FHI/IMPACT Ethiopia
Final Evaluation Report 
May 30, 2006
By
Ruth Hope, Consultant, Team Leader
Omer Ahmed, USAID/Ethiopia
Refissa Bekele, Oromia Regional ART Coordinator
Seyoum Dejene, USAID/Ethiopia
Endale Engida, Deputy Head, Amhara RHB
Sahlemariam G/Senbet, HIV/CDC Team Leader, SNNPR
Tekeste Kebede, CDC/Ethiopia 
Erssido Lendebo, Consultant, formerly Head SNNPR HAPCO
Meskele Lera, CDC Dept. Team Leader, SNNPR
Nathan Linsk, Fulbright Scholar University of Addis Ababa
Ann McCauley, USAID/Nairobi
Brenda Moreno, Coordinating Consultant - Logistics
John Palen, OGAC Consultant, Palliative Care Specialist
Alison Surdo, USAID/Washington
Aseged Woldu, M&E, Ministry of Health
Woubishet W/Michael, Consultant, formerly Addis Ababa RHB
Sale Workneh, Amhara RHB
ii
Executive Summary
In April 2006, a team of 17 experts evaluated the Family Health International/
Implementing HIV/AIDS Prevention and Care Project (FHI/IMPACT). The evaluation
focused on VCT, TB-HIV care, facility-based OI and non-ART care and support,
home- and community-based care, and support for referral systems and linkages. 
Members of the team visited field sites in Amhara, Oromia, and Southern Nations,
Nationalities and Peoples regions, and Addis Ababa. 
The evaluation findings indicate that FHI/IMPACT has achieved its overall objectives
of contributing to decreasing HIV prevalence and improving the quality of life of
people living with HIV and AIDS by strengthening the continuum of prevention, care,
support and treatment. 
FHI/IMPACT has achieved results through transparent, collegial, peer-based relations
with Ministry of Health (MOH) staff and close relationships with its partner NGOs.
FHI technical assistance has led to a rapid and dramatic increase in the number of sites 
providing VCT services and a rapid uptake in the use of these services. FHI/IMPACT
has achieved more than double its President’s Emergency Plan for AIDS Relief
(PEPFAR) target for people trained to provide clinical TB-HIV services, and nearly 
double its target for people trained to provide general HIV-related palliative care. Some 
health centers have established chronic care clinics offering co-located TB-HIV and OI 
and other non-ART care. Along with the MOH, FHI/IMPACT has provided formats
and guidelines for health centers, including registration of patients. FHI/IMPACT has
established referral systems between services within the health center, and between the
health center and hospital.
FHI/IMPACT has faced challenges in meeting its goals due to shortages and outages of 
needed supplies and personnel attrition at health centers. The major challenges to
providing reliable VCT services include staff attrition and stockouts of test kits.
Shortfalls in the number of health centers providing TB-HIV services (84% of target)
and of persons receiving TB-HIV services (65% of target) resulted from delays in
training that were beyond FHI/IMPACT’s control. Similarly, shortfalls in the number
of health centers providing general HIV-related palliative care (89% of target) and of 
persons receiving palliative care (95% of target) arose because FHI/IMPACT could not 
begin training before the end of 2004. Health centers frequently experience stockouts
and shortages of drugs to treat OIs and for OI prophylaxis due to weak logistics and 
supply management at the national and regional levels. Health centers have not all
implemented effective internal referrals and linkages between units. Referrals between
TB care and VCT are weakest. As a result of these shortages of supplies and personnel, 
health centers are not able to provide optimal prevention, care and treatment for
HIV/AIDS. 
A further hindrance to providing the full continuum of palliative care is the model in
use at health centers which is too focused on treating symptomatic infections. There is 
no provision for assessment and treatment of mental health conditions and for
assessment and treatment of pain. Health center staff have little understanding of the 
need to provide services for “well positive persons” to maintain good health and a 
productive life, and to include family planning and other preventative services. The
only referrals for home- and community-based care (HCBC) appear to be to kebeles for 
iii
poverty certification and to certain faith-based and other organizations that provide for 
those in extreme economic need.
In 14 urban centers, FHI/IMPACT has trained HCBC nurse supervisors employed by
partner NGOs, who in turn have trained HCBC volunteers managed by local idirs. The 
programs have achieved more than double the PEPFAR targets for HCBC support.
However, the NGOs require direct financial support for salaries and for basic office
equipment and supplies. Idirs have a hugely increased financial burden, and one idir
has gone bankrupt as a result of its support to bedridden AIDS patients while others are 
seriously depleting their mutual funds. HCBC nurses and volunteers commonly spend
their own money on provisions for individual clients and families. 
The evaluation team has concerns about the appropriateness of the training curriculum
and materials on the needs of bedridden HCBC beneficiaries, given the situations in 
which HCBC nurses work. People who have AIDS often deplete their household
resources and lose their means of livelihood before becoming eligible for HCBC. They 
then remain dependent on HCBC after commencing ART and recovering their physical 
health. The end-of-life model is an inefficient entry point to ART.
Cross-cutting issues include stigma, which remains a major barrier to people living
with HIV/AIDS (PLHA) accessing diagnostic, care and treatment services, and
branding of the FHI/IMPACT program. Many people believe that FHI is a donor
organization and in the regions personnel believe that they will not function adequately
without FHI/IMPACT support. They do not realize that there will be a follow-on 
PEPFAR/Ethiopia activity.
The evaluation team’s principle recommendations for the follow-on activity for
treatment, care and support of PLHA at health centers and in the community are
outlined here and described in full detail in the report. The follow-on activity should
strengthen and expand VCT services, with promotion to high-risk populations as well
as the wider community. The follow-on activity should build MOH and HIV/AIDS 
Prevention and Control Office (HAPCO) capacity to improve health systems and
service management at the federal, regional and local levels and to ensure sustainability
of the improved health services. It should provide health centers with further support to 
improve the quality of care for PLHA from diagnosis as HIV positive to end-of-life 
care and bereavement support. The follow-on activity should provide technical
assistance to enhance health worker in-service training in general HIV palliative care,
including TB-HIV and OI services, to reinforce the concept of integrated general
palliative care services for PLHA and to improve the quality of care provided by health
centers for PLHA. The evaluation team recommends a broader definition of palliative
care as defined by the World Health Organization (WHO) and reflected in the Office of 
the Global AIDS Coordinator (OGAC) guidance. Services should encompass a more
comprehensive, holistic approach to delivering a continuum of palliative care services,
which initiates care at the time of diagnosis and establishes a network of providers –
including home-based and facility-based care – in the delivery of a full range of services. 
Pediatric palliative care services are recommended.
iv
General palliative care in the community must draw on existing community resources
rather than create dependency on donor resources. Existing and proposed new cadres of 
community outreach workers and community-based HCBC volunteers need training in
new skills to mobilize communities for development of local care and support 
mechanisms for PLHA and their families. The training must include skills for
mobilizing resources for orphans and vulnerable children drawing on existing social
capital. The evaluation also recommends establishing an enhanced tracking system to
identify bottlenecks in service provision and places and/or referral linkages where
clients and beneficiaries are lost to follow-up. The follow-on activity should support
local staff on the use of collected data in order to enhance decision-making and
improve services. Finally, the follow-on activity must be branded as PEPFAR/Ethiopia 
so that all health sector staff and beneficiaries know that the assistance is provided by 
the American people. The follow-on mechanism must have a clearly-articulated exit
strategy with local ownership and institutionalization of innovations and services for
sustainability.
In conclusion, services for diagnosis, care and treatment of PLHA in Ethiopia need
further technical assistance to integrate service provision in the community, at health 
centers and at referral hospitals. The optimum service will:
· facilitate access to services needed by PLHA and their families at all levels of
health care and at different stages of HIV infection;
· track clients, patients and beneficiaries to coordinate care and treatment at
different levels, and identify and follow-up those who fail to attend or default
from care and treatment;
· avoid duplication of services and gaps in provision of services; and
· reduce barriers to care and congestion at referral hospitals by appropriately
moving services to health centers and into the community and home. 
This optimum service can best be achieved through implementation of the network
model proposed in The PEPFAR U.S. Five-Year Global HIV/AIDS Strategy. The
follow-on activity should assist the Government of Ethiopia (GOE) and MOH/HAPCO 
to build capacity in the community, at health centers, and at the regional level to fully
implement the network model. The new cadre of case managers, and new and existing 
cadres of community-based extension workers and HCBC volunteers, will have key
roles in establishing the efficient functioning of the network model for providing
enhanced HIV services to PLHA in Ethiopia. 
v
Abbreviations, Acronyms and Ethiopian Terms 
ANC antenatal care
ART anti-retroviral therapy
ARV anti-retroviral [drugs]
BCC behavior change communication
CBO community-based organization
CDC communicable disease control
CDC/Ethiopia Centers for Disease Control/Ethiopia
COP Country Operating Plan
DOTS internationally recommended strategy for TB control
ETB Ethiopian birr — the local currency
FBO faith-based organization
FGAE Family Guidance Association of Ethiopia
FHI Family Health International
GFATM The Global Fund to fight AIDS, Tuberculosis and Malaria
GOE Government of Ethiopia
HAPCO HIV/AIDS Prevention and Control Office
HAPCSO Hiwot AIDS Prevention Care and Support Organization
HBC home-based care
HCBC home- and community-based care
HHS Health and Human Services
HSDP Government of Ethiopia Health Sector Development Plan
idir a community-based, mutual burial association
IMPACT Implementing HIV/AIDS Prevention and Care Project
kebele neighborhood
M&E monitoring and evaluation
MOH Ministry of Health
MCH mother and child health
NGO nongovernmental organization
OGAC Office of the Global AIDS Coordinator
OHA [USAID’s] Office of HIV and AIDS
OI Opportunistic Infection
OSSA Organization for Social Services for AIDS
PASDEP Government of Ethiopia Plan for Accelerated and Sustainable 
Development to End Poverty in Ethiopia
PEPFAR President’s Emergency Plan for AIDS Relief
PICT provider-initiated counseling and testing
PLHA person(s) living with HIV/AIDS
RHB Regional Health Bureau
SNNPR Southern Nations, Nationalities & Peoples Region
TB tuberculosis
USG Government of the United States of America
VCT voluntary counseling and testing [for HIV]
woreda district

vii
Acknowledgments
The evaluation team would like to thank Family Health International/Ethiopia and
Family Health International staff in the regions for guidance on scheduling field visits,
being our field guides, and making our introductions to various stakeholders. Our
gratitude also goes to all the many busy GOE staff at Regional Health Bureaus,
Regional HAPCOs, and health centers that spared time to answer our questions. The 
staff of FHI/IMPACT’s “mentoring partners” – HAPCSO, FGAE, OSSA and Medan
Acts – are also thanked for taking time to meet with the evaluation team and to
organize visits with beneficiaries in their homes. Idir and HCBC volunteers gave their
time willingly, and beneficiaries who often lived in highly-disadvantaged 
circumstances allowed us into their homes and graciously answered our questions. For
this, too, we are grateful.
The United States Government (USG)-appointed members of the evaluation team 
highly appreciate the contributions of the GOE members of the team. Their tremendous
experience and insights contributed invaluably to the evaluation and this report.
Lastly, but certainly not least, we are truly grateful to Melissa Jones, PEPFAR/Ethiopia, 
for her guidance, and to Brenda Moreno, local coordinating consultant, who undertook 
all the logistics support, coordination and other arrangements for the evaluation team’s
field visits. 
The Evaluation Team
April 26, 2006

ix
TABLE OF CONTENTS
Page
Executive Summary ii
Abbreviations and Acronyms v
Acknowledgments vii
I METHODOLOGY 1
II INTRODUCTION 2
III FINDINGS 4
General Findings 4
Intervention 1: VCT Services 6
Intervention 2: TB-HIV Care 10
Intervention 3: Facility-based non-ART Care and Support 12
Intervention 4: Home - and Community-Based Care for PLHA 14
Intervention 5: Referral Networks and Linkages for PLHA 21
Cross Cutting Issues 23
IV FUTURE DIRECTIONS FOR CARE AND SUPPORT OF PLHA 24
Expansion and Improvement of VCT Services 24
General Palliative HIV Care at the Health Center 26
General Palliative HIV Care in the Community 29
Referral Networks and Linkages for PLHA 31
Cross Cutting Issue s 33
V CONCLUSIONS 34
Annex 1 Scope of Work
Annex 2 Daily Record Sheet
Annex 3 Field Visit Data Summary Report
Annex 4 Field Visit Guidance Sheet
Annex 5 List of Places Visited and Persons Met
Annex 6 Field Visit Consensus Recommendations
Annex 7 Field Visit Itinerary
Annex 8 HCBC Kit Contents
1
I. METHODOLOGY
A team of 17 persons conducted this evaluation prior to the scheduled closure of the 
Family Health International/Implementing AIDS Prevention and Care Project
(FHI/IMPACT) in September 2006. Members of the team included eight senior
Government of Ethiopia (GOE) experts from Regional Health Bureaus (RHBs) and the 
Ministry of Health (MOH); an expatriate specialist in HIV program assessment,
planning and design who served as consultant team leader; two experts from
USAID/Ethiopia; one USAID/Washington voluntary counseling and testing (VCT)
specialist; one USAID/Kenya expert; one home- and community-care (HCBC) expert
from the Office of the Global Aids Coordinator (OGAC); an Addis Ababa University
professor/Fulbright Scholar; a CDC/Ethiopia expert; and a local coordinating
consultant. 
Prior to heading out to the field, team members reviewed project documents provided
by PEPFAR/Ethiopia, USAID and FHI/IMPACT. The team leader reviewed relevant
interview instruments and prepared two data-recording tools: a “Daily Record Sheet”
and a “Field Visit Data Summary Report” to collect qualitative data regarding the
achievements and shortfalls in FHI/IMPACT performance against its PEPFAR targets. 
The team leader also prepared a “Guidance Sheet” to prompt questions for interviewing
various stakeholders. (See Annexes 2-4) These tools included data and information
collection mechanisms for the five intervention areas to be evaluated: 1) voluntary
counseling and testing, 2) TB-HIV care, 3) facility-based OI and non-ART care and 
support, 4) home- and community- based care, and 5) support for referral systems and 
linkages. 
For the field visit stage of the evaluation, the team divided into five sub-teams that
undertook eight days of fieldwork in project areas, including Amhara, Oromia, SNNPR
and Addis Ababa. Although sites were initially selected randomly, team members
modified the field visit itinerary somewhat to ensure that they used their time
efficiently in the field. The team eliminated some very remote sites as well as sites
where security concerns existed, however members were careful to include rural sites,
including some in remote locations. While FHI/IMPACT works in seven regions and
two special administrative areas, the team evaluated sites in four geographic areas
where FHI/IMPACT has worked since the project’s inception. The primary objective of 
the field visits was to observe project activities as implemented by FHI/IMPACT at
health centers and the HCBC activities of FHI/IMPACT’s local partner NGOs. The
sub-teams also consulted with regional, zonal, woreda, kebele and idir officials in an
effort to determine how the project was addressing critical HIV/AIDS needs in the
country (see Annex 5 for list of places visited and persons met). All sub-teams visited 
at least one hospital providing ART to evaluate referral linkages within the wider health
system. Finally, the sub-teams all visited at least two HCBC beneficiaries in their
homes to observe, interview, and gain their perspectives of the care and support they
are receiving. 
2
All of the sub-teams used common interview guides to ensure consistency in
information-gathering and reporting of the qualitative data collected. Upon completion
of their fieldwork, the five sub-teams reconvened in Addis to review their findings and 
recommendations, highlighting the strengths of the project and the challenges
confronting it. Finally, the entire team came to consensus on proposed
recommendations for the follow-on, PEPFAR/Ethiopia-supported HIV/AIDS project.
Following the fieldwork, a smaller group of team members completed primary
stakeholder interviews in Addis Ababa with FHI, USAID and the Global Fund. The
writing team then prepared a first draft of the evaluation report based primarily on the 
field findings and recommendations, but refined and modified based on the additional
stakeholder interviews and a review of relevant FHI/IMPACT training materials. The
methodology did not gather quantitative data from the field and does not support
quantitative analysis of the findings. The evaluation findings are at the output result
level for which FHI/IMPACT is accountable under PEPFAR. 
II. INTRODUCTION
FHI/IMPACT has been the leading HIV/AIDS technical assistance project in Ethiopia
since its inception in September 2001. The goals of the project are to contribute to
decreasing HIV prevalence and to improve the quality of life of people living with HIV
and AIDS (PLHA) by strengthening the continuum of prevention, care, support and
treatment. 
To achieve these goals, FHI/IMPACT has built strong partnerships with the MOH and 
HAPCOs at the national, regional and local levels. The PEPFAR/Ethiopia-funded 
FHI/IMPACT project works in collaboration with other partners, especially the Global
Fund, Intra-Health, Linkages, JHPEIGO, I-Tech and JSI, to avoid duplication of
efforts, ensure efforts are comprehensive, and strengthen referral linkages between
service providers.
FHI/IMPACT has received substantial PEPFAR/Ethiopia support. Under its 
cooperative agreement with USAID, FHI/IMPACT has received $20,600,700 in 
USAID and PEPFAR/Ethiopia funds since 2001. In addition, FHI/IMPACT more
recently began receiving financial support from the Netherlands Government.
The environment in which FHI/IMPACT works is challenging. With 77 million people,
and an annual population growth rate of 2.7 percent, Ethiopia is the second most
populous country in Sub-Saharan Africa. Ethiopia’s rugged topography, very low levels 
of education and health, low GDP per capita, poor infrastructure, and high levels of
animal and human disease all impede economic growth. Eighty-five percent of the
population lives in rural areas, compounding the logistical and staffing difficulties of
providing health services to the vast majority of the population. 
3
Ethiopia has a generalized HIV/AIDS epidemic with an average prevalence of 4.4%. 
However, this average masks a wide rural-urban disparity in prevalence, with 12.6% in 
urban areas and 2.6% in rural areas (all percentages are 2003 figures based on ANC 
data; updated DHS data are forthcoming). The estimated number of persons living with 
HIV in 2003 was 1.5 million, of whom 96,000 are children. Furthermore, 537,000
children had been orphaned by AIDS as of 2003.1
 
In response, PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria
(GFATM) and other donors are devoting substantial resources to the fight against
HIV/AIDS. Ethiopia is one of 15 PEPFAR focus countries receiving support from the
USG and is the largest recipient of grants from the GFATM. In March 2006,
PEPFAR/Ethiopia signed a Memorandum of Understanding with the GFATM to jointly
commit to provide ARVs to Ethiopia for five years. Under this agreement, the GFATM 
provides first line ARVs and PEPFAR/Ethiopia provides second line ARVs, as well as 
both first and second line pediatric ARVs. The GFATM provides drugs for prophylaxis 
and treatment of tuberculosis and opportunistic infections. Additionally,
PEPFAR/Ethiopia funds training and other assistance to build Ethiopian capacity for
care and treatment of PLHA. 
Momentum in Ethiopia’s health sector is significant. The GOE’s decentralization effort,
initiated in 2000, has moved resources, management, and decision-making authority to 
the regional and woreda levels, thereby enhancing their participation in health sector
development. Within the framework of the Government’s Health Sector Development
Plan (HSDP), the implementation of the Ministry’s Health Extension Package (HEP) is
underway and health extension workers (HEWs) are already being deployed to kebeles 
in the regions. Further developments on the health front include the training and
deployment of health officers to health centers and the “logistics plan” for drugs and
contraceptives. Finally, and perhaps most importantly, the HIV/AIDS epidemic has
been recognized at the highest levels of government, contributing to a new commitment 
for action including the establishment of HIV/AIDS Prevention and Control Offices
(HAPCOs) at the local, regional and national levels as well as a comprehensive
National Strategy for prevention, care and treatment of HIV/AIDS. 
The environment in which FHI/IMPACT operates has changed radically since the
inception of the project. In 2001, there were extremely few VCT sites, HCBC programs 
were rare, and no facilities provided ART. The activities of FHI/IMPACT have had a 
major impact in helping PEPFAR/Ethiopia reach its targets for prevention, voluntary
counseling and testing, TB-HIV and non-ART/OI care at health centers, and home- and 
community-based care for PLHA. FHI/IMPACT has also supported the development of 
referral systems and linkages in the wider network of services for people living with
HIV, both at the facility and community levels.
 
1 U.S. Embassy, Ethiopia - Ethiopia Country Profile based on AIDS in Ethiopia (5
th Edition, 2004), 
Ministry of Health. 
4
FHI/IMPACT’s approach towards achieving these objectives is also in line with
PEPFAR/Ethiopia’s mission of working in concert with Ethiopian and other partners,
within and outside government, to reach specific treatment, care, support and
prevention targets. At the same time, through their cooperative agreement with USAID, 
FHI/IMPACT is supporting USAID’s Strategic Objective 14: To Increase Human
Capacity and Social Resiliency. Specifically, FHI/IMPACT addresses the Mission’s 
sub-intermediate results: 14.2.1 to reduce risky behaviors; 14.2.3 to increase access to 
care, treatment and support for PLHA; 14.2.4 to expand access to care and support for 
OVC; and 14.2.5 to provide a more supportive environment for responding to
HIV/AIDS. 
The near-term objective of this assessment is to assist PEPFAR/Ethiopia in identifying
the project’s strengths as well as its shortcomings, and to propose recommendations
that may assist in shaping the direction of the new PEPFAR/Ethiopia care and support 
follow-on activity. A longer-term objective of the review is to stimulate a broader
discussion among PEPFAR/Ethiopia, the MOH, donors and others as they consider
ways to respond to the challenges inherent in addressing HIV/AIDS in Ethiopia.
This report highlights the findings of the external evaluation of FHI/IMPACT
conducted in April 2006. Findings and recommendations are presented by the five 
intervention areas reviewed by the evaluation. Recommendations for the
PEPFAR/Ethiopia follow-on activity that will begin on or around November 2006 are
presented in Section IV: Future Directions for Care and Support of PLHA.
III. FINDINGS
Cooperative Agreement Program Interventions 
FHI/IMPACT’s program approach was originally organized to address intervention
areas specified by USAID in the RFA released for IMPACT. With the roll-out of
PEPFAR/Ethiopia in 2004, the project has focused its activities on supporting
PEPFAR/Ethiopia’s Five-Year Plan targets at the health center and community levels. 
The PEPFAR/Ethiopia intervention areas reviewed in this evaluation include:
1. Voluntary Counseling and Testing
2. TB-HIV Care
3. OI and non-ART Care and Support
4. Home- and Community-based Care
5. Referral Systems and ART Linkages for PLHA
Evaluation findings are presented by these intervention areas. Discussion for each
intervention area includes an overview of PEPFAR/Ethiopia targets, the project’s
achievements, results from FHI/IMPACT data and reports, and findings from the sub￾teams’ fieldwork and interviews with key stakeholders. Program constraints and issues
– identified as “challenges” – are often systemic in nature and beyond FHI/IMPACT’s 
control. These challenges are cited in order to provide a more complete understanding
of the sometimes problematic context in which the project operates.
5
Overarching observations regarding the FHI/IMPACT project include:
· FHI/IMPACT has introduced updates to training and has begun to reduce the 
stigma associated with AIDS at the household and community levels. 
FHI/IMPACT’s training and technical assistance have directly resulted in a
rapid and extensive increase in the number of sites providing VCT services and 
a correspondingly rapid uptake in the use of VCT services. 
· FHI/IMPACT has achieved results through transparent, collegial, peer-based 
relations with RHB staff. FHI/IMPACT has collaboratively undertaken
assessments, data review and planning with the RHBs. The RHBs greatly 
appreciate the joint visits to health centers for supportive supervision of trained
health center staff, and value FHI/IMPACT’s flexibility and responsiveness to
RHB problems. Several RHB staff went out of their way to emphasize that they
did not think their RHB could function effectively without FHI/IMPACT
support. 
· Similarly, FHI/IMPACT’s close relationship with its partner implementing
NGOs (“mentoring NGOs” – HAPCSO, FGAE, OSSA and Medan Acts) is
described as supportive and has enabled the NGOs to enhance their response to 
HIV/AIDS in the communities they serve. However, these organizations also
require direct support to pay for staff salaries and such items as basic office
equipment and computers. The mentoring NGOs have no readily apparent
means of maintaining staffing and activity levels without continued external
financial support. 
· Staffing levels at health centers limit the capacity to provide HIV/AIDS
services. Few health centers outside Addis Ababa have a doctor on-site, and in 
many rural health centers, health officers are also scarce. Highly-dedicated, yet 
resource-strained nurses provide the bulk of health center diagnostic and
curative services throughout the country. Staff turnover at all levels further
strains personnel resources and impacts the level of training and, therefore,
services available on-site. 
· Referral linkages both within health centers and to-and-from the wider health
system are nascent at best. Use of formal internal referral systems within health
centers is uneven. FHI/IMPACT has provided a flow-diagram for internal
referrals, however most health centers have not yet internalized the procedures
and put them into practice. Although health centers are referring patients to the 
hospital for ART, once the patient has been treated and released there are no 
feedback mechanisms in place either for follow-on chronic care at the health
center or transfer of medical records. 
6
Intervention 1: Voluntary Counseling and Testing 
FHI/IMPACT has worked with RHBs in Addis Ababa, Amhara, Oromia and SNNPR to 
set up and/or strengthen VCT services in health facilities with a focus on training new
personnel, ensuring refresher training for those already trained, providing on-site 
supervision, conducting monitoring and evaluation, and ensuring quality control. 
FHI/IMPACT’s aim is to build the capacity of the RHBs to take on a strong leadership 
role in VCT program management and quality control. Specific PEPFAR/Ethiopia
targets for fiscal years 2004 and 2005 related to FHI/IMPACT and the project’s
corresponding achievements are detailed in the table below:
Table 1: Voluntary Counseling and Testing
FY 2004 FY 2005
Targets Results Target Results
Individuals trained in counseling and testing 631 1,269 1,170 1,703
Individuals received counseling and testing 125,000 46,843 216,000 288,029
Service outlets providing counseling and 
testing 228 359 223 469
 Targets are based on PEPFAR/Ethiopia COP for 2004 and 2005. Results are as reported by FHI/IMPACT.
VCT service set-up and strengthening in Amhara and SNNPR did not start until the end 
of 2004 and FHI/IMPACT, therefore, fell short of its target for individuals that received 
counseling and testing for FY04. After services were established in all four regions,
FHI/IMPACT met its PEPFAR/Ethiopia FY05 targets for voluntary counseling and
testing, both in terms of individuals trained and persons receiving services.
Furthermore, the project far surpassed its targets for setting-up service outlets providing 
VCT in both FY04 and FY05.
FHI/IMPACT uses the Ethiopian MOH VCT training curriculum and “generic” FHI￾produced VCT skills training curriculum and reference guide in its 15-day VCT
training program. Approximately 10 training days are devoted to coursework followed
by five days of practical on-site training. FHI/IMPACT’s own materials fill gaps in
such areas as couples and youth counseling. With MOH approval, FHI/IMPACT has
also begun using a WHO manual, prepared for Africa, to train on provider-initiated 
counseling and testing (PICT).
Major Achievements:
FHI/IMPACT, in partnership with the MOH, has taken the lead in providing training
and equipment to rapidly and dramatically increase the number of health centers
providing VCT. Prior to the project, VCT services were very limited in Ethiopia; at
present, this service is now available to a large proportion of the population. By the end 
of FY05, counseling and testing services had been provided to 288,029 persons as a
result of this project, an impressive increase from the 46,843 persons who had received 
VCT services by the end of FY04. All health centers visited by the evaluation team had 
VCT services in place, at least one VCT-trained staff member, and at least one room
designated for VCT services. 
7
The following comment by Wzo. Amarech Agedew, HIV Prevention and Control
Sector Head, SNNPR RHB, echoes sentiments shared by RHBs in all geographic
regions evaluated:
“The RHB appreciates the training provided by FHI/IMPACT for VCT 
counselors, as well as the training of trainers. FHI/IMPACT’s BCC 
campaigns have been excellent and well-received. FHI/IMPACT’s VCT 
supervision is strict and feedback is sent directly to the RHB for action 
and follow-up.” 
Specifically, FHI/IMPACT’s achievements were noted as follows: 
· Training: FHI/IMPACT, together with the MOH and RHBs, has trained
counselors, trainers and lab technicians, thereby greatly expanding the
availability of VCT services in Ethiopia. In general, VCT staff are highly￾motivated and committed to providing services to their clients, even when faced 
with multiple responsibilities and limited resources.
· Infrastructure: FHI/IMPACT has provided significant infrastructure support for
VCT rooms, including furniture, confidential filing cabinets, and equipment
(including refrigerators) for laboratories. 
· Increased VCT uptake and improved service: With new VCT centers and more 
trained personnel, uptake of VCT clients has increased rapidly. Most health
centers are able to provide VCT services without interruption. Areas where
HCBC services are provided have seen particularly high increases in uptake. 
Due to the availability of care and treatment, and provider-initiated referrals
from TB clinics, there is a slight shift towards symptomatic persons also
seeking VCT.
VCT services are provided free at all of the facilities visited by the sub-teams, 
with the exception of one. All clients can receive their test results on the same 
day. Some sites are able to process the testing immediately and provide post-test 
counseling within an hour. Many VCT counselors are interested and able to do 
HIV testing. As the MOH moves toward approving simpler rapid-test kits that 
do not require venous blood draws, non-lab technician staff can more easily
perform tests and increase the possibility of giving same-hour results.
· Supervision, Monitoring and Reporting: FHI/IMPACT in most cases performs 
quarterly joint supervisory visits with RHB staff and may additionally provide
further technical assistance in the first two years of implementation at a given
site. Health Center staff regard supportive supervision as extremely beneficial. 
All health centers visited had handmade VCT registration and laboratory log
books, pre-printed national client forms, and FHI/IMPACT-provided monthly
and quarterly reporting forms. Some sites had wall charts with monthly VCT
activity reports.
8
Major Challenges:
· Staff attrition and service interruption: High staff turnover at some health
centers is a serious challenge to maintaining services, especially in more rural
areas. High attrition leads to service interruption and increased workload for
remaining staff. When new staff members are brought in, they often need
training before they can begin to provide VCT. 
VCT services may be interrupted if the VCT-designated nurse is pulled away
for duty at another clinical service or for outreach activity. Some counselors
become overextended or burnt out trying to provide VCT and cover their
regular duties as well.
· Test kit shortages and stockouts: Lack of and/or expired test kits are causing 
service interruption in many of the health centers visited, and for as long as
three weeks in the case of Shashemene Hospital. Most health centers currently
do not have the tie-breaker test (Unigold), and many others have received long
expired or at expiry confirmatory tests (Capillus). Some also have stock-outs of 
the screening test (Determine). Some centers stop testing if even one of the tie￾breaker tests is out of stock, while others appropriately decide to continue
testing if two tests are available. There also appear to be problems in managing 
supplies and/or logistical bottlenecks at the regional or national level.
· Stigma and discrimination are still deterrents to increasing the uptake of VCT. 
Despite community mobilization and BCC efforts nationally and regionally,
people are still reluctant to learn their HIV status, even with the availability of
care and treatment. Self stigma causes clients to seek services in health centers 
outside their own town or village, causing congestion in some urban areas and 
under-utilization in rural sites. 
· Quality control: While all sites appear to retain client blood specimens for
quality control testing, it is not clear how regularly these specimens are
collected and tested. It is also not clear whether the feedback from the quality
control mechanism is provided at the sites.
· Referrals from VCT inadequate: Guidance for counselors on how to make
referrals for HIV negative or asymptomatic HIV positive clients is not provided 
systematically. Some counselors are well aware of the services available for
referrals, while others are not and do not understand the concept of palliative
care for asymptomatic HIV positive persons. Even referrals of symptomatic
VCT clients to TB and OI services, or chronic care clinics, can be problematic 
as the counselor may not have elicited that the client is symptomatic during the 
counseling, believing that assessment of symptoms is not their responsibility. 
9
· Referrals to VCT for patients with TB or common OIs are very low: 
FHI/IMPACT has rolled out provider-initiated counseling and testing (PICT)
training, and the MOH adopted a policy supportive of PICT in September 2005, 
but this has yet to be implemented in many health centers. Patients presenting
with TB or common OIs need a diagnostic HIV test to determine the medical
care needed. These patients do not need full VCT with a risk assessment and
risk reduction plan. Given the current structure of services, it is not feasible for 
the TB nurse or the outpatient health officer to provide this lengthy intervention. 
The current procedure requiring full VCT for sick patients overloads the VCT
service and reduces the availability of VCT to self-referred clients. As a result, 
many TB patients are not being tested for HIV.
· Condoms: Although most VCT rooms have condoms for demonstration along
with model penises, most health centers do not also stock condoms for
distribution to clients in their VCT rooms. Condoms are usually kept in the
family planning or MCH clinics, and counselors retrieve some for “clients who 
need them” or refer clients to the family planning clinic. This approach creates a 
barrier to easy access. Since self-initiated VCT clients are likely to have some 
risk for HIV, they should be routinely offered condoms with the option to
decline. All positive clients should leave with some condoms.
· Inadequate space and signage: Clients seeking VCT services in some urban
sites with heavy client flow experience long waits or must take a next-day 
appointment. Some sites, such as the Shashemene Health Center, have just one 
room for counseling and testing and one health professional doing counseling,
testing and laboratory work, greatly limiting the number of clients served in one 
day. Other sites, in particular Awassa, Woreta, Kolla Diba and Salem health 
centers, lack adequate waiting areas. Most health centers lack proper signage
directing clients to VCT. Several health centers have FHI/IMPACT-provided 
posters hung outside the VCT room but this practice is not uniform. 
· Waste management: Health care waste management and infection prevention in
the laboratories need improvement in some sites. There were blood￾contaminated syringes in general trash containers inside some laboratories and
also in the patient waiting area at Salem Health Center in Addis Ababa. Some 
laboratories also had resheathed needles in their sharps boxes. Supervisory
visits can help identify sites in need of attention.
· Distance: The distance that many clients must travel to reach their woreda
health centers for VCT can be prohibitive. Clients in rural kebeles may have to 
travel up to four to six hours to reach the health center. 
· Ownership: Evaluators perceive that some health facility staff members
consider the role of FHI/IMPACT in VCT services as indispensable. 
PEPFAR/Ethiopia should critically review the impact of this tendency on the
long-term ownership of the program by the government.
10
Intervention 2: TB-HIV Care
FHI/IMPACT achieved its FY05 target for individuals trained to provide prophylaxis
and/or treatment for TB to HIV positive individuals. These figures include training of
HCBC workers to identify potential TB cases and refer clients to a health facility for
diagnosis and treatment. The shortfall in the numbers of HIV positive individuals,
diagnosed or presumed, receiving clinical prophylaxis and/or treatment and in the
number of service outlets providing services to such clients results from a delayed start 
of the TB-HIV training. TB-HIV targets were not included in the PEPFAR/Ethiopia
FY04 COP.
Table 2: TB-HIV Care
FY 2004 FY 2005
Targets Results Target Results
HIV positive (diagnosed or presumed) 
individuals received clinical prophylaxis 
and/or treatment
n/a n/a 25,652 16,757
Individuals trained to provide clinical 
prophylaxis and/or treatment for TB to HIV 
positive individuals
n/a n/a 452 903
Service outlets providing clinical 
prophylaxis and/or treatment for TB to HIV 
positive individuals
n/a n/a 237 198
 Targets are based on PEPFAR/Ethiopia COP for 2004 and 2005. Results are as reported by FHI/IMPACT.
FHI/IMPACT began the TB-HIV training program considerably later than its VCT
training program due to the need to gain MOH approval of the TB-HIV guidelines and 
procedures. At most of the health centers, staff have received training as recently as 
January or March 2006. Although FHI/IMPACT has exceeded its target for individuals 
trained in TB-HIV, often only one person at the health center has received such training 
and there are already signs that staff attrition may become a problem. 
Some health centers have very recently initiated chronic care services that combine TB
and OI care in one clinic. However, many health centers have not yet done so, making
meaningful assessment of chronic care services at health centers impossible at this
time. Continued training in TB-HIV for additional groups of health center staff will be 
essential in the follow-on activity to sustain TB-HIV services at health centers. 
Furthermore, the more recently trained TB-HIV focal persons have not yet received
much supportive supervision, which will also be essential in the follow-on activity to
ensure quality TB-HIV care.
FHI/IMPACT’s TB-HIV training for health professionals draws heavily upon three
sources: (i) the WHO Integrated Management of Adult and Adolescent Illness (IMAI) 
Acute Care module (adapted for Ethiopia in September 2005), which addresses when to 
suspect TB and HIV infection; (ii) the IMAI Chronic Care Module, which provides
guidance on assessing an HIV positive person’s tuberculosis status at every health
encounter; and (iii) the national TB-HIV guideline.
11
Tuberculosis and leprosy services in Ethiopia have long been vertically-supported by
various organizations, the most notable being Royal Netherlands TB Association
(KNCV), German Leprosy and TB Relief Association (GLRA) and the World Health
Organization (WHO). Since 2003, the GFATM is the major supporter of Ethiopia’s TB 
control program. As a result, health centers do not have shortages or stock-outs of TB 
treatment drugs. However, availability of TB prophylaxis medications at health centers
is extremely limited. In practice, persons with suspected TB are identified in the
outpatient department at health centers and are diagnosed by microscopy of three early
morning sputum samples. Chest X-rays are unavailable at health centers. Even when
chest X-rays are available from private clinics in urban areas, they are frequently
unaffordable for most public sector patients. Tuberculin skin testing is not available at
the health center level. Persons found to be sputum-positive are sent to the TB focal
person in the health center for initiation of anti-TB drugs. As part of the internationally 
recommended strategy for TB control (DOTS), TB patients are followed-up daily at the 
health center during what is referred to locally as the “intensive phase” of treatment. 
These TB procedures are long established in Ethiopia. 
The existence of well-established DOTS programs in health centers creates a solid
framework for building the TB-HIV initiative. As well as TB drugs, reagents for TB
diagnostics are generally available at health center laboratories. Thus HIV positive
persons can receive clinical treatment for TB at all health centers.
Major Achievements:
· TB-HIV Initiative: In collaboration with MOH and the RHBs, FHI/IMPACT has 
undertaken training for the TB-HIV initiative and trained staff are present at
some health centers. FHI/IMPACT has provided formats and guidelines that are 
available at most health centers. 
· TB-HIV committees: At some health centers (for example Awassa and Salem), a 
TB-HIV committee has been established. These committees share knowledge of
TB-HIV case management from persons who have had training with other
personnel at the health center, and provide direction for provider-initiated 
counseling and testing (PICT) and other TB-HIV initiatives. The committees
also provide a potential forum for discussing care and treatment issues,
including referrals for VCT. A few health centers have initiated PICT programs. 
Major Challenges:
· Limited VCT referrals of TB patients: The majority of TB patients are not being 
referred for VCT. The FHI/IMPACT formats and guidelines are only being
implemented in a few health centers. Where implemented, TB registers indicate
that more people are being referred to VCT than prior to TB-HIV training, and 
several registers have records of TB clients who are identified as HIV positive. 
Staff members have only recently been trained in TB-HIV procedures and have 
received little if any supportive supervision. It is too early to determine whether 
the formats and guidelines have been internalized and will be effectively used.
12
· Poor rate of referral from VCT to TB screening: Many VCT clients found to be 
HIV positive are asymptomatic and unlikely to attend TB or OI (or chronic 
care) follow-up without additional motivation and support. Most VCT
counselors provide only counseling and do not take clinical histories to elicit if
the VCT clients have symptoms of OIs or TB. Furthermore, there is no system
to track referrals of HIV positive clients to TB or OI services.
· Limited trained personnel: Few staff members have received training to date
and staff attrition is already evident at some health centers. The service is thus
interrupted when no trained staff member is present. There is no TB-HIV 
committee or plan of action present in many centers. 
· Limited availability of prophylaxis: TB prophylaxis is not available at many of 
the health centers visited. In practice, this is not a major problem as most health
centers do not have access to x-rays and are thus unable to diagnose sputum￾negative tuberculosis. Isoniazid prophylaxis should only be given to HIV
positive persons when sputum-negative tuberculosis has been excluded. 
Intervention 3: Non-ART Care and Support
In FY04, FHI/IMPACT missed its target for individuals provided with general HIV￾related palliative care. Training for OI care strengthening and assistance to ART efforts 
only started at the end of 2004 and thus clients did not begin receiving FHI/IMPACT￾supported services until early 2005. In FY05, FHI/IMPACT attained 95 percent of its 
target for providing non-ART care and support to 172,700 individuals, reaching
164,283 individuals. FHI/IMPACT surpassed both its FY04 and FY05 targets for
individuals trained to provide general HIV-related palliative care.
Table 3: Non-ART Care and Support
FY 2004 FY 2005
Targets Results Target Results
Individuals provided with general HIV￾related palliative care 56,580 n/a 172,700 164,283
Individuals trained to provide general HIV￾related palliative care 362 415 4,752 8,813
Service outlets providing general HIV￾related palliative care 196 158 240 214
 Targets are based on PEPFAR/Ethiopia COP for 2004 and 2005. Results are as reported by FHI/IMPACT.
The evaluation team reviewed FHI/IMPACT’s OI/ART training materials for nurses,
including nurse supervisors working in HCBC programs, along with related modules
from the IMAI Ethiopian adaptation guides. The materials are grounded in Ethiopian
policy, guidelines and epidemiology, and cover all the major issues and a number of
less-common conditions. Materials included simple decision charts and treatment
protocols.
13
Major Achievements: 
· Trained personnel: Trained personnel are providing diagnosis and treatment for 
OIs and follow-up of HIV positive patients for non-ART care at many health
centers.
· Chronic care clinics: Some sites have established chronic care clinics, with
technical assistance from FHI/IMPACT, in preparation for providing chronic
care for patients on ART. Chronic care clinics offer TB-HIV and OI and other 
non-ART care in the same clinic. Such chronic care clinics are a major step
forward for the provision of non-ART general palliative care in the health
center.
· Formats and guidelines: FHI/IMPACT, along with the MOH, provided formats 
and guidelines for health centers, including registration of patients. Self-made 
registration books for chronic HIV follow-up care are available and in use at
some centers (excellent at Shashemene).
· ART readiness: Most health centers have some preparations in readiness to
follow-up patients on ART. Staff at health centers in Oromia, Amhara, SNNPR
and Addis Ababa are trained on ART readiness.
Major Challenges: 
· Limited establishment of chronic care clinics: Much of the training is relatively 
recent, implementation of the training is incomplete, and little or no supportive
supervision has occurred. Furthermore, the number of OI-trained personnel is
inadequate at many health centers and chronic care clinics are not yet
established at all health centers. Of those established, not all OI clinics and
chronic care clinics provide STI diagnosis and treatment. Instead, patients are
referred to STD clinics for diagnosis and treatment of STI symptoms. 
· Model for general palliative care is too medical: The number of persons
registered and receiving chronic HIV follow-up care at health centers is 
relatively few compared with the number of clients who have tested HIV
positive. For example, Salem Health Center in Addis Ababa has only 11 chronic 
care clients although it has been providing VCT for more than two years. The 
majority of the chronic care clients are Stage 3 and 4, with only a few Stage 2 
and no Stage 1 clients. This situation reflects the prevailing medical model
focus on the sick for general palliative care that only addresses diagnosis and
treatment, and in some cases prophylaxis, for major opportunistic infections. 
Services for pain assessment and relief, and general mental health assessment
and care, as well as wider services such as family planning are not yet available. 
Furthermore none of the health service staff interviewed understand the concept 
of services for asymptomatic or “well” positive people.
14
· Stockouts and shortages of OI drugs: Opportunistic infection drugs are often in 
short supply or out of stock, including cotrimoxazole, STI and anti-fungal 
medicines, and others. Patients are given prescriptions, but must then buy
medicines on the private market if there is not a “special pharmacy” at the
health center as there are stockouts of free medications at the health centers.
Many patients go without needed medications due to lack of funds. In some
clinics where medications are available, eligible patients are unable to get
poverty certificates from their kebele and are therefore unable to access free
medication.
Intervention 4: Home- and Community-Based Care for PLHA
FHI/IMPACT has trained home- and community-based nurse supervisors who, in turn, 
have trained idir-managed volunteers in programs in 14 urban centers. FHI/IMPACT 
trained HCBC volunteers in the areas of basic hygiene and home nursing, establishing a 
supportive environment through community education and mobilization, nutrition
counseling and support, promotion of safe sexual practices, referrals to medical care
services, linkages or provision of other support services (e.g., counseling, prevention,
nutrition, income-generating activities, etc.), psychological support for the issues 
associated with terminal illness. 
Table 4: Home- and Community-Based Care 
FY 2004 FY 2005
Targets Results Target Results
Ill and bedridden persons provided with 
HCBC support 11,620 24,075 10,000 22,862
Individuals trained to provide HCBC support 4,340 5,790 no 
target
7,910
 Targets are based on PEPFAR/Ethiopia COP for 2004 and 2005. Results are as reported by FHI/IMPACT.
FHI/IMPACT has surpassed its targets in both FY04 and FY05 for the number of
bedridden persons provided with HCBC support, as well as the number of individuals
trained to provide such support. In both years the project supported more than double 
the number of bedridden individuals originally targeted. This achievement is
tremendous given the resource-constrained environment in which FHI/IMPACT and its
partner NGOs operate, and is a testament to their impressive mobilization of
communities. 
HCBC services are delivered by volunteers and nurse supervisors in a compassionate,
humane manner to beneficiaries and families who often live in extreme poverty
andsocial isolation. The volunteers are an enthusiastic cohort, willing to dedicate a
large amount of time and often their personal resources to provide HCBC. 
15
It is apparent from home visits that the beneficiaries are grateful for the services and the 
manner in which they are provided. As attested by one beneficiary:
“My mother or father may abandon me. But when the volunteers washed 
me and treated me as a human that empowered me to improve. Before 
the volunteers came, only my children cared for me. But from the first 
day, the volunteers said that I would have some life, and that I would see 
the fate of my children.” 
34-year-old Jimma woman who has received HCBC for more than one 
year and been on ART for 11 months
FHI/IMPACT has created a standard training manual to instruct nurse supervisors to
train HCBC volunteers. FHI/IMPACT developed the manual to facilitate a TOT
process whereby the nurse facilitators learned how to teach HCBC volunteers over a
10-day classroom and 60-day field period. The training is structured in specific
modules addressing service areas that are based on didactic and interactive sessions,
problem-based learning with case studies, and other adult learning methods. 
FHI/IMPACT also provided the nurse supervisors and HCBC volunteers with a
handbook containing relevant information on care and support, which forms the basis
of HCBC volunteer training. Additionally, the HCBC volunteers use the handbook in
the community as a reference. 
Major Achievements: 
· Nurse supervisors trained: FHI/IMPACT has trained nurse supervisors in the
care and treatment of HIV/AIDS. The training manual includes an introduction
to the immunology, natural history, and epidemiology of HIV; diagnosing and
managing HIV-related conditions with information on treatment and follow-up; 
general information on HIV positive women and children; ARV adherence and
monitoring activities; and providing supportive care, including end-of-life 
palliative care. The training manual both underpins the training and provides a
general guide for HCBC in resource-poor settings. The training is in two parts:
five days are devoted to clinical management and three days to ARV therapy.
· HCBC volunteers trained: HCBC volunteers provide home care visits to four or 
five beneficiaries on a regular basis with nurse supervision and oversight as 
needed for basic nursing and social support. Volunteers and supervisors meet to 
review client care. The volunteers each have a home care kit that supports the 
provision of basic hygiene and nursing activities. The content of HCBC kits is
standardized and approved by the MOH (see Annex 8: HCBC Kit Contents). 
Furthermore, volunteers train family members in PLHA care. Additional
supplies are available to the nurse supervisors to address acute and chronic
medical problems, including access to additional analgesics and antibiotics. 
16
· Strong partnership with idirs: The partner NGOs all worked with idirs as the 
implementing CBO. Idirs were chosen as implementing partners because these
strong, indigenous community and social organizations are present in all
communities and have the traditional function of providing burial and
bereavement support. Idir members go house-to-house identifying chronically
bedridden persons, and idir leaders organize and manage HCBC volunteers. 
FHI/IMPACT’s engagement of idirs has prompted a shift in thinking and action
among idir members. Members have decided to help and provide support to
people when they are alive and in need, rather than only after death. 
Idir community members are beginning to assume ownership of the program,
providing and managing a high number of volunteers, and some collecting an
additional 0.25 to 1.00 birr monthly dues per member specifically for funding
HCBC activities. Others have accepted HCBC clients who are not members of
the idir and who are not all able to pay membership dues. With FHI/IMPACT’s 
technical assistance, the idirs have implemented excellent selection criteria for
volunteers, resulting in very low turnover and high continuity of care.
· Reduction of stigma: Self-stigma and fear of discrimination create significant
barriers for individuals and families in accessing and/or using HIV care
services, including HCBC. FHI/IMPACT’s HCBC training includes methods
for raising community awareness and mobilizing beneficiaries’ neighbors
through coffee ceremonies. The HCBC volunteers attest that coffee ceremonies
are an effective strategy for reducing stigma and discrimination. Further, the
appearance of HCBC programs in communities makes evident the benefits of
using HIV care services (and, thus, the benefits of knowing one’s HIV status) 
through the improved health conditions of beneficiaries. This outcome may
foster an increased awareness of and demand for VCT. 
· Increased availability of OI drugs and better access to services: HCBC
programs are providing cotrimoxazole prophylaxis to their beneficiaries. Some
volunteers also purchase other drugs prescribed by the health center or hospital
that the beneficiaries cannot afford, if the HCBC center is unable to provide
them. Some HCBC nurse supervisors have formed an association to which they 
contribute regular membership dues. These dues are also used for purchasing
drugs and other care that HCBC beneficiaries need and cannot afford.
Patients receiving HCBC generally receive in a timely manner treatment for OIs 
and other conditions that arise while they are on ART. Volunteers accompany
HCBC beneficiaries to VCT and ART services if there is no available family
member to do so. Nurses refer HCBC beneficiaries with notes or in person to 
chronic care clinics at health centers or hospitals; these referrals allow patients
to receive services without waiting and streamline the registration and payment
process. 
17
Major Challenges:
· Insufficient training in some areas: Training and skill development (as reflected 
in the TOT manual) for HCBC volunteers do not cover the assessment and
management of common HIV-related symptoms experienced by clients with
advanced HIV disease. For example, the control of neuropathic and other
sources of pain, severe nausea and vomiting, unremitting diarrhea and
unintentional weight loss, advanced dermatological conditions, and persistent
febrile illness are not covered. To the extent that these conditions are assessed 
and managed in the home, the nurse supervisor assumes responsibility to a
degree, although how this is done is not clear from the nurse training manual.
Nurse supervisors interviewed said that they make referrals to health centers or 
hospitals to fully assess and manage these conditions. In some HCBC programs, 
idirs request that their HCBC volunteers receive more training on assessing and 
managing more complex medical and psychological conditions. 
· Nurse training not always suitable for home environment: Training and skill
development for nurse supervisors includes important information on clinical
diagnosis and therapeutic remedies as well as the management of common HIV￾related symptoms for persons with advanced disease and requiring end-of-life 
care. However, the training manual provides limited information on specific
assessment and management strategies appropriate for the home and how they
can be initiated and managed by the HCBC volunteers under the supervision of
the nurse. No information is provided regarding protocols for determining
conditions or situations that require further consultation and/or referral from
HCBC to a health facility. Finally, the manual often refers to diagnostic services 
often only available in hospital facilities (e.g., FBC, X-ray, and others). 
Overall, the nurse training manual does not appear to be well-tailored for use in 
HCBC programs or to the conditions of the Ethiopian health care system. 
· Sustainability: PEPFAR/Ethiopia, via the FHI/IMPACT project, gives sub￾contracts to partner NGOs to run HCBC programs. The NGOs appreciate their
collaborative relationships with FHI/IMPACT and voice the need for the
continuation of these relationships. It is doubtful whether the partner NGOs
could continue their activities without outside donor assistance as there is no
clear mechanism for long-term financial sustainability.
It is interesting to note that in Welliso, Oromia Region, a non￾PEPFAR/Ethiopia-supported HCBC program is being planned by the Ethiopian
Red Cross, South West Shoa Branch. This HCBC program will sustain itself
financially via rental income from a commercial building owned by the Red
Cross in the center of Welliso, off-setting the need for continual donor support.
· Demand for services greatly outstrips supply: HCBC programs are not available 
to bedridden persons outside of the program’s 14 urban centers. Within these 
urban centers, the capacity to provide services has generally been reached and 
idirs are no longer able to take on new patients. The vast majority of HIV
positive persons in Ethiopia are receiving no form of HCBC services.
18
· Focus on end-of-life rather than comprehensive palliative care: The HCBC 
programs implemented by FHI/IMPACT are limited by entry criteria to
critically-ill clients that have been bedridden for longer than one month. Based
on such criteria, HCBC programs are providing services to persons at end-stage 
disease. Thus, the program has limited opportunities to affect disease
progression or prevent the onset of AIDS-defining conditions (e.g.,
pneumocystis carinii pneumonia, tuberculosis and toxoplasmosis) for persons in
early or moderate stages of immunosuppression. By restricting eligibility for
HCBC program/services to critically-ill clients, a relatively small number of
clients are receiving intense services, making high demands on a limited
number of HCBC workers, and incurring high per-client program expenditures. 
Consequently, the high demand for costly services among a limited number of
clients has created an inefficient and unsustainable approach to delivering
HCBC services.
The requirement for and limited availability of external financing constrains the
ability of HCBC programs to expand either their scope or the geographic
distribution of their services. Furthermore, the use of an end-of-life model to
identify persons in need of ART and treatment for OIs is a very inefficient entry 
point to ART and prevention treatment. Many persons will die before becoming
eligible for HCBC and thus will not access ART or other prevention and
treatment services. Those who do access ART have already expended their
family resources on care and treatment prior to HCBC, and many have already
lost their jobs or other means of livelihood and are thus unable to provide for
their families when their physical health recovers on ART. 
· Financial burden for idirs: The involvement of idirs to manage and organize
volunteer activities has resulted in a significant financial burden to these
organizations. Idirs provide services to bedridden HCBC beneficiaries without
any prior membership payments at a time when the recipients are often unable 
to contribute even nominal dues. This additional financial burden has resulted in
bankrupting at least one idir, and may be seriously depleting the mutual funds of
others. 
· Financial and other burdens for volunteers: Volunteers devote substantial time 
to their HCBC activities and provide a tremendous service. Most beneficiaries
are low-income women with already-heavy family and other responsibilities. 
The 50 birr stipend that most programs provide does not even cover their basic 
expenses, such as transport to and from beneficiaries’ homes, to and from
training meetings, and to and from hospitals and health centers. Volunteers in
the Awassa HCBC program noted that they routinely subsidize the expenses of
their beneficiaries, such as meals for the patient while waiting all day at the
hospital, from their own budgets. 
19
· Limited pain management and psychosocial support: GOE policies related to 
the access and prescription of a wide range of analgesics, particularly level II
and III analgesics, outside the hospital setting are creating barriers to
appropriate management of pain in HCBC settings. In addition, procedures and 
protocols for assessing and managing pain with available medications in the
HCBC setting are either not established or implemented. This situation is
demonstrated by the limited and restrictive use of paracetamol by HCBC
volunteers and/or nurses in the home.
Although the program provides services in basic nursing and other support
service areas, there is limited or no availability of other types of services
necessary to address pain and suffering on a psychological or spiritual level. 
The HCBC team is limited to the volunteer and clinical nurse and does not
appear to include or collaborate with other types of caregivers such as social 
workers, religious/spiritual leaders, or mental health counselors within the local
community. Based on training manuals, nurses are not trained in areas of HIV￾specific mental health assessment and counseling or spiritual support. 
· HCBC services for children lacking: HCBC services for children affected by
AIDS and for HIV positive infants and children are unavailable in HCBC
programs. There is no apparent assessment of the vulnerability of children in
HCBC beneficiaries’ households. HCBC volunteers are not trained in
assessment of basic health care issues for HIV positive infants and children. 
Although nurse supervisors are exposed to HIV pediatric care in training, the
level of knowledge and skill is insufficient to assess and manage many of the
HIV-related symptoms and conditions of children in beneficiary households. 
Referrals to pediatric providers and facilities are reportedly limited due to lack
of provider capacity. 
Most importantly, HCBC programs do not appear to link or collaborate with
MTCT programs for purposes of referral or entry. HCBC providers, both
volunteers and nurses, are often unaware of the existence of MTCT programs. 
HCBC programs need to forge stronger links with OVC programs such as the 
PC3 project and assure that vulnerable children are gaining access to services.
· Linkages to other community-based services weak (nutrition, housing, income￾generating activities): Within communities, the HCBC services are limited to
general care with home nursing, limited nutritional support, and ad hoc financial
support often from the volunteer’s or the HCBC nurse supervisor’s own pocket. 
Positive living advice and referral of clients’ family members for VCT and
tuberculosis care are said to be in place. No spiritual, legal, psychosocial or 
mental health care is evident. 
20
Many HCBC beneficiaries and their volunteers argue for the changing needs of
HCBC beneficiaries on ART. With improvement in their physical health,
beneficiaries need nutritional and livelihoods support to “stop the culture of
dependency”. HCBC beneficiaries have often lost their jobs and depleted their
family resources during the period of chronic ill health before they became
eligible for HCBC. Clients on ART may dramatically recover physically but
then have limited opportunities for sustaining their livelihoods and remain
dependent on the HCBC support. As a result, the partner NGOs cannot absorb 
new clients while continuing to support their existing clients on ART. Linkages
to other community HIV services are often missing. 
Nutritional support, housing, and income-generating activities are often
mentioned as the highest priority among clients, however, a limited number of
programs and direct services are available to address these needs. Most
bedridden patients are living in extremely substandard housing and even still are 
unable to pay their rent. Although most kebeles are refraining from collecting
rent from bedridden patients, the patients are insecure regarding their shelter
since rent waivers are not formalized. Private landlords may not be so
sympathetic to HCBC clients. Beneficiaries also note that loneliness is still a
challenge for bedridden patients, especially for those with broken family ties.
· Limited involvement of PLHA: Although FHI/IMPACT has trained HCBC 
volunteers in methods for reducing community stigma and discrimination,
limited effort is directed at mobilizing PLHA groups or individuals to work
collaboratively with the HCBC providers in areas of direct service delivery,
community education or advocacy. The local Bahir Dar branch of Mekdim, a
national PLHA association, collaborates with the OSSA HCBC program, 
however their involvement is limited by lack of funds. Other affected people,
specifically women’s associations and youth clubs, are not engaged or working
collaboratively with the HCBC programs. 
· Untapped potential of volunteer “graduates”: The HCBC programs visited
“graduate” their HCBC volunteers after 18 months of service. After a
transitional period, the volunteers hand over their case loads to new HCBC
volunteers and their participation in the program ceases. One ex-volunteer who 
was met in the Addis Ababa HAPCSO program has become a paid social
worker for the HCBC program. However, there appears to be no plan to further 
train volunteers to deliver a higher level of clinical care and support within
HCBC programs, either as a compensated staff member or volunteer. The
potential exists to build upon the basic knowledge and skills gained during their 
initial volunteer period and fill gaps in meeting the demand for HCBC services 
and for graduated HCBC volunteers to be trained as lay counselors in VCT
clinics. 
21
Intervention 5: Referral Networks and Linkages for Persons Living with
HIV/AIDS
PEPFAR/Ethiopia targets:
· Links between health facility services and home- and community-based care; 
· Positive living support for HIV positive symptomatic and asymptomatic persons
through support groups at the community level; 
· Referral systems and care networks at the community level, between community
and health center, between services within the health center, and between the
health center and hospital.
FHI/IMPACT results:
· Referral systems are in place between services within the health center, and
between the health center and hospital.
· Referral systems and care networks for bedridden or previously bedridden
persons exist at the community level, and between the community and health
center in areas where HCBC programs are active.
Major Achievements:
· Internal referral systems introduced at health centers: All health centers visited 
had flow diagrams on the walls that indicated, inter alia, internal referral from
and to VCT, to either OI or chronic care services, and from TB care to VCT; 
and external referral from the health center to the referral hospital for ART
services. In many health centers, the FHI/IMPACT-designed referral system
includes referral slips that are completed by the referring health worker. When
the referred patient has been seen, the bottom of the referral slip is completed 
and returned to the referring health worker. 
· Health center referrals to hospitals for ART: Of the external referral linkages, 
the referral processes to hospitals for ART and/or CD4 count are the strongest.
· HCBC referrals to health system: HCBC programs, where they exist, are
referring patients to health centers and hospitals for VCT, TB care, ART and OI 
treatment. Patients coming from HCBC programs may be treated earlier for
infections and other conditions that arise after they have commenced ART as
compared to others on ART due to increased care-seeking behavior and
advocacy by HCBC providers. 
Major Challenges:
· Internal referral system weak at many health centers: Although referral
procedures are in place, there is little evidence that they are being fully used in 
most health centers visited. Referrals are most commonly seen in the records of
the VCT counselor and TB focal person, with slips returned from VCT to TB
indicating HIV infection status. The internal health center linkage most often
judged to be weak is the OI to TB referral.
22
· Limited referral of HIV positive patients from health center to HCBC providers: 
Health centers are referring the most destitute clients to kebeles for poverty
certificates, and in some areas to faith and other organizations that provide for 
the poor. However, due to lack of services available and/or little understanding
of the needs of HIV positive asymptomatic persons, the vast majority of patients 
are not being linked to adequate community-based palliative services. 
· Absence of feedback from hospitals to health centers and/or HCBC services:
There are no referral mechanisms back to the health center or HCBC program, 
nor are records for follow-up care provided for patients that are released from
the hospital. Also, for patients referred to the hospital, there is no tracking
system to determine if they actually receive hospital services. 
Staff at health centers that are more than 100 kilometers from an ART hospital
state frankly that their patients do not attend for ART services when referred. 
Staff at health centers that are geographically closer to ART hospitals in
different regions than their own zonal ART hospital argue for changes in the
referral system to permit referrals to the nearest ART hospital.
· Health center to hospital referral gaps: TB patients are not generally referred 
from the health center to the hospital for possible ART. Patients identified as
HIV positive via health center tests are not officially referred to hospitals; in
many instances VCT is being repeated at the hospital. 
· Patient default and limited tracking: Follow-up of client referrals is weak. 
People default between VCT and chronic care, between TB and VCT, and
between health center and ART at hospitals. There is little to no tracking of
clients’ chronic care treatments.
· Weak networks of HCBC providers: HCBC provider networks are weak or non￾existent, creating the possibility for duplication of efforts and difficulties for
patients seeking additional benefits from other organizations that are not 
covered by their “primary organization”. Few if any referrals exist between
HCBC programs and other services in the community, including associations of
PLHA. Furthermore, HCBC programs are rarely referring children or family
members of beneficiaries for VCT, even when they have symptoms of illness.
· Weak linkages in rural areas: In rural areas, health centers have poor links with 
health extension programs for VCT uptake. There are also limited linkages with
communities for care and support, primarily due to the lack of adequate
programs in rural areas.
23
Cross-cutting issues for the follow on activity 
Shortages of test kits, reagents, test tubes, and drugs for prophylaxis and treatment of
OIs are creating avoidable barriers to accessing HIV care and treatment through the
public health system. The evaluation team learned that HAPCO, with its Global Fund
grant, is to address the strengthening of procurement and logistics at the national level. 
There is additionally need for strengthening logistics and supply chain management at
the regional and woreda levels.
HCBC volunteer “graduates” are an untapped resource in their communities. Staff
shortages and attrition of nurses trained as counselors are limiting both current VCT
provision and further expansion of VCT services. Providing graduated HCBC
volunteers with further training and engaging them as lay counselors would be an
effective strategy for expanding VCT services and providing the additional post-test 
counseling in PICT as the lay counselors are less likely to move elsewhere.
Branding of the FHI/IMPACT program has resulted in many people believing that FHI 
is a donor organization. Even senior staff at RHBs do not realize that FHI/IMPACT is a 
PEPFAR/Ethiopia HIV/AIDS project. This confusion has created a climate of anxiety
in the regions where personnel believe that they will not function adequately without
FHI/IMPACT support, not realizing that there will be a follow-on PEPFAR/Ethiopia
activity. 
 24
IV. FUTURE DIRECTIONS FOR CARE AND SUPPORT OF PLHA
The following recommendations are focused on providing guidance for the implementation
of the follow-on activity for care and support of people living with HIV/AIDS. They build on
the achievements of FHI/IMPACT and the lessons learned from the evaluation.
Expansion and Improvement of VCT programs
Promotion of VCT to High-Risk Populations: 
Increasing uptake of services at the current stage of the epidemic in Ethiopia requires that
VCT be promoted for both the wider communities and for persons at high-risk. Some health 
facilities have been trying innovative VCT promotion approaches with promising results. 
· In general, promote VCT through the active participation and involvement of
community outreach workers and community health promoters to integrate VCT
promotion in other health campaigns such as immunizations, promotion of
breastfeeding, and hygiene and sanitation. Include VCT promotion in community
conversations and other community mobilization activities conducted by community
outreach workers and woreda/kebele health offices.
· Emphasize the benefits of testing with a goal of getting people to come for testing
before they are sick, when they can most benefit from the preventive care package.
· Incorporate mechanisms to extend the hours of VCT services to evenings and
weekends to improve access for working clients.
· Provide VCT outreach where at-risk youth congregate, or where other most at-risk 
persons live or work, to increase uptake by those most in need of care, support and 
prevention interventions; youth services have to be appealing and “youth friendly”.
· Facilitate the formation of PLHA associations that provide examples of living
positively to combat stigma and address discrimination in the community.
Community outreach workers might do this with additional training and supervision. 
Build on the capacity of MOH and HAPCO to improve health systems and service 
management at the federal, regional and local levels to ensure sustainability of
improved health services:
· Provide logistics and supply chain management training for RHBs that will
complement the HAPCO/GFATM activities to strengthen logistics and supply chain
management at the national level.
· Provide training and supportive supervision for the implementation of new testing
algorithms that are developed as the MOH approves a new range of HIV rapid test 
kits.
· Train VCT sites and woreda and zonal offices on improved data management,
collection and analysis so that locally-collected data are used by local health managers 
and providers to improve services. Such local use of data for decision-making is
known to increase the quality of data collection as well as improve the services
provided, and can identify the referral linkages and/or service points from where
PLHA are frequently lost to follow-up.
 25
Support provider-initiated, diagnostic HIV testing and counseling:
Emphasize provision of abbreviated diagnostic testing and counseling to TB patients and
outpatients at health centers who present with signs of opportunistic infections. Utilize lay 
counselors to provide additional counseling for those who test positive and are in need of
additional support.
Improve VCT linkages and referrals:
Assist MOH, HAPCOs (from federal to local levels), RHBs, and zonal and woreda health
offices to develop mechanisms for clear linkages and referrals between VCT sites, between
community services and ART hospitals, and between care and support services. Provide
technical assistance to develop a referral tracking system to follow PLHA and ensure they
receive the package of services they need. The introduction of care coordinators should
greatly enhance referral tracking. Consider introducing preprinted VCT registration forms
similar to those provided for chronic care patients. Standard forms would ensure that all sites 
collect the same data. Assist MOH and RHBs to improve data collection and analysis at all
levels and use data to inform service decisions.
Lay Counselors:
Provide technical assistance for the implementation of the forthcoming MOH policy that will
allow health centers to train and employ lay counselors for VCT to expand VCT provision,
enhance PICT post-test counseling, and provide some stability in the cadres of counselors to 
counter the attrition of nurse counselors. Provide technical assistance to the training,
deployment and supervision of lay counselors by senior counselors, as this will free up nurses 
for clinical care. Lay counselors from health centers could also provide VCT outreach at
kebele health posts, bringing VCT closer to people’s homes. 
Follow-on training:
Provide assistance to a regular schedule of MOH/RHB training for VCT counselors and lab 
technicians to sustain provision of service in the face of high staff turnover/attrition. Support
RHB staff to undertake regular supportive supervisory visits to VCT sites and on-site quality 
assurance supervision to enhance service quality.
Consider providing support for whole-site training programs that address skill development
by and sharing between all health workers. This approach should include strengthening
referral mechanisms between the different health care services within the health center, and
strengthening health center management in areas such as staff deployment and space usage.
This approach will also allow for local needs assessment and problem-solving, as well as the 
development of solutions specific to each health center, rather than a cookie-cutter approach 
to staff deployment and space utilization.
Increase condom availability at VCT sites: 
Promote the best practice of making condoms available in all VCT rooms for easy access. 
All at-risk and HIV positive clients should be offered condoms.
Signage:
Address such issues as clear signage marking VCT sites. Promote adoption of a standard logo 
that indicates availability of quality, certified VCT services.
Policy knowledge in the field: 
Ensure that health center staff and VCT counselors are aware of changes in MOH policy
regarding age of consent for VCT. Many staff members are unaware of changes making it
legal to test young people aged 15-18 years who can give their own consent.
 26
Training materials:
Ensure appropriate training materials are available and that the length of training is
appropriate for VCT counselors, senior VCT counselors, and lay VCT counselors. The
national MOH VCT training curriculum was adapted from USG HHS/CDC materials. 
However, now that ART is available, HHS/CDC has updated the counseling materials and
put more emphasis on discussing care and treatment for HIV positive clients, making
referrals for all clients, and making partner referrals for all clients. The updated materials
streamline the counseling protocol so that pre-test counseling is much shorter and based on
informed consent, while risk reduction counseling takes place post-test based on the
individual client’s HIV test result. 
General Palliative HIV Care at the Health Center
Support enhanced delivery of HIV services at the health center for better quality of care 
for PLHA from initial diagnosis through end-of-life care, as well as bereavement 
support for family members.
For sustainability after USG support ceases, expand training of trainers for RHB and 
HAPCO staff, and assist them to provide a regular program of training in general palliative
care for HIV positive persons and their families from diagnosis through to death and
bereavement, with continued training in TB-HIV and OI care within the framework of
general palliative care. This approach will ensure the needed transformation of health
services for PLHA from the end-of-life model to wider HIV palliative care. Specifically:
· broaden health workers’ understanding of PLHA needs for care and support in areas 
wider than the current, more limited, model of diagnosing and treating symptoms by
introducing the WHO/OGAC concept of palliative care into the primary training and
in-service training for health workers;
· provide technical assistance including training, system analysis, and establishment of
procedures and processes for RHBs to strengthen logistics and supply chain
management, and secure the supply of test kits, reagents, materials and essential drugs 
for prophylaxis and treatment at all health centers. This capacity-building should
complement the HAPCO/GFATM effort to strengthen supply chain management at
the national level and is needed to ensure availability of HIV services at the health
center;
· increase the delivery of quality HIV services at the health center by strengthening the 
integrated chronic care approach such that all clinical services required by PLHA are 
available on the same day in one clinic. Such an approach will decrease the
likelihood that HIV positive persons will default from attending and thus receiving the 
services needed to maximize their quality of life and enable them to remain
productive members of their families and communities;
· continue to strengthen linkages and referrals within the health center, particularly
between VCT and TB-HIV/OI services. Promote PICT in the TB clinic and general
Outpatient Department and emphasize the need for all HIV positive TB patients to be 
referred for ART to ensure those who need TB and HIV care receive it promptly, thus 
reducing the forward transmission of TB and HIV infection. The linkages and
provisions of service for persons known to be HIV positive are best met by
establishing chronic HIV care clinics that provide integrated care and treatment across 
the continuum of general palliative care;
 27
· to address the woefully inadequate provisions for HIV infected and affected children,
build linkages between PMTCT and general palliative HIV care in the health center
and the community to ensure HIV positive mothers and HIV exposed infants are not 
lost to follow-up, and that they receive appropriate palliative care, including
cotrimoxazole prophylaxis for the infant, in the community. The HCBC volunteer
then has the critical role of referring the mother and the infant, if needed, for general
palliative care at the health center and ART services at the hospital. Another
important function of palliative care for the mother and infant should be support for 
disclosure to the mother’s sexual partner so that he, too, is able to access general
palliative care and ART when needed;
· establish/enhance the functioning of health center HIV/AIDS chronic care committees
that currently exist at only a minority of health centers. Forge links between the health 
center committee and community HCBC providers to provide a lower cost, and thus 
sustainable, mechanism for support and supervision of HCBC volunteers. Facilitate
health center HIV/AIDS chronic care committees to: (i) regularly review and share
with all staff new policy and other guidance received, (ii) review the training and
supervision needs of all staff, (iii) address continued service provision when staff are
deployed to outreach campaigns, on leave, or resign from service, (iv) review the
functioning of referral procedures and the tracking of PLHA through the health
system to ensure they receive the package of services that meet their changing needs, 
and (v) provide guidance and support to HCBC volunteers caring for PLHA in their 
homes; 
· establish community outreach workers to mobilize communities for prevention,
diagnosis, and general palliative HIV care at the health center and in the community
to both increase demand for VCT, and provide a lower cost and thus sustainable
mechanism for support to HCBC than the current high-cost, inefficient model; 
· develop the skills of community outreach workers in: (i) mapping community
resources and community-based organizations providing services that could benefit
PLHA and their families, and (ii) building linkages with and making referrals of
PLHA to available community resources and services, and to health centers and ART
services, to enhance the quality of HCBC provisions across the full continuum of
general palliative care for PLHA; and
· promote the introduction of the treatment helper approach, often called a “buddy”
system in the literature and considered a best practice in care for PLHA. Through this 
approach, PLHA are encouraged to disclose their status to a confidante of their own
choice -perhaps a relative or close friend- who agrees to provide personal assistance 
and support, including accompanying the PLHA to the health center for general
palliative HIV care and to ART services, encouraging the PLHA to adhere to
treatment, and negotiating access to HCBC services as required. Treatment helpers
have been introduced with good results in other PEPFAR country programs.
 28
Enhance the effectiveness of health worker in-service training in general HIV palliative 
care, including TB-HIV and OI services, to reinforce the concept of integrated general 
palliative care services for PLHA, as well as improve the quality of care provided by 
health centers for PLHA, by: 
· using on-site and whole-site training at health centers to ensure all health workers
receive palliative care training and understand the expanded concept of palliative care 
and the roles of different cadres in providing such care. Problem- solving on issues 
related to human and other resource management, as well as patient flows and
referrals, should be part of the training;
· creating mechanisms for sharing skills and knowledge across staff at each health
center such that staff who receive training from other organizations are able to
transfer their new knowledge and skills to their colleagues to maximize effectiveness
of training, and ensure continuation of services when staff are on leave or deployed
elsewhere; 
· supporting RHBs to provide regular post-training coaching and supervision to
increase effectiveness of training and enhance quality of service provision at the
health center. Consideration should be given to providing incentives such as awards
and public recognition for innovation and good services in the provision of care and 
treatment for PLHA to raise staff morale and reduce attrition;
· introducing the use of job aids such as diagnosis, care and treatment algorithms and
checklists that facilitate the provision of the full package of services needed by all
PLHA at each health center visit to enhance the quality of general palliative care
services for PLHA; and
· providing refresher training to improve application of new knowledge and skills and
raise staff moral by providing a venue for staff to present and solve problems and
issues they face providing general palliative care and other HIV services at the health
center. This will enhance the quality of general palliative care services for PLHA at
the health center and address the problem of staff attrition. 
 
 29
General Palliative HIV Care in the Community 
Palliative care in the community should encompass a more comprehensive, holistic approach to 
delivering a continuum of services to clients, which initiates care at the time of diagnosis and 
establishes a network of providers, including home-based and facility-based care, in the delivery 
of a full range of services. An important focus of palliative care is the assessment and
management of symptoms, including pain, within the home setting. An effort is now needed
to address assessment and management of symptoms in the home in Ethiopia; training,
service standards and HCBC kits, as established by USG and GOE/MOH policy, should
reflect this need. For example, volunteer community health workers and nurse supervisors
should be trained in assessing and monitoring pain and common HIV-related symptoms, and 
have access to a range of analgesics and medications to relieve HIV-related conditions (e.g., 
foot pain, nausea and vomiting, diarrhea, dermatological conditions) as well as prevent the
onset of clinical conditions such as pneumocystis carinii, toxoplasmosis, and tuberculosis.
Within HCBC kits, medications should be available for use in the home, based on accepted 
protocols and procedures. Pain and symptom assessment and management must not be
available only through health facility services or providers, and current policies should not
intentionally or unintentionally create this situation. Discussion with the Drug
Administration and Control Authority may be necessary to determine the extent to which
Level II and III analgesics are available in community- based programs, including health
centers, and modification of existing policies to assure clients have in-home access to these 
drugs should be made if necessary. Finally, it is critical to engage the affected community, 
PLHA, women and others in the delivery of services, thereby increasing community
awareness and providing necessary advocacy to change community and government policies. 
Based on these and other goals, the following are recommendations to support the
development of a more comprehensive, community-based palliative care program in
Ethiopia: 
Adopt a broader definition of palliative care:
PEPFAR/Ethiopia staff and its implementing partners should adopt a broader definition of
palliative care as defined by WHO and reflected in the OGAC guidance (see Annex 6: Field 
Visit Recommendations). The definition should include: (i) a more comprehensive, holistic
approach to delivering a continuum of services to clients, (ii) initiating care at the time of
diagnosis, and (iii) establishing a network of providers that includes community-based care,
health centers and hospitals in the delivery of a full range of services. In doing so, it may be 
important to establish consensus with the GOE and existing implementing partners regarding
the general definition of HIV/palliative care as described in USG policy guidance, and
designate a basic set of services (physical, psychological, social and spiritual) to be provided 
at the community and facility levels. Existing materials established by normative or expert
organizations, such as the WHO IMAI modules, may be useful in this effort. 
Update training to address the complete continuum of care:
All community-based providers should be trained in areas of palliative care based on existing
training manuals, such as those developed by the federal MOH, as well as WHO IMAI
modules adopted for Ethiopia, or other manuals produced by other Sub-Saharan African
countries. Materials should cover the full scope of delivering essential palliative care services 
– particularly pain and symptom management – that begins at the time of diagnosis and
covers all four dimensions of palliative care: clinical, psychological, social and spiritual.
Materials should demonstrate a continual process of assessment and management of the client 
that begins in the home by a trained family member, volunteer community-based provider
and/or nurse, and is coordinated with service providers at the facility level. 
 30
Service delivery by multi-disciplinary teams:
A multi-disciplinary team that includes a physician/health officer, nurse, community volunteer,
caregiver, religious leader, social worker, and counselor as available and needed should deliver 
palliative care services. Emphasis should be put on building up on existing community systems, 
service providers and organizations. Palliative care training, as discussed above, should be
provided for the entire team in order to support the concept of “team management”. It is
recommended that training be done as a “whole-site” experience to support this concept. 
Expand existing provider capacity:
It may be necessary to expand the existing provider capacity in order to deliver a higher level of 
palliative care in communities. Suggestions include: (i) retrain volunteer HCBC providers after 
their 18 months of service within existing programs to provide a higher level of assessment and 
management in the home and/or community, (ii) train community outreach workers and other 
related professionals located at health posts to provide higher levels of counseling and support to 
families, (iii) identify and fund existing local community providers (e.g., OSSA and Red Cross) 
that are trained in delivering home- and community-based palliative care, and (iv) continue to 
train nurses and health officers in providing higher levels of clinical and psychological
assessment and treatment in the home and at health centers. Finally, the training and
involvement of family members in the provision of care and treatment in the home should be a 
vital component of community-based care initiatives. 
Service delivery through a network model:
Palliative care and support services should be delivered through a network model that includes 
formally-linked service sites including community-based care services, health centers (including
the chronic care clinic, TB clinic, and VCT services), and hospital facilities. The network should 
coordinate services through an established referral process (e.g., referral slips, etc). Referral 
mechanisms should be strengthened to assure that patients can navigate the network and that 
essential information is appropriately shared between the sites. This outcome could be
accomplished through the use of a “care coordinator” located at the health center level. In
addition, links need to be established: (i) between health centers and community-based care 
programs and local PMTCT and OVC programs, and (ii) between health centers and hospitals
and community-based providers for the purpose of providing ARV and HIV specialty
services. Hospitals should establish referral and discharge procedures with community-based 
programs with the referral process facilitated by the “care coordinator”. 
Engage and mobilize affected communities:
Engagement and mobilization of affected communities, such as PLHA and youth, is essential
in reducing stigma and discrimination, and increasing the capacity to deliver services in the
community. Affected groups may be trained to provide community-based services, increase
awareness and reduce stigma and discrimination, and provide advocacy activities. These
groups should work in collaboration with community-based programs and be included as part 
of the palliative care “team”. 
 
 31
Introduce pediatric palliative care services:
Services for HIV positive infants and children are beginning to emerge in Ethiopia. 
However, these services, to the extent they are available, are predominantly delivered within
secondary facilities with limited or no clinical care follow-up available at the community
level. In order to understand the opportunities and methods of developing pediatric
community-based care programs, the evaluators recommend that a group of clinical and
programmatic experts convene to discuss this issue. Specifically, it is recommended that the 
USG convene a meeting of pediatricians caring for HIV positive infants and children,
program staff of pediatric care facilities, organizations representing women as caregivers, and
other experts. They would be charged with developing and implementing pediatric programs 
or care standards in order to develop a consensus document on scaling-up community-based 
pediatric HIV care and support services for infected infants and children. The meeting should 
include a discussion of: (i) minimum services to be provided in the home and the first level
facility; (ii) training pediatric care providers (RNs, Health Officers) for home- and facility￾based care; (iii) identifying the unique clinical, psychological, social and spiritual needs of
pediatric clients and translating these into care and training strategies; and (iv) the support
and resources provided to mothers and other caregivers for the care and support of children in 
the home and community.
Referral Networks and Linkages for PLHA
The follow-on activity for care and support for persons living with HIV/AIDS should provide 
additional assistance to strengthening the regional, decentralized, public health system for
enhanced efficiency and effectiveness in providing the continuum of HIV prevention, care, 
support and treatment services through the network model. This approach will ensure
optimum quality of services and sustainability when USG support ceases.
Technical assistance to strengthen linkages:
Provide technical assistance to the MOH, HAPCOs, RHBs, and zonal and woreda health
offices to develop mechanisms for further strengthening the linking of health centers and
hospitals to community-based programs and services. The introduction of case managers/care 
coordinators will facilitate the establishment of the network model and the efficient
movement of PLHA through the services that they need at the different stages in their
disease. 
To maximize numbers of PLHA accessing diagnosis, care and treatment services as well as to 
increase secondary prevention of HIV infection, kebele health posts and community outreach
workers must be fully integrated into the enhanced public health system delivery of the
continuum of HIV prevention, care, treatment and mitigation services in the community and
home. 
 32
Train community outreach workers and community-based volunteers to expand the
provision of general palliative care in the community by drawing on community
resources rather than creating dependency on donor resources. 
The existing and proposed new cadres of community outreach workers and community-based 
HCBC volunteers need training to enable them to: 
· mobilize indigenous community mechanisms and resources that can organize to
provide care and support to PLHA and their families in their homes. Such “social
capital” includes post-test clubs, PLHA associations, women’s associations, youth
clubs, religious leaders willing to minister to PLHA and their families and address
spiritual needs, as well as idirs and other community service organizations;
· facilitate access to the preventive care package by persons who have been diagnosed 
as HIV positive but who do not yet have symptoms that would make them seek
further medical care;
· identify those in the community who need health center HIV services, including VCT
before they become seriously ill, and promote the benefits of accessing the services,
such as having a better and longer life by taking prophylaxis against infection and
commencing ART before AIDS-defining conditions develop;
· link PLHA and their families with community services and resources such as local 
legal advice, support for making wills and laying out provisions for care of children,
and production of memory books or boxes, as well as with health center and ART
services. 
Strengthen efforts to address stigma and discrimination in the community through the
involvement and mobilization of PLHA, in- and out-of-school youth, religious leaders and
others in the community who can educate and raise awareness, and provide examples of
“living positively with HIV,” as well as contribute to community-based services for PLHA
and their families.
Employment of PLHA as case managers/care coordinators would contribute to addressing
stigma by providing roles for PLHA that enhance the visibility of living positively, and of
PLHA as valuable members of society. The use of case managers will also strengthen the
referral and linkage networks between health centers, ART hospital services and community￾based programs, enabling PLHA and their families to gain better access to the full package of 
services that will meet their changing needs from diagnosis to death and bereavement.
Establish an enhanced tracking system: The follow-on activity should support the
establishment of an enhanced tracking system to identity: (i) bottlenecks in service provision, 
and (ii) places and/or referral linkages where clients and beneficiaries are lost to follow-up. 
The care coordinators will use the tracking system to review care plans and service utilization
by PLHA, and to identify those lost to follow-up to ensure their needs are being met and that 
they are linked to services at the health center and in the community as their needs change
over time.
 33
Cross-Cutting Issues for Care and Support for PLHA
The follow-on activity must be PEPFAR/Ethiopia-branded so that all health sector staff and
beneficiaries know that the assistance is provided by the American people.
The managers and implementers of the follow-on activity will need to build strong working
relations with the federal MOH, HAPCO and RHBs. This effort will inevitably take some
time to establish and will likely set back attainment of PEPFAR/Ethiopia targets during the
follow-on mechanism’s first year in operation. FY07 targets in the COP should reflect this
need for the new activity to establish a foundation of strong working relationships during its
start-up phase before becoming fully operational with interventions in support of the Ethiopia
PEPFAR strategy, and FY07 COP. 
The approach to working with the MOH and RHBs should emphasize transparency,
collaboration, responsiveness and mentoring in a manner similar to the approach employed
by FHI/IMPACT and preferred by MOH and RHB staff. This approach will maximize the 
effectiveness of the working relationship in enhancing MOH and RHB capacity and
performance as the agencies oversee the decentralized provision of HIV/AIDS services at the 
health center and in the community. Such an approach will also ensure the potential for
supporting region-specific interventions rather than a set of standard interventions that are
less well matched to local needs. 
To avoid the development of dependency, the follow-on mechanism must have a clearly￾articulated exit strategy with local ownership, and ensure institutionalization of innovations 
and services for sustainability.
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V. CONCLUSIONS
The evaluation findings indicate that FHI/IMPACT has achieved its overall objectives of
contributing to decreasing HIV prevalence and improving the quality of life of people living
with HIV and AIDS by strengthening the continuum of prevention, care, support and
treatment. 
FHI/IMPACT has largely attained its targets for persons trained and persons receiving
services, including achieving dramatic increases in the numbers of sites providing VCT. 
However, for reasons beyond FHI/IMPACT’s control, much of the training in TB-HIV care 
and OI care was only recently undertaken and trained staff attrition is a widespread problem. 
In the long-term, it will be far more efficient and effective, in the primary training of health
workers to introduce concepts of “living positively with HIV” and general palliative care for
PLHA through a continuum of services from diagnosis to end-of-life care and bereavement
support, rather than rely on in-service training in these essential areas. In-service training and 
follow-up supportive supervision can then focus on improving service quality, enhancing
staff morale, and reducing attrition.
FHI/IMPACT has achieved excellent working relations with the MOH and HAPCO at
national, regional and local levels. While these relations have enabled FHI/IMPACT to make 
huge contributions to achieving PEPFAR/Ethiopia targets, they have also fostered, to a
degree, feelings of dependency by RHB and health center staff. The follow-on activity must 
address local ownership from the onset and articulate a clear exit strategy in the design. 
The current end-of-life model for HCBC creates dependency, is an inefficient entry point to 
ART services, and depletes PLHA and their families’ resources and livelihoods. The focus of 
the follow-on mechanism should be on promoting the benefits of early access to the
preventative package of services to maintain good health. Furthermore, the follow-on 
activity should mobilize existing social capital for HCBC. The human capacity development 
approach presented at a USAID–sponsored side event at the Barcelona International AIDS
Conference provides one proven approach to facilitating stronger community responses to
HIV, including both prevention and care and support responses for PLHA in the community. 
There are Africa regional resources for human capacity development that the follow-on 
activity might draw upon to build local capacity rather than create the dependency that the
current model for HCBC creates. 
Further, all PEPFAR-funded projects should seek to build the capacity of the MOH to
provide palliative care within health centers and the community, and not bypass the MOH
entirely with an NGO implemented model for HCBC that is quite separate from the public
health services as the GOE has overall and accountable responsibility for health in Ethiopia. 
Services for diagnosis, care and treatment of PLHA in Ethiopia need further technical
assistance to integrate provision of service in the community, at health centers and at referral 
hospitals. This optimum service can best be achieved through implementation of the network 
model proposed in The PEPFAR U.S. Five-Year Global HIV/AIDS Strategy. The follow-on 
activity should assist the GOE and MOH/HAPCO to build capacity in the community, at
health centers, and at the regional level to fully implement the network model.
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The follow-on activity should track beneficiaries to coordinate care and treatment from the
household, community and health facilities and to identify and rectify bottlenecks and gaps in 
service provision and/or referral linkages where patients are lost to follow-up. One objective 
of the follow-on activity should be to reduce congestion at referral hospitals by appropriately
moving provision of services to health centers, the community and home. To the end, the
future project should consider introducing care coordinators at health centers to facilitate
referrals and linkages and expand training of volunteer outreach workers to provide services
in the community, thereby ensuring a continuum of palliative care at all levels of health care 
and at the different stages of illness. 
The FHI/IMPACT project has had substantial success in rapidly enhancing the response to
HIV/AIDS in Ethiopia. FHI/IMPACT’s activities provide a solid base in terms of human
resources and infrastructure at health centers and in the community from which to expand
PEPFAR/Ethiopia’s care and support initiative.