimination.
 The policy protects against mandatory HIV testing
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 Defense of the right of HIV positive employees to medical
leave
 Job reallocation and provision of guidelines for the

establishment of AIDS funds to assist employees
 Existence of favorable polices and laws to protect the rights of

PLHIV though there is weak enforcement.
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HIV Counseling and Testing
 HIV testing is the gateway to HIV prevention, treatment, care
and other support services.
 People’s knowledge of their HIV status through HIV testing

services (HTS) is crucial to the success of the responses made
by the government and other collaborating partners.
 The Joint United Nations program on HIV/AIDS

(UNAIDS)and the World Health Organization (WHO) have
endorsed global goals to achieve “zero new HIV infections,
zero discrimination and zero AIDS-related deaths”.
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HIV Counseling and Testing…….
 Because of the potential serious medical, social and
psychological consequences of misdiagnosis of HIV(Either
false-positive or false-negative), all programmers and people
providing HIV testing must strive also for zero misdiagnoses.
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Goal of HIV testing
The goals of HIV testing services are to:
 Identify people with HIV to provide quality services for
individuals, couples and families
 Link individuals and their families effectively to appropriate
HIV treatment, care and support, as well as HIV prevention
services, based upon their status
 Support the scale-up of high impact interventions to reduce
HIV transmission and HIV-related morbidity and mortality
through the provision of antiretroviral therapy
(ART),voluntary medical male circumcision (VMMC),
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,prevention of mother-to-child transmission (PMTCT), pre-
exposure prophylaxis (PrEP) and post-exposure prophylaxis
(PEP).
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Principles of HIV testing and counseling
All forms of HIV testing and counseling should be voluntary and
adhere to the five C’s.
Consent: People receiving HTS must give informed consent to
be tested and counseled. They should give verbal consent;
written consent is not required. They should be informed of the
process for HIV testing and counseling and of their right to
decline testing.
Confidentiality: HTS must be confidential, meaning that what
the HTS provider and the client discuss will not be disclosed
to anyone else without the expressed consent of the person
being tested.
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Principles……..
Counseling: Pre-test information can be provided in a group
setting, but all people should have the opportunity to ask
questions in a private setting if they request it. All HIV testing
must be accompanied by appropriate and high-quality post-test
counseling, based on the specific HIV test result and HIV
status reported.
Correct: Providers of HIV testing should strive to provide high-
quality testing services, and QA mechanisms should ensure
that people receive a correct diagnosis.
Connection: Linkage to prevention, treatment, and care services
should include effective and appropriate follow-up, including
long-term prevention and treatment support.
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HIV testing service approaches
WHO recommends making HTS available through a
wide range of approaches, both in facilities and in the
community, as appropriate to local epidemiology and
context.
1. Facility-based HIV testing services
Facility-based HIV testing services refer to HTS
provided in a health facility or laboratory settings
which include:
Voluntary counseling and testing
Provider-initiated testing and counseling
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Approaches……
2. Community-based HIV testing services
 It is an important approach for increasing early diagnosis,
reaching first-time testers and people who seldom use
clinical services, including men and adolescents in high
prevalence settings and people from key populations in all
settings.
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 Community-based HTS include a number of approaches
including:
 Door-to-door/home-based testing
 Mobile outreach campaigns
 Testing in workplaces, parks, bars, places of worship and

educational establishments.
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Treatment, care and support
 There is no cure for HIV, but with proper care and
treatment, most people with HIV can avoid getting
AIDS and can stay healthy for a long time.
 The good news is that HIV and its complications can
often be treated.
 With proper treatment with antiviral therapy known
as antiretroviral drugs, most infected patients can lead
relatively normal lives for many years.
 Even with the onset of AIDS, symptoms can be
greatly diminished by treatment.
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Treatment, care and support…..
 Treatment options include: treatments for infections, treatments for
cancers, treatments for symptoms.
 Antiretroviral drugs slow the progress of HIV because fewer HIV
cells are formed.
 Antiretroviral therapy (ART) is delivered as part of a comprehensive
care, which includes Voluntary Counseling and Testing (VCT), the
diagnosis and treatment of sexually transmitted diseases (STDs),
Tuberculosis (TB), Opportunistic Infections (OI), and the prevention
of mother to child transmission (PMTCT) as well as the treatment of
pregnant women.
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Treatment, care and support…..
 ART changes a uniformly fatal disease to a manageable
chronic illness.
 Successful use of ART suppresses HIV viral replication,
consequently slowing down disease progression, improving
immunity, and delaying mortality.
 Even if ART is not a cure, it prolongs and enhances the
quality of life of PLHIV.
 Once ART is started, it has to be taken for life time duration.
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Case study
Read the following case study and answer the questions that
follow individually first and then discuss your answers with
one or two of your classmates.
John is a second year student at Wachemo University. When he
went to WCU hospital to get medical treatment for his recurring
cough, John was privately informed that he is HIV positive and
needs to make great precaution. However, he decides not to
expose his status to any anyone and not to change his behavior.
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Case study….
• Even he is not interested to inform Meron, who was his only
girlfriend for some time during his first year of the
university stay. He intends to make unprotected sex with
other females.Meron is a beautiful second year student from a
poor family of Dire Dawa city administration. After she
completed her preparatory school, she was involved in some
construction activities going in the city administration. She had
different sexual partners at that time and often practiced unsafe
sex. Currently, she is dating with another student, who knows
neither his nor Meron’s HIV status.
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Case study……
1. What is the possible cause of John’s HIV infection?

2. What were the ethical and behavioral mistakes of John
and Meron?
3. What are the possible reasons that John does not want to
disclose his HIV status to others?
4. What were risk and vulnerable factors of John and
Meron behaviors?
5. What advice do you provide to John and Meron to
minimize the spread of HIV/AIDS and its
consequences?
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CHAPTER TWO
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Learning Objectives
After completing this chapter, students will be able to:
 Define key terms related to sex, sexuality, sexual

orientation, and sexual identity;
 Identify common SRH problems and their

manifestations;
 Enumerate various contraceptive options in family

planning;
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Learning Objectives….
 Describe the relationship between gender and
common SRH problems;
 List common SRH Problems;
 Develop the skills to prevent sexual and reproductive

health problems; and Show commitment to curve
HIV/AIDS.
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Introduction
Definition
 Reproductive health is a state of physical, mental,
and social well-being that is related to the
function and processes of the reproductive
system.
 It implies that people have the freedom to decide
whether or not to have sex and/or reproduce
thereby; and are able to enjoy safe sex.
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Introduction…
 All members of the community have the right to
access information and receive safe health care
services.
 Unfortunately, adolescents and youth appear to have

failed to exercise this right thus, be at risk from a
broad health-related perspective.
 Young people, particularly, are at risk of unintended

pregnancy, pregnancy-related complications, STIs,
and HIV infections.
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Brainstorming
Write down on a piece of paper what first comes to your

mind when you heard the word
“Sex” and “sexuality
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Sex and Sexuality
 Sex (as in sexual activity) Sex can be a normal part of life
for many older adolescents and adults.
 Unsafe sex is any kind of sex that puts a person or a

person‘s sexual partners at risk of getting a sexually
transmitted infection (STI), including HIV, or unwanted
pregnancy.
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Sex and Sexuality
Unsafe sex…..
 It is very important for health workers to be comfortable talking
about sex and reproduction with their adolescent clients.
 Honest, factual discussions about sex and sexuality can provide

adolescents with the information they need to protect themselves
and their partners from STIs and unplanned pregnancy.
 Some adolescents acquire HIV, or are at risk of acquiring HIV,

because of sexual abuse.
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Sex and Sexuality
Sexuality
 It is more than sex and sexual feelings;
Includes all the feelings, thoughts, and behaviors of being a
girl, boy, man, or woman, including feeling attractive, being
in love, and being in relationships that include sexual
intimacy and physical sexual activity
 Exists throughout a person‘s life and is a component of the

total expression of who we are as human beings (male or
female);
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Sex and Sexuality
Sexuality …
 It is a part of us from birth until death;
 Is constantly evolving as we grow and develop.
Aspects of sexuality
 Each of these aspects is connected to one other and contributes

to making a person who he or she is.
Body image: How we look and feel about ourselves and also how
we appear to others.
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Sex and Sexuality
Aspects of sexuality …..

Gender roles: The way we express being either male or
female, and the expectations people have for us based
on our sex.
Intimate relationship: A romantic and/or sexual
involvement with another person
Intimacy: Sharing thoughts or feelings in a close
relationship, with or without physical closeness.
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Sex and Sexuality
Aspects of sexuality …….
Love: Feelings of affection and the ways we express those
feelings for others.
Sexual arousal: The arousal of sexual desires and the state of

sexual readiness in preparation for sexual behavior. Sexual
arousal has mental and physical components.
Social roles: How we contribute to and fit into society.
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Sex and Sexuality
Aspects of sexuality ……
Genitals: The reproductive and sexual organs: the testicles and

penis of a male or the labia, clitoris, and vagina of a female.
Sexual abuse: Sexual abuse is forced, unwanted, improper, or

harmful sexual activity inflicted on another person.
Ways we can express our sexuality: Through dancing, talking,

wearing attractive clothes, experiencing sexual dreams or
daydreams, feeling sexual near others, masturbating, etc.
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Sexual and Reproductive Health
Definition
Sexual Health: Sexuality is a central aspect of being human

throughout life and encompasses sex, gender identities and roles,
sexual orientation, eroticism, pleasure, intimacy and
reproduction‖ (WHO, 2002).
Human Sexuality is an expression of who we are as human being,

how people experience the erotic and express themselves as
sexual beings; the awareness of themselves as males or females;
the capacity they have for erotic experiences and responses.
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Sexual Health….
 The way someone is attracted to another person of the opposite sex
(heterosexuality), to the same sex (homosexuality), to both sexes
(bisexuality), or attracted to no sexes (asexuality).
 Sexuality is experienced and expressed in thoughts, fantasies,

desires, beliefs, attitudes, values, behavior, practices, roles, and
relationships.
 It is a function of one‘s whole personality that is life long,

beginning from birth.
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Factors Influencing Human sexuality
Group Discussion
• List some of the factors that influence human sexuality

from your experiences
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Factors Influencing Human sexuality…
 Sexuality is influenced by the interaction of biological,
psychological, social, economic, political, legal, cultural,
historical, religious, & spiritual factors.
 Sexuality goes beyond sex (sexual intercourse) to include feelings

about one‘s own body (sensuality), the ability and need to be close
to someone else (intimacy), feelings of sexual attraction, and the
capacity to reproduce.
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Elements (circles) in human sexuality
1. Sensuality
2. Intimacy and Relationships
3. Sexual identity
4. Sexual Health
5. Sexuality to control others
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Elements (circles) in human sexuality….
1. Sensuality is how our bodies derive pleasure.
 It is part of our body that deals with the five senses: touch,
hearing, smell, and taste.
 Any of these senses when enjoyed can be sensual.
 The sensual- response cycle is also part of our sensuality because

it is the mechanism that enables us to enjoy and respond to
sexual pleasure.
 Our body image is part of our sensuality.
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Elements (circles) in human sexuality….
Sensuality….
 It also involves our need to be touched and held by others in

loving and caring ways. This is called ―skin hunger,
Adolescents typically receive less touch from family members
than young children do.
 Therefore, many teenagers satisfy their skin hunger through

close physical contact with peers. Sexual intercourse may
result from adolescent‘s need to be held, rather than from
sexual desire.
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Elements (circles) in human sexuality…..
 Fantasy is another part of our sensuality. Our brain gives
us the capacity to fantasize about sexual behaviors and
experiences without having to act on them.
2. Intimacy and Relationships
 Our ability to love, trust, and care for others is based on
our level of intimacy.
 Emotional risk taking is part of intimacy.
 In order to have true intimacy with others, an individual
must open up and share feelings and personal
information.
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Elements (circles) in human sexuality…..
3. Sexual identity
Every individual has his or her own personal sexual identity. Four
components make up an individual‘s sexual identity:
i. Biological Sex: based on physical and hormonal influence
being male or female.
ii. Gender Identity: this is based on natural sex but involves the
feeling we have being male or female.
• This process starts to form around age two, when a little boy or
girl realizes that he or she is different from the opposite sex.
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Elements (circles) in human sexuality……
Sexual identity…
 If a person feels like he or she identifies with the opposite
biological sex, he or she often considers him or herself –
transgender.
 In the most extreme cases, a transgendered person will have
an operation to change his or her biological sex so that it
can correspond to his/her gender identity.
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Sexual identity…
iii. Gender roles: society‘s expectation of oneself based on

biological sex.
iv. Sexual Orientation: is the fourth part of sexual identity.
 It refers to the biological sex we are attracted to romantically.
 One‘s sexual orientation can be Heterosexual (attracted to the

opposite sex), bisexual (attracted to both sexes), homosexuality
(attracted to the same sex).
 In some situations, asexuality (not attracted to any sex).

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4. Sexual Health
 Involves our behavior related to produce children, enjoying sexual
behaviors, and maintaining our sexual and reproductive organs.
 Issues like sexual intercourse, pregnancy, and sexually transmitted

infections are part of our sexual health.
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5. Sexuality to control others
 This element of sexuality is not healthy.
 Unfortunately, many people use sexuality to violate
someone else or get something from another person.
 Rape is a clear example of using sex to control
somebody else.
 Sexual abuse and commercial sex work are others.
 Even advertising often sends messages of sex in order to
get people to buy products.
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Sexuality to control others….

 This also can be said as sexualization which is defined as
using sex or sexuality to influence, manipulate or control
other people's behaviours including seduction, &
withholding sex from a partner to 'punish' the partner or to
get something, offering money for sex, selling products
with sexual messages, sexual harassment, sexual abuse and
rape.
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Sexual Response Cycle
 The sexual response cycle refers to the sequence of

physical and emotional changes that occur as a person
becomes sexually aroused and participates in sexually
stimulating activities, including intercourse and
masturbation.
 Knowing how the human body responds during each

phase of the cycle can enhance the relationship and help
one pinpoint the cause of sexual dysfunction.
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Sexual Response Cycle
What do you understood the phrase sexual

response cycle?
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Sexual Response Cycle…
 The sexual response cycle has four phases: excitement, plateau,
orgasm, and resolution.
 Both men and women experience these phases, although the timing
usually is different.For example, it is unlikely that both partners will
reach orgasm at the same time.
 In addition, the intensity of the response and the time spent in each
phase varies from person to person.
 Understanding these differences may help partners better

understand one another‘s bodies and responses, and enhance the
sexual experience.
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Reproductive Health
Reproductive health encompasses:
The ability to reproduce;
 Freedom to control reproduction;
 The ability to go through pregnancy and childbirth

safely, with successful maternal and infant survival
and outcomes;
The ability to obtain information about and access to

safe, effective and affordable methods of family
planning;
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Reproductive Health
Is reproductive health same as sexual health or different

from sexual health? How?
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Reproductive Health…
 The ability to have a satisfying, safe sex life, free from fear of
pregnancy and disease;
 The ability to minimize gynecologic disease and risk throughout

all stages of life RH, then, is concerned with people‘s ability to
have a responsible, satisfying & safe sex life, their capability to
reproduce, & their having the freedom to decide if, when & how
often to do so.
 Embedded in this set of concerns are certain implicit rights of both

men and women:
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Reproductive Health…
 To be informed of safe, effective, affordable & acceptable
methods of fertility regulation;
 To have access to safe, effective, affordable and

acceptable methods of fertility regulation of their choice;
 To have access to appropriate health care services that

will enable women to go through pregnancy and
childbirth safely, and provide couples with the best
chance of having a healthy infant.
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Anatomy of Male & Female Reproductive
Organ
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Male Reproductive Organ
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Male Reproductive Organ….
 Urinary Bladder: It serves as a reservoir for urine and is
connected to the urethra.
 Urethra: Tube through which urine and semen (including
sperm) pass out of the body.
 Epididymis: Area where sperm is stored in the testicles.
 Vas Deferens: Tubes that carry sperm from the epididymis.
 Seminal Vesicle: small sac at the back of the prostate gland
where the thick milky fluid in semen is produced.
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Scrotum: Sac that holds the two testicles.
Pubic hair: Grows around the penis after puberty.
Prostate Gland: The prostate gland is a walnut-sized structure that is

located below the urinary bladder in front of the rectum. The
prostate gland contributes additional fluid to the seminal fluid.
Testicles: Glands (which fell like two small balls) which produce
sperm and the male sex hormone. (Where, Temp, sign of normality
etc…)
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Penis: made up of spongy tissue. Normally soft, but fills up with
blood and becomes stiff (erect) when a boy is sexually aroused.
Urethral Opening: Through which urine and semen pass.
Unlike girls, boys have the same opening for urine and sexual
fluids.
It is not possible for urine to pass through the urethra at the same
time as semen is being ejaculated.
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Female Reproductive Organ
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Female Reproductive Organ….
 Every girl‘s body looks similar.
 Girls should wash the outside of the genital area
daily.
 The vagina has a natural cleansing mechanism and
should not frequently be washed inside.
 Frequent washing of the inside (douching) can
increase risk of infection, especially if done before
sexual intercourse.
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External Female Reproductive Organ
Pubic Hair: Is hair that grows around the vulva after

puberty.
Monsvenris: Is a pad of fat that lie in front of the

symphysis pubis and is covered with hair at puberty
Outer Labia/Majora: two folds, or lips, of skin which

protect the vulva.
Inner Labia/Minora: two smaller folds, or lips, of skin

which lie between the outer labia.
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External Female Reproductive Organ……..
Clitoris: Small bump at the top of the inner labia, filled with
nerve endings. It is very sensitive to touch. Stimulation of the
clitoris can be pleasurable and lead to orgasm.
Vulva: The different parts of the vulva make up the woman's
outside reproductive organs.
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External Female Reproductive Organ…….
Urethral Opening: small opening below the clitoris through which

urine passes out of the body.
Vaginal Opening: Opening below the urethral opening & above

the anus. It leads to the vagina, cervix, & uterus.
It is through the vaginal opening that menstrual blood passes out of

the body, the penis may enter during sex, and babies are born.
Hymen: Is the membrane that covers the opening of the vagina.

Hymen is also a sign of virginity.
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Internal Female Reproductive Organ
Ovaries: Two glands, one at the end of each uterine tube, which
produce eggs and female sex hormones.
Uterine (Fallopian) Tubes: Two tubes that connect the uterus to
the ovaries. An egg is released from one of the ovaries each
month, and passes along a uterine tube into the uterus.
Uterus or Womb: Hollow sac of muscle, shaped like an upside
down pear. This is where an embryo develops into a baby during
pregnancy.
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Internal Female Reproductive Organ….
Cervix: Mouth of the uterus, connecting it to the vagina. It has

a very small opening and is kept moist by mucus. The
cervix feels round, hard and smooth, with a small bump in
the middle.
Vagina: A moist tube of muscles, normally about 8cm long,

which connects the vulva to the inner reproductive organs.
 It is very flexible.
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Internal Female Reproductive Organ….
It secretes slippery mucus during sexual arousal.
The vagina and cervix are lower reproductive
tract.
The uterus, uterine tubes, and ovaries are upper
reproductive tract.
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Reproductive System
1. Female Reproductive System
The Menstrual Cycle :An egg starts to develop in the ovary.

While the egg is developing, the lining of the uterus is getting
thick and soft.
 The egg is released by the ovary.
 The egg travels to the uterus. If the egg doesn‘t meet a sperm, it
dissolves
 About two weeks later, since the lining of the uterus is not
needed for a pregnancy, it comes out through the vagina.
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Reproductive System…
2. Male Reproductive System
The Life of a Sperm Cell
I am produced in the testicles. When the penis becomes erect, I
leave the body through the urethra in a white, milky fluid in a
process called ejaculation.
I go through a woman‟s vagina in search of an egg cell.
If I can find the egg before the other sperm do, I will be the
winner: part of a fertilized egg!
Without me, an egg cell couldn't begin the process of
reproduction.
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Reproductive System…….
Similarities between Male and Female Reproductive Systems
 Both sexes develop from similar embryonic tissue,
 Have gonads that produce (sperm and egg or ovum) and

sex organs.
 Both Systems experience maturation of their reproductive

organs, which become functional during puberty as a
result of the gonads secreting sex hormones.
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Differences between Male and Female Reproductive Systems
 A male, who is healthy, and sexually mature,

continuously produces sperm. But
 Women‘s eggs is arrested during fetal

development/predetermined number
of oocytes and cannot produce new ones.
 The ovaries of a newborn baby girl contain about one

million oocytes.
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• This number declines to 400,000 to 500,000 by the
time puberty is reached. On average, 500-1000
oocytes are ovulated during a woman's reproductive
lifetime.
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Menstruation
 Is the normal, predictable physiologic process whereby

the inner lining of the uterus (endometrium) is expelled
by the body.
 Menstruation has many effects on girls and women,

including emotional and self-image issues.
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• Genetics is the most important factor in
determining the age at which menarche starts,
but geographic location, nutrition, weight,
general health, nutrition, and psychological
factors are also important (Shelby & Ruocco,
2007).
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Menstruation…
 Pubertal events preceding the first menses have an
orderly progression:
Thelarche, the development of breast buds;
Adrenarche, the appearance of pubic and then axillary hair,
followed by a growth spurt;
Menarche (occurring about 2 years after the start of breast
development).
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Menstruation…
 In healthy pubertal girls, the menstrual period varies in flow
heaviness and may remain irregular in occurrence for up to 2
years following menarche.
 After that time, the regular menstrual cycle should be
established.
 Most women will experience 300 to 400 menstrual cycles
within their lifetime (Diaz, Laufer & Breech, 2006).
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Menstruation…
 Normal, regular menstrual cycles vary in frequency

from 21 to 36 days (with the average cycle lasting
28 days), bleeding lasts 3 to 7 days, and blood loss
averages 20 to 80 mL (Schuiling & Likis, 2006).
 Irregular menses can be associated with irregular

ovulation, stress, disease, and hormonal imbalances
(Cunningham et al., 2005).
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Reproductive Cycle
 Referred to as the menstrual cycle, results from a
functional hypothalamic–pituitary– ovarian axis and a
precise sequencing of hormones that lead to ovulation.
Cycle length: 21 to 36 days,
Duration of flow: 3 to 7 days
 Amount of flow: 20 to 80 ml.
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Reproductive Cycle….
The female reproductive cycle involves two cycles that occur
simultaneously:
The ovarian cycle: during which ovulation occurs, and the
Endometrial cycle, during which menstruation occurs.
Ovulation divides these two cycles at mid-cycle.
 Ovulation occurs when the ovum is released from its follicle;
after leaving the ovary, the ovum enters the fallopian tube and
journeys toward the uterus.
 If sperm fertilizes the ovum during its journey, pregnancy
occurs.
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Puberty (Sexual Maturation)
Brainstorming:
1. What is puberty?
2. How does puberty happen?
3. How old are boys and girls when they go through
puberty?
4. What happens to your body during puberty?
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Puberty ………
 Is the period of growing and changing from a child to

an adult.
 The pituitary gland sends out hormone messages to
certain parts of the body to tell them to change.
 Girls: anytime between the ages of 9 and 16.
 Boys: anytime between the ages of 10 and 16.
6/3/2019 171
Sexual and Reproductive Health Rights
List some of sexual and reproductive health rights?
6/3/2019 172
Sexual and Reproductive Health Rights
 Sexual, and reproductive health rights are the right for all
people, regardless of age, gender and other characteristics,
to make choices regarding their own sexuality and
reproduction, provided that they respect the rights of
others.
 It includes the right to access to information and services

to support these choices and promote sexual and
reproductive health (SRH).
6/3/2019 173
Sexual and Reproductive Health Rights…..
Lists of Sexual Rights
They include the right of all persons, free of coercion,

discrimination, and violence, to:
– The highest attainable standard of sexual health, including

access to sexual and reproductive health care services;
– Seek, receive and impart information related to sexuality;
– Sexuality education;
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Lists of Sexual Rights……….
– Respect for bodily integrity
– Choose their partner;
– Decide to be sexually active or not
– Consensual sexual relations;
– Consensual marriage;
– Decide whether or not, and when, to have children; and
– Pursue a satisfying, safe, and pleasurable sexual life.
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Why is SRHR important now?
 Cheap, effective interventions are available for many SRH

problems, according to WHO unsafe sex is the second most
important risk factor leading to disability, disease or death in
developing countries and the ninth most important in developed
countries (Glasier, 2006)
SRH policy and access to services are heavily influenced, often

negatively, by sociocultural and political factors in the local and
international context.
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Key SRH problems include:
 Maternal mortality is the leading cause of death for women of

reproductive age in many developing countries, & is largely
preventable.
 This indicator shows the widest disparity in human development

between north & south.
 Maternal mortality is declining in some Asian countries but not in

Africa (Horton, 2006).
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Key SRH problems………..
 There are now almost 40 million people infected with
HIV across the world, 24.7 million in sub-Saharan Africa
& 7.8 in South & South-East Asia (UNAIDS, 2006).
 Other STIs are often the second most important cause of

healthy life years lost in women in developing countries
(after maternal mortality).
6/3/2019 178
Common SRH Problems and Misconceptions
A. Sexual Difficulties
 Sexual difficulties may begin early in a person's life, or they
may develop after an individual has previously experienced
enjoyable and satisfying sex.
 It may develop gradually over time, or may occur suddenly as a
total or partial inability to participate in one or more stages of
the sexual act.
 The causes can be physical, psychological, or both.
6/3/2019 179
Common SRH Problems and Misconceptions….
Origins of Sexual Difficulties

I. Organic factors:
– Vascular, endocrine, neurological
– Illnesses & Disabilities (diabetes, arthritis, cancer,
multiple sclerosis, stroke
– Spinal Cord Injuries, cerebral palsy, blindness, deafness
Coping mechanism: help the clients accept limitations &
explore options.
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II. Cultural Influences
– Negative childhood learning about sexuality
– Narrowly defined sexuality
– Rigid goals often leading to performance anxiety
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Origins of……
II. Cultural Influences

– Negative childhood learning about sexuality
– Narrowly defined sexuality
– Rigid goals often leading to performance anxiety
6/3/2019 182
Origins of……
III. Individual Factors
– Sexual knowledge & attitudes
– Self-concept & body image;
– Emotional problems
– Sexual abuse & assault
IV. Relationship Factors
- Unresolved problems – dislike, resentment, anger, lack of
trust, respect, and power.
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Origins of……
-Ineffective Communication- Inaccurate assumptions,

reliance on gender stereotypes and lack of listening &
negotiations.
- Fears about pregnancy or STI/Ds - Concealment of

true sexual orientation
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Origins of……
• Sexual Difficulty can be in understood by segregating the

difficulties in to sexual response cycle Phases:
1. Desire Phase Difficulties

• Hypoactive sexual desire/inhibited sexual desire: it is low or
absent sexual desire which is usually temporary; often due to
relationship problems, past abuse, internalized – attitudes.
• Dissatisfaction with frequency of sexual activity: inability to
compromise!
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Origins of……
 The reason is differing levels of desire, polarization: one

feels deprived, other feels pressured
 Sexual Aversion Disorder (SAD): extreme, irrational fear

of sexual activities or ideas; consistent phobic response,
often due to sexual abuse or assault.
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Origins of……
2. Excitement Phase Difficulties
Female Sexual Arousal Disorder: inhibited lubrication; often due
to apathy, anger, fear, decreased estrogen levels. The suggestion
can be non coital activities may increase lubrication; use of water-
soluble jelly also helps.
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3. Orgasm Phase Difficulties
Female Orgasmic Disorder/anorgasmia:
absence of orgasm might be situational or cultural factors.

Male Orgasmic Disorder: inability to ejaculate during sex.
Premature Ejaculation: it varies with couples; and the definition is

based on subjective satisfaction.
Many men experience this - 25% often; and physiological

predisposition &anxiety are the commonest reasons.
6/3/2019 188
Orgasm Phase Difficulties…
Faking Orgasm: this is pretending as they reached to orgasm but

not in reality due to performance pressure, caretaking of
partner, lack of hope/ability to achieve orgasm.
 The negative consequences; creates emotional disturbance;

guilt, resentment, anger.
 This can be stopped with effort (learning about what works

better, communicating desires & needs, therapist maybe).
6/3/2019 189
4. Dyspareunia (Pain during sexual intercourse)
Painful intercourse in men: The cause may include phimosis

(tight foreskin); infected/irritated foreskin.
Painful intercourse in women: decreased lubrication because of
many reasons, like Infections, negative attitude towards sexual
intercourse, fear
Vaginismus: strong, involuntary contractions of outer 1/3 of
vagina; due to fear, hostility, chronic pain, strong sexual taboos.
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Sexually Transmitted Infections
6/3/2019 191
Sexually Transmitted Infections
Group Discussion
Discuss on the following questions and present what
you discussed to whole class.
1. What are the names of some STIs (Sexually
Transmitted Infections)?
2. How are STIs transmitted?
3. How do you know if you have an STI?
4. Can all STIs be treated? Where can you go for
help?
5. How can you protect yourself?
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Introduction
Definition:
 Sexually transmitted infections (STIs) are a group of infections

similar to one another only in that they can be acquired through
sexual contact.
 STI is a term now used in place of sexually transmitted

diseases (STDs).
 You don't necessarily have to have sex to get sexually

transmitted infections (STIs), but sexual activity is the most
common way for them to be spread.
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Introduction…
• The infections are caused by different organisms and
have a wide variety of symptoms.
 WHO estimates ½ of PLHIV are <25yrs, 1/2 of new

infection occurs among 15-24 years of age.
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Introduction…
 In Ethiopia, STI prevalence among 15-24 years is 0.35% &

0.4% in 15:54 female and male respectively. HIV prevalence
in adolescent and youth is about 4.1%.
 Since there is strong inter-relation b/n STI and HIV

providers should successfully prevent new cases & manage
existing cases of STIs and HIV in adolescents and youths.
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Types of STIs
Sexually Transmitted Infections (STIs):- Infections caused by
organisms that are passed through sexual activity with an infected
partner.
Endogenous infections: - Infections that result from an overgrowth of
organisms normally present in the vagina.
• These infections are not usually sexually transmitted, and include
bacterial vaginosis and candidiasis.
Iatrogenic infections: -Infections introduced into the reproductive
tract by a medical procedure such as menstrual regulation, induced
abortion, IUD insertion, or childbirth.
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A. Common Bacterial Infections
Neisseria gonorrhoeae (causes gonorrhoea or gonococcal
infection)
Chlamydia trachomatis (causes chlamydial infections)
Treponema pallidum (causes syphilis)
Haemophilus ducreyi (causes chancroid)
Klebsiella granulomatis
-previously known as Calymmato bacterium granulomatis causes granuloma
inguinale(donovanosis).
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B. Common viral infections
Human immunodeficiency virus (causes AIDS)
Herpes simplex virus type 2 (causes genital herpes)
Human papilloma virus (causes genital warts and certain

subtypes lead to cervical cancer in wome
 Hepatitis B virus (causes hepatitis and chronic cases

may lead to cancer of the liver)
Cytomegalovirus (causes inflammation in a number of

organs including the brain, the eye, and the bowel).
6/3/2019 198
C. Parasitic Organisms
Trichomonas vaginalis (causes vaginal trichomoniasis)
Candida albicans (causes vulvovaginitis in women;

inflammation of the glans penis and fore-skin [balano-
posthitis] in men).
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Mode of transmission
Through unprotected penetrative sexual intercourse (vaginal or
anal) which is main way from mother to child: east milk (e.g.
HIV);
– During pregnancy(e.g. HIV and Syphilis
– At delivery (e.g. gonorrhea, chlamydia and HIV)
– After birth through breast milk (e.g. HIV)

– Through the use of unsterile needles or injections or other
contact with blood or blood products (e.g. syphilis, HIV and
hepatitis).
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Symptoms and Complications of untreated STIs
 Many people with STIs might have no obvious symptoms at

all.
 As a result, the person may not seek treatment for a long time.
 This delay could result in higher risks of STI-related health

problems or complications, as well as the possibility of
spreading the STI to partners.
6/3/2019 201
Symptoms and signs of STI………….
A number of symptoms can indicate the existence of an

STI,although specific symptoms are unique for different
infections
 heavier than normal vaginal discharge
 discharge from the penis or rectum
 itching in genital or anal areas
 sores or rashes in genital or anal areas, sometimes also in the

mouth
6/3/2019 202
Symptoms and signs of STI….
 pain during intercourse
 painful or more frequent urination
 swollen glands in the groin fever, headache, general feeling of

illness
 pelvic pain that is not related to your period
6/3/2019 203
Syphilis
 sores called chancres often appear about 3 weeks after exposure
 If left untreated, this first phase of syphilis lasts 3 to 6 weeks.
 A rash over larger areas of the body can follow 3 to 6 weeks after
the sores appear.
 People with syphilis may also get aching muscles and swollen
lymph glands as well as flat warts during this stage.
 Syphilis can also lead to eye inflammation, causing blurred vision.
 In the second stage, symptoms may come and go over the next 1
to 2 years, then disappear.
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About one-third of people in the second stage of syphilis will go on

to the third stage, where the infection damages the brain, heart,
nervous system, bones, joints, eyes, and other body areas.
Hepatitis B
 Can cause many symptoms including a decrease in appetite

(associated with nausea and vomiting), jaundice, dark yellowing of
urine, and aching in the muscles and joints.
 These symptoms are signs of liver inflammation or damage.
6/3/2019 205
Genital herpes
 produces a tingling sensation in the genitals.
 Sores develop in and around the male and female

genitals, anus, thighs, buttocks, and mouth.
Chancroid
 is caused by a bacterial infection in the genital area.
 4 to 7 days after exposure to the bacteria, sores form,

often with a red border around them.
6/3/2019 206
• Although this infection is more common in tropical
areas, it is possible to get it elsewhere. Antibiotics
treat this infection normally within 2 weeks.
6/3/2019 207
Complications associated with STIs:
 Infertility, pregnancy complications, or higher risks of cervical
cancer can occur in women.
 Gonorrhea, if not treated, can spread via the blood stream to joints
and heart valves.
 Both gonorrhea and chlamydia can cause eye infections in

newborns that came in contact with the bacteria during delivery.
 If syphilis is not treated, it may eventually cause serious

damage to the bones, heart, eyes, brain, and nervous
system.
6/3/2019 208
Complications Associated with STIs….
 Hepatitis B can lead to long-term liver damage and higher risks of
developing liver cancer.
 HIV weakens a person's immune system, putting them at risk for

many different infections.
 Chancroid makes a person more susceptible to HIV infection

when they're exposed to the virus.
 An active herpes infection at the end of a pregnancy will require

delivery by a caesarean section to avoid spreading the infection to
the baby.
6/3/2019 209
Consequences of STIs
A. Long term health consequences of STIs
 It may result in permanent infertility, chronic pain from PID,

cervical cancer.
 Heart and Brain damage may also occur.
 STIs are also a risk factor for HIV, low birth weight, prematurity,
and risk of other disease, infection, and blindness from ophthalmic
neonatorum.
6/3/2019 210
Consequences of STIs….
B. Long term social consequences of STIs
• STIs also results long term social consequences.
• Some of these long term social consequences includes:
• infertility and loss of community credibility, possible judgment,

/rejection by service providers etc.
6/3/2019 211
Importance of Early Diagnosis, Treatment, and Partner
Notification
 Your doctor will ask you questions about your symptoms &
perform a physical exam.
 To help DX STI, your doctor may order blood tests, urine tests,
or may take a swab from the genital area, which will be sent to
a laboratory for evaluation.
 Sexually active individuals, particularly those with multiple

partners, are recommended to have regular checkups with a
family doctor.
6/3/2019 212
Importance of……
 In some cases, there are no obvious symptoms & the infections
that cause STIs can only be identified through regular STI
screening tests.
6/3/2019 213
Treatment and Prevention
 Antibiotics can be used to treat bacterial infections, like the ones

that cause gonorrhea, syphilis, or chancroid.
 Gonorrhea often occurs at the same time as chlamydia, so doctors

usually prescribe antibiotics to treat both gonorrhea and
chlamydia.
People with acute hepatitis B are usually treated only for
symptoms.
6/3/2019 214
Treatment and Prevention….
 There is no cure for HIV.
 Doctors prescribe different combinations of antiviral
medications to slow down the progress of the disease.
 RX secondary infections that result from a weakened
immune system.
 Don't be shy about asking new sexual partners if they have
STIs, or letting them know if you have one.
 To avoid spreading STIs, people who are sexually active
and have multiple partners can be routinely screened - and
rapidly treated - by a doctor.
6/3/2019 215
Treatment and Prevention….
If you want to prevent getting STIs, you should:
 Avoid having unprotected sex.
 Always use either a male/female condom& learn how to use

them correctly to best protect against STIs.
 Avoid using shared, non-sterile needles for drugs, body

piercing, or tattoos.
 Visit your doctor regularly to check for STIs.
 Learn more about STIs.
6/3/2019 216
If you want to prevent……..
 The more you know about STIs, the better you can
protect yourself against them.
 Speak to your doctor or pharmacist and look for

resources in your community.
6/3/2019 217
The global strategy for the prevention and control of STIs
Prevention by promoting safer sexual behaviors;
General access to quality condoms at affordable prices;
 Promotion of early recourse to health services by people

suffering from STIs and by their partners;
 Inclusion of STI treatment in basic health services;
 Specific services for populations with frequent or unplanned

high-risk sexual behaviors such as sex workers, adolescents,
long-distance truck-drivers, military personnel, substance users
and prisoners;
6/3/2019 218
Cont…
The global strategy ……
 Proper treatment of STIs, i.e. use of correct and
effective medicines, treatment of sexual partners,
education and advice;
Screening of clinically asymptomatic patients, where
feasible; (e.g. syphilis, Chlamydia);
Provision for counseling and voluntary testing for HIV
infection.
6/3/2019 219
Why is it so difficult to control the spread of STIs?
Biological factors;
– 70–80% of infected women may be asymptomatic and so will
not seek RX. social and behavioral factors
– Ignorance or misinformation
– The social stigma so often attached to STIs
– The difficulty of notifying sexual partners
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Unintended pregnancy
6/3/2019 221
Please list the consequences of Unsafe sex from the following
scenario
There is a young 18-year old college student. She has friends
from different backgrounds. She feels attracted to a boy in her
class and develops a friendship with him. She really begins to
like him and spends time with him. Eventually he asks her to
have sex with him. She was not in a position to resist his
pressure and they made unsafe sex. After 3 month she found
herself pregnant.
6/3/2019 222
 An unintended pregnancy is a pregnancy that is reported to
have been either;
unwanted (that is, the pregnancy occurred when no

children, or no more children, were desired) or
mistimed (that is, the pregnancy occurred earlier than

desired),
 Unintended pregnancy is mainly results from not using

contraception, or inconsistent or incorrect use of effective
contraceptive methods.
6/3/2019 223
Cont…
 Unintended pregnancy is when the pregnant woman decides
on her own freewill that the pregnancy is undesired; hence
intends to terminate her pregnancy.
 Each year in the world there are about 75 million unintended

pregnancies that result in abortions of which the majority are
known to be unsafe.
6/3/2019 224
Teenage pregnancy
 It is defined as a teenage girl, usually within the ages of
13-19, becoming pregnant.
 Which refers to girls who have not reached legal

adulthood, which varies across the world, who become
pregnant each year.
 An estimated 14 million adolescents between the ages of

15 and 19 give birth globally, and more than 90% of these
live births occur in developing countries.
6/3/2019 225
Teenagers suffer from a disproportionate share of:
early marriage, unwanted pregnancies,
unsafe abortions, STIs including HIV/AIDS,
female genital mutilation,
malnutrition and anemia,
Infertility,
sexual& gender based violence, &
other serious reproductive health problems (Ethiop. J.
Health Dev. 2010; 24(1):30).
6/3/2019 226
Cont…
 Teenage pregnancy is a major health concern because of its
association with higher morbidity and mortality for both
mother and child.
 Childbearing during the teenage years frequently has adverse

social consequences as well, particularly on educational
attainment, because women who become mothers in their
teens are more likely to curtail their education.
6/3/2019 227
Cont…
 Teenagers in rural areas are much more likely to have
started childbearing than their urban counterparts (15%
and 4%, respectively).
 Teenagers with less education are much more likely to

have started childbearing earlier than those who are better
educated.
 Teenagers in the lowest wealth quintile are almost four

times as likely to start childbearing early as women in the
highest wealth quintile (21% and 6%, respectively).
6/3/2019 228
Cont…
 An estimated 70,000 teenage girls die each year during
pregnancy and childbirth & more than one million infants
born to adolescent girls die before their first birthday.
 Due to such a grave health consequences teenage pregnancies

are termed a death sentence in poorest countries.
 About 2 million or more of them suffered chronic illness or

disabilities, shame and abandonment.
6/3/2019 229
Some factors associated with teenage pregnancy in
Ethiopia
 age
 educational status
 place of residence
 employment
 contraceptive use etc.
6/3/2019 230
Consequences of teenage pregnancy
 Global level- population growth
 Societal level- a negative impact on their position and
potential contribution to society
 Individual level
– Adverse maternal and child health outcomes including
obstructed labor, low birth weight, fetal growth retardation,
and high infant and maternal mortality rate, etc.
6/3/2019 231
How to intervene?
 Concerted efforts are needed to empower teenagers
to:
Educate community about its adverse effects
fight early marriage
promote education &
encourage the utilization of family planning targeting
the rural teenage
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Abortion
6/3/2019 233
Abortion
 Abortion is the termination or initiation of termination of

pregnancy before reaching viability (before 20weeks or
<500grams according to WHO or before 28 weeks of gestation or
less than 1kg fetal weight in Ethiopia and UK).
 It can be spontaneous where termination is not provoked

deliberately or induced when there is a deliberate interference with
the pregnancy for the sake of terminating it.
6/3/2019 234
Abortion…….
 Clinical stages of spontaneous abortion are: threatened,
inevitable, incomplete, complete, or missed abortion.
 If any of the stages mentioned get infected it is called septic

abortion.
6/3/2019 235
Magnitude of Abortion
 About Fifteen percent of all clinically recognizable
pregnancies end in spontaneous abortions.
 It is estimated that 30 to 50 million induced abortions are

performed annually in the world and about half of these
are performed illegally.
 In Ethiopia it is estimated that there are 3.27 million

pregnancies every year of which approximately 500,000
end in either spontaneous or unsafely induced abortion.
6/3/2019 236
Unsafe abortion
 WHO characterizes unsafe abortion by the lack of skilled
providers, unsafe techniques, and/or sanitary facilities.
 Unsafe abortion is the commonest cause of maternal

mortality accounting for up to 32% of all maternal deaths in
Ethiopia.
 Abortion is more than a medical issue, or an ethical issue,

or a legal issue.
 It is above all a human issue, involving women and men as

individuals, as couples and as a member of the society.
6/3/2019 237
Complications of abortions
A. Acute Complications
Incomplete abortion
Sepsis
Hemorrhage
Uterine Perforation
Bowel injury
6/3/2019 238
B. Long-term Complications
Chronic pelvic pain
Pelvic inflammatory disease
Tubal blockage and secondary infertility
Ectopic pregnancy
Increased risk of spontaneous abortion or premature
delivery in subsequent pregnancies.
 These complications can limit women’s productivity

inside and outside the home, constrain their ability to
care for children and adversely affect sexual life.
6/3/2019 239
Magnitude of Abortion in Ethiopia
 Accurate estimates are difficult to get, but it is clear
that abortion is widespread and generally performed by
untrained persons.
 It is the leading cause of maternal mortality.
 In a community-based study, abortion accounted for

54.2 % of the direct causes of maternal deaths.
 It is one of the top ten causes of admissions among

women.
6/3/2019 240
Cont…
 The majority of unwanted pregnancies occur in Non-

users of contraceptive methods.
 Despite the fact that family planning services are more

effective and available than ever before, estimates
suggest that ,worldwide:
350 million couples lack access to information

about contraceptives and a full range of modern
methods
6/3/2019 241
Cont…
105 million married women have unmet need for
FP.
12 to 15 million women may also lack access to

services that will enable them to achieve their
reproductive intentions.
6/3/2019 242
Why Women Find Themselves with Unwanted
Pregnancy?
 None use of contraception
 Contraceptive failure
 Sexual coercion or rape
 Other factors include:
 Lack of control over contraception;
 Young age or single marital status;
 Abandonment or unstable relationship;
 Mental or physical health problems;
 Severe malformation of the fetus; and
 Financial constraints.
6/3/2019 243
Decision to get an abortion
 A woman's decision to get an abortion is not made in

a vacuum, but is bound up in society's feelings about
abortion as well as her feelings about the pregnancy:
 There are several social factors influencing the

emotional decision of obtaining abortion
6/3/2019 244
Factors influencing women’s decision to get abortion
• Religious attitudes
• Personal and interpersonal reasons
• Age and marital status
• Poor access to family planning information and services
• Legal status of abortion
6/3/2019 245
What can be done about unwanted pregnancy?
 Ensure universal access to family planning
 Increase the availability of safe abortion services to the
extent allowed by law
 Improve the quality and accessibility of post-abortion care
 Educate communities about reproductive health and unsafe
abortion; and
 Work for changes in policies to safeguard women’s
reproductive health.
6/3/2019 246
Offering abortion services
 Providing women centered and post abortion care is very

important to reduce the morbidity and mortality related to
abortion.
 The recently promoted abortion care approach is women-centered

approach of provision of the services.
 In the woman – centered approach, the provider asks for and

focuses on woman’s concerns and interests and takes a
comprehensive approach to meeting every woman’s medical and
psychological needs at the time of treatment.
6/3/2019 247
Key elements of post abortion care include:
1. Treatment of incomplete and unsafe abortion;

2. Counseling;
3. Family planning services;
4. Links to comprehensive reproductive health
services;
5. Community and service provider partnerships.
6/3/2019 248
Supportive Laws and Policies
 Evidences shows that, when abortion is illegal;
 It is most difficult for a woman to obtain it,
 Society is generally against abortion, and
 The psychological trauma is generally great
 restrictive legislation is associated with higher rates of unsafe
abortion and correspondingly high mortality.
 Once abortion is legalized, a supportive relationship can be
established and the decrease in external stress will be
accompanied by a similar decrease in negative feelings.
6/3/2019 249
Grounds on Which Abortion is Permitted, revised abortion
law of Ethiopia, (House of Parliament, 2005)
 When the pregnancy puts the woman’s life at risk
 Fetal impairment or deformity
 When pregnancy follows Rape or incest (based on the woman’s
complaint only)
 When pregnancy occurs in minors (stated maternal age <18 years)
 The woman is physically and mentally unable to care for the
would-be born child.
6/3/2019 250
Component of Sexual and Reproductive Health Services
6/3/2019 251
Component of Sexual and Reproductive Health Services
A. Family Planning
There are three rationales of family planning
1. Demographic Rationale
 Reducing high fertility and slowing population growth

provided the dominant rationale for FP programs in the
1960s and 1970s.
6/3/2019 252
Demographic Rationale….
Demographic Rationale….
• The rationale was based on concerns over the

potentially negative effects of rapid population
growth and high fertility in the developing world.
6/3/2019 253
2. Health Rationale
 During the 1980s, the public health consequences of

high fertility for mothers and children are set of
concerns for international community especially for
developing countries.
 High rates of infant, child, and maternal mortality as

well as abortion and its health consequences, were
pressing health problems in many developing nations.
6/3/2019 254
Health Rationale….
2.1. Benefits to Women’s Health

 Simply by providing contraceptives to women who
desire to use it, we can reduce maternal deaths by as
much as one-third because:
Avoiding pregnancy at the extremes of maternal age
Preventing high-risk pregnancies: decrease maternal
deaths by quarter
6/3/2019 255
• Decreasing risks by decreasing parity: If all women
had five births or fewer, the number of maternal
deaths could drop by 26 % worldwide.
6/3/2019 256
 Prevention of unwanted pregnancy: reduces unnecessary

risks of pregnancy, childbirth and risks of induced abortion
 Improving health through non-contraceptive benefits

including prevention of STIs and reproductive cancers.
6/3/2019 257
2.2. Family planning benefits children’s health
 Family planning indirectly contributes to children’s

health, development, and survival by reducing the risk of
maternal mortality and morbidity.
 Spacing births at least 2 years apart has to do with their

survival: On average, babies born less than two years
after the previous birth in the family are about twice as
likely to die in the first year as babies born after at least a
2-year interval.
6/3/2019 258
 Even older children who are spaced too closely face an
increased risk of death during the toddler and childhood
years.
 Planning births during the mother’s optimal age-not too

old or too young: women who are very young or very old
are more likely to have an infant or child death.
6/3/2019 259
• Family planning prevents further. pregnancies in a
mother who has had numerous pregnancies already
and avoids close birth spacing and sharing limited
resources such as food.
6/3/2019 260
2.3. Family planning benefits women and their societies
 Family planning reduces the health risks of women and gives them
more control over their reproductive lives.
 With better health and greater control over their lives, women can
take advantage of education, employment, and civic opportunities.
 If couples have fewer children in the future, the rate of population

growth would decrease.
6/3/2019 261
 As a result, future demands on natural resources such

as water and fertile soil will be less.
 Everyone will have a better opportunity for a better

quality of life.
6/3/2019 262
3. Human Rights Rationale
 This rationale became preeminent in the 1990s, in part

because of the excesses reactions to the demographic
rationale.
 It rests on the belief that individuals and couples have a

fundamental right to control reproductive decisions,
including family size and the timing of births.
 This rationale found its strongest articulation at the

ICPD, held in Cairo, in 1994.
6/3/2019 263
Family Planning Methods
The commonly used family planning methods

are:
1. Natural Method
– Breast feeding (Lactational amenorrhea method)
– Abstinence
– Withdrawal (Coitus interrupts)
– Calendar methods
– Cervical mucus (Billing’s Method)
– Sympathothermal
6/3/2019 264
Cont…
2.Artificial methods
A. Barrier methods
Diaphragm
Condom
Intra-uterine device (IUD)
B. Hormonal
Pills
Implants
Injectable
6/3/2019 265
Cont…
C. Surgical methods (Permanent)
Tubal ligation (ligating the oviduct).
Vasectomy (legating the sperm duct).

D. Emergency contraception
IUD
Levonorgestrel-only or combined estrogen-

progesterone
6/3/2019 266
Cont…
 Even though various methods are available and
accessible, clients do not get the opportunity to discuss
with health care providers how/when to use and where to
go.
 Therefore, it is important to ensure provision of

information and counseling in family planning services.
6/3/2019 267
Cont…
 The major activities to be carried out are:
1. Review of all available methods in a simple and

understandable manner.
2. Understanding and respecting the clients’ right.
3. Follow the acronym GATHER- greet, ask, tell,
help, explain, and return
6/3/2019 268
B. Youth Friendly Services
 Youth: Period between childhood & adulthood,which
involves distinct physiological, psychological, cognitive,
social, & economic changes.
 According to WHO definitions:

Adolescent: the age between 10-19 years.
Youth: 15-24 years of age
Young: 15- 29 years of age
6/3/2019 269
Youth Friendly Health Services….
 Defined by WHO as “Services that are: accessible, safe,

effective, acceptable, and appropriate for adolescents in
meeting their need, in the right place, at the right price (free
where necessary)”.
6/3/2019 270
Why reproductive health focuses on youths?
 Number/ proportion:
Account to 60% of the population in Ethiopia (below
25 years of age)
 Nature of adolescents and young on sexuality

Major physical, cognitive, emotional, sexual, and
social changes occur during adolescence and affects
young people’s sexual behavior
 Many young people engaged in risky behaviors due
to
Curiosity, Peer pressure, Sexual maturation, A feeling
6/3/2019 271
Cont…
The increasing gap between puberty and marriage:
Unmarried youth require reproductive health care for
a longer period
 Health and health related issues:
This is related to the higher proportion of HIV and STI
among adolescents and young.
Higher risk of maternal death among 15-19 year of age
as compared to 25-29 years of age (4X).
Many young women are sexually active and do not use
contraceptive methods.
6/3/2019 272
Reasons youth fail to receive RH care service
Poor treatment,
fear of being judged by service provider,
lack of privacy,
feeling that services are intended for
married people, and
unaware of service locations or services
offered.
6/3/2019 273
Approaches for working with youth directly
1. Motivation-Stimulating behavior changes in individuals by

marketing a product, service, or action.
2. Health Education in reproductive health issues
3. Counseling on RH issues
4. RH services-Such as STI screening & treatment, FP,
pregnancy care… etc.
6/3/2019 274
Chapter Three
Gender and gender based violence
6/3/2019 275
Learning Objectives:
Students will be able to:
o Define gender and related terminologies
o Differentiate Sex and Gender
o Describe gender equality and equity
o Explain gender roles and gender Needs
o Identify the causes and Impacts of gender based
violence
o explain gender practices in Ethiopia
o Link among SRH, GBV and HIV
6/3/2019 276
Gender and related terminologies
Gender
o Refers to the social and cultural construction of maleness

and females and not to the mere state of being male and
female in its entirety (Connell 2002: 6; Lorber 1994:4).
o It encompasses beliefs, expectations, and activities and

attributes that a particular community considers
appropriate for its men and women.
6/3/2019 277
Gender
Sex Socially
constructed
Biological (male roles,
or female) responsibilities
Universal and behaviors
Born with (Masculine or
Generally feminine)
unchanging (with Cultural
the exception of Learned
surgery) Changes over
Does not vary time
between or Varies within and
within cultures between cultures
6/3/2019 278
Sample Statement
Sex Gender
Men are responsible for the financial
welfare of the household.
Women are at greater risk for HIV
infection than men.
Only men can provide sperm for
fertilization.
Women are more loving and caring than
men.
Women tend to be poor managers.
Women can menstruate while men
cannot.
Men think and act more rationally than
women.
6/3/2019 279
What is sex? What is gender?
Sex Gender
Men are responsible for the financial welfare of
the household.
Women are at greater risk for HIV infection
than men.
Only men can provide sperm for fertilization.
Women are more loving and caring than men.
Women tend to be poor managers.

Women can menstruate while men cannot.
Men think and act more rationally than
women.
6/3/2019 280
Con…
Characteristics of Gender
 Relational: it is socially constructed
 Hierarchical: Power Relations exist between the two

genders
 Changes: Changes over time
 Context: Varies with ethnicity, class, culture
 Institutional: it is systemic
6/3/2019 281
Con…
Gender mainstreaming
 It is a strategy for integrating gender concerns in the

analysis, formulation and monitoring of policies and
programmes (UNFPA, 2009)
 It is an important factor in ensuring gender equality.
 Gender mainstreaming “seeks to produce

transformative processes and practices
6/3/2019 282
con…
Gender equality
 It is equal treatment of women and men in laws and

policies
 It is equal access to resources and services within

families, communities, and society at large
 A discussion on gender equality would be incomplete

without a definition of ‘gender equity because these
terms are interrelated.
6/3/2019 283
Con…
 Gender equity is the process of ensuring fairness and
equal distribution of resources among men and
women.
 Equity leads to equality and where gender inequality

exists it is the women who are excluded in relation to
decision-making and access to economic and social
resources’(UNFPA, 2009).
6/3/2019 284
Con…
 The empowerment of women is a critical aspect of
promoting gender equality
 Gender equality ensures that access to resources is

not weighted in men’s favors, so that men and women
participate fully as equal partners in development
6/3/2019 285
Con…
The fit between gender equality and gender mainstreaming
Real equality
 is transforming the mainstream, ridding it of gender
stereotypes, gender biases, and gender discrimination and
replacing the segregated standards associated with masculinity
and femininity.
 is not changing the legislative frame of the university
6/3/2019 286
Con…
Gender equity
o means fairness and justice in the distribution of benefits and

responsibilities between women and men.
o often requires women-specific programmes and policies to end

existing inequalities.
Gender discrimination
o any distinction, exclusion, or restriction made on the basis of

socially constructed gender roles and norms which prevents a
person from enjoying full human rights.
6/3/2019 287
Con…
Gender stereotypes
 refer to beliefs that are so ingrained in our consciousness

that many of us think gender roles are natural and we
don’t question them.
Gender bias
 refers to gender based prejudice; assumptions expressed

without a reason and are generally unfavorable.
6/3/2019 288
Con…
Gender analysis
 is a research tool that helps policy makers and

program managers appreciate the importance of
gender issues in the design, implementation, and
evaluation of their projects
6/3/2019 289
Gender and Sexual Reproductive Health (SRH)
• Is there a relation between gender and sexual

and reproductive health?
6/3/2019 290
Con…
o Reproductive health is a state of complete physical, mental,
and social well-being and not merely the absence of disease
or infirmity in all matters relating to the reproductive
system, its functions and processes(Magowe, 2014).
o Reproductive health there fore implies that people are able
to have a satisfying and safe sex life
o They have the capability to reproduce and the freedom to
decide when and how often to do so.
6/3/2019 291
Con…
o Men and women to be informed and to have access to
safe, effective, affordable, and acceptable methods of
family planning of their choice.
o It also includes the right of all to make decisions
concerning reproduction free of discrimination, coercion,
and violence.
6/3/2019 292
Con…
 Increasing access to voluntary and non-coercive family
planning services for all women can avoid unintended
pregnancies
 Enables women to choose the number and spacing of their
children thereby improving their health and well-being
(UNAIDS, 2013:13-14).
6/3/2019 293
HIV Vulnerability in Relationship among Women
 Risk of sexual ill health begins with the onset of

unsafe sexual activity and continues as long as the
unsafe activity or harmful sexual practices are
engaged in (UNAIDS 2012:16).
 Unequal power relations between men and women

increase their vulnerability to HIV infection (Higgins,
Hoffman&Dworkin2010:436).
6/3/2019 294
Con…
Risk factors for HIV in women
 Contextual variability in risk,
 Physiological factors
 Socio-economic vulnerabilities
 Behavioral factors
 Structural
 Alcohol consumption
(Ramjee & Daniels 2013:2-4,
others).
6/3/2019 295
Couples' Sexual Negotiation
 Unequal sexual power and economic disparities, leads
to limited ability to negotiate protected sex and few
alternatives to adopting practices for women.
 Counselling and condom promotion cannot focus on
sexual behaviour alone because a woman does not
make sexual decisions in isolation within her life
context
6/3/2019 296
Con…
Sexual behaviour is greatly influenced
Individual’s culture
Sexual orientation
Experience
Knowledge
(UNAIDS, 2009:3).
6/3/2019 297
HIV Infection's Risk Perception among Women
 HIV infection rates is rising among girls and women
 It requires prevention, treatment and care
 Effective prevention is composed
o education,
o health services,
o media campaigns,
o behaviour change,
o life skills building
o job trainings.
6/3/2019
(UNAIDS/UNFPA/UNIFEM 2004:11). 298
Gender-based violence (GBV)
 It refers to all forms of violence that happen to
women, girls, men, and boys
 It is due to unequal power relations between the

victim and perpetrators.
 Women’s subordinate status making them more

vulnerable & “contribute environment that accepts,
excuses, and even expects it”
6/3/2019 299
Violence against Women (VAW)
 Violence against Women(VAW) is any act of gender-based
violence that results in
 physical,
sexual,
psychological harm
suffering to women,
threats ( acts, coercion, or arbitrary deprivations of
liberty)
 It can be occurred in public or private life.

6/3/2019 300
Con…
 Intimate partner violence accounts for the lion share of
VAW.
 Intimate partner violence is behavior within an intimate

relationship
 IPV causes
 physical, sexual, or psychological harm
 acts of physical aggression, sexual coercion
 psychological abuse and controlling behaviors
6/3/2019 301
Concepts of Gender Violence
GENDER EQUALITY:
o Equal treatment of women and men in laws and policies, and

equal access to resources and services within families,
communities, and society at large.
GENDER EQUITY:
o Fairness and justice in the distribution of benefits and

responsibilities between women and men.
o Programmes and policies that specifically empower women

are often needed to achieve this.
6/3/2019 302
Con…
GENDER-BASED VIOLENCE:
 Violence involving men and women, in which the female

is usually the victim
 It is derived from unequal power relationships between

men and women
6/3/2019 303
Con…
VIOLENCE AGAINST WOMEN:
 Any public or private act of gender-based violence that

results in physical, sexual or psychological harm or
suffering to women
INTIMATE PARTNER VIOLENCE:
 Any behaviour by a man or a woman within an intimate

relationship that causes physical, sexual, or psychological
harm to those in the relationship.
6/3/2019 304
Gender Violence
o Gender violence is a very broad concept, that may take
many different forms
the rape of a virgin woman or child in the belief that it

would cure HIV/AIDS
the rape of a woman in a train
the sexual oppression of a girl student by staff

members
wife being treated with hostility with the justification

that a bride price was paid for her
6/3/2019 305
Types of Gender Based Violence(GBV)
Physical Violence
Psychological violence / mental harm
Sexual Violence
6/3/2019 306
Violence against Women (VAW)
 Violence against Women (VAW) is a term that is
often interchangeably used with Gender Based
Violence (GBV)
 GBV is refer to violence perpetrated against women,

girls, men and boys
 GBV is often perpetrated against both women, times

women due to the unequal power relations between
men and women
6/3/2019 307
Types of VAW
1. Physical, sexual and psychological
 Violence that occurs in the family including
Battering
Sexual abuse of female children in the household
Dowry-related violence
Marital rape
female genital mutilation
non-spousal violence
violence related to exploitation
6/3/2019 308
Con…
2. Physical, sexual and psychological violence
 Occurs within the general community
Rape
sexual abuse
sexual harassment
intimidation at work, in educational institutions and
elsewhere
trafficking in women
forced prostitution
6/3/2019 309
Con…
3. Physical, sexual, and psychological violence
Perpetrated or condoned by the State, wherever it
occurs.
6/3/2019 310
Physical Violence:
 Kicking
 Punching
 Burning
 stabbing,
 pouring boiled water,
 setting on fire
 gunshot
6/3/2019 311
Psychological violence / mental harm
 Repeated verbal abuse
 Spitting on
 Constant humiliation
 This is very difficult to measure but have long lasting

sequel
6/3/2019 312
Sexual Violence
 Coerced sex through threats, Intimidation, or physical
force, forced prostitution
 Rape (Forced unwelcome sex),
 Abduction
 What gender based health problems being faced by
females throughout life span?

6/3/2019 313
What can be done against Gender Based Violence
(GBV)?
6/3/2019 314
Initiatives against GBV
 police and judicial reforms
 Legislative initiatives
 community mobilization to encourage behavior change
 the reorientation of health services.
 Empowering women
 Raising their status
 Combating norms of violence
 Reducing poverty
 Alcohol consumption
6/3/2019 315
Gender Issues in Ethiopia
 Many developing countries exhibit considerable
gender inequality in education, employment, and
health outcomes
 For example there are large discrepancies in
education between the sexes in South Asia and in
Sub-Saharan Africa
6/3/2019 316
Con…
 Importance of gender inequality can be distinguished as
Intrinsic:
 Capabilities of longevity and education as critical
constituent elements in well-being
 Any reduced achievements for women in these capabilities
are intrinsically problematic
Instrumental
 Gender inequality may have adverse impacts on a number
of valuable development goals.
6/3/2019 317
Con…
Effect of gender inequality
Expansion of education on the next generation
Reduce economic growth
6/3/2019 318
Gender related problems in Ethiopia
 Gender issue has become an important area of concern in
national and sub-national economic development
 Ethiopia strives to continue its steady rate of development
by systematically including women
 There are several aspects that compose the general
framework of the relationships between socio-economic
and cultural roles of men and women
6/3/2019 319
Con…
Different dimensions to gender inequality
 Access and achievement in education
 Improvement in health
 Indexes of legal and economic equality of women in

society and in marriage
 Measures of women’s empowerment
6/3/2019 320
Causes of Violence against Women (CVAW)
 Systemic domination of
 Disability
women by men
 Religion
 Economic status
 Culture intersect
 Class
 Age
6/3/2019 321
Consequences of VAW
 Health impacts  Early pregnancy

 violations of human rights
 Many children
 limiting one’s choices
 Exposure to HIV and
 Discontinuation of
AIDS
schooling
6/3/2019 322
6/3/2019 323
Interventions of GBV
 Government created enabling environment to
empower women to become active participants of
the development process and benefit from it
 The ultimate goal here is to achieve a level where
government policies on economic, political, and
social spheres and all development intervention
plans become gender-sensitive and gender inclusive
6/3/2019 324
Con…
 The ENPW recognizes the significant role NGO "All
NGO and donor countries engaged in development
activities here in Ethiopia too are expected to do their
utmost toward the implementation of the Policy."
 Modalities of cooperation to strengthen Gender initiatives

between the Government National machinery (WAO at
the Prime Minister Office) and the National Umbrella
NGO organization have reached to agreement.
6/3/2019 325
Con…
This agreement includes:
 Gender Mainstreaming,
 Advocacy
 capacity building,
 creating grassroots women movement
 Organization
 National Machinery
 Participation of Civil Societies
 Women's Groups
 Others
6/3/2019 326
Thank You
6/3/2019 327

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WACHEMO UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH

DEPARTMENT OF PUBLIC HEALTH

WACHEMO UNIVERSITY STUDENTS

 HIV is an abbreviation of human immune deficiency

 Accordingly, AIDS is an acquired (not inherited) disease

 It is the disease of the immune system due to infection

 AIDS syndrome represents the late clinical stage of

 HIV destroys the CD4 T lymphocytes (CD4 cells) of

AIDS patients are people whose resistance to diseases is severely

Characteristics of People infected with HIV

 The immunity of the persons has not been severely

 During the second to fourth week after HIV has

• Do you have any information about the time

 Since its discovery in 1981 in a cluster of cases of

 A total of 1.6 million people died from AIDS-related

 HIV/AIDS is a major public health concern and cause

 Although the continent is home for about 15.2 percent

Figure 1: Age and sex distribution of HIV prevalence (EDHS 2011)

Figure 2: HIV Prevalence by region (EDHS, 2011)

• With one or two of your classmates, please discuss

• Report your answers to the whole class.

 By inhibiting public and private sector development and

 By eventually impairing economic growth, the epidemic has

 Therefore HIV/AIDS is changing the contours and

 Specifically, HIV/AIDS has the following socio-economic

 In response to the HIV/AIDS epidemic, in Ethiopia

this was charged with directing and overseeing the multi-

 In June 2002, the National HIV/AIDS Prevention and

Control Office (HAPCO) was established by

proclamation to coordinate and lead the multi-sectorial

The government introduced its ART program in 2003,

 What actions do you think should be taken here by the

The HEIs have been implementing several anti-AIDS programs

 The institutions are sensitive to socio-cultural contexts and other

 All learning institutions have to design and implement

 Repeated episodes of sexually transmitted infection (STIs) and

 Lack of adequate knowledge and skills to protect one-self

 Inaccessible and inadequate basic HIV service coverage,

 In groups of 3 or 4 people coming from different localities, please

 One of the factors that accelerate HIV/AIDS spread is poverty. How

Relationship between Poverty and HIV spread

Existing literature (FHAPCO, 2011; Ramos, 2008; WHO

Deep-rooted structural poverty: This usually arises from

 It results from a range of factors that reduce the ability of

individuals and communities to avoid HIV infection.

 Lack of knowledge and skills

 social and cultural norms

 beliefs and laws that stigmatize and disempowering certain

 Inappropriate use of money by students

 Economically/financially weak students who do sexual

High risk (or key) populations are defined as a group within a

 In some cases, the behaviors or HIV sero-status of their sexual

 High risk populations are diverse in Ethiopia and have not

1. Unprotected sexual contact with an infected partner

Through unprotected sexual intercourse a person infected

2. Blood and blood products

 Contact with broken skin (exposure to blood through cuts or

3. Mother to child transmission (MTCT)

 What misconceptions about HIV and AIDS do you

 What do you think are the causes of the

 Misunderstandings about scientific knowledge