HIV/AIDS in Eritrea: Some Insight on Progress and Continued Challenges

Eritrea on track to meet 6 out of 8 Millennium Development Goal
Eritrea on track to meet 6 out of 8 Millennium Development Goal

By Fikrejesus Amahazion,

According to UNAIDS, East and Southern Africa remain the areas most heavily affected by the HIV/AIDS epidemic, with 10 countries in the region accounting for 34% of the world’s HIV/AIDS cases.[1]

However, amidst these stark figures and though HIV/AIDS remains one of Africa’s most significant public health challenges,[2] significant progress has been made. For example, prior to 2001, HIV/AIDS treatment in Africa was nearly nonexistent; yet by 2012, approximately 7.5 million Africans were receiving anti-retroviral therapy (ART).

As well, a 2013 UNAIDS report found that the annual number of new infections continues to decline, with especially sharp reductions in the number of children newly infected,[3] while Africa has become a global leader in the drive to eliminate mother to child transmission of HIV.[4]

One African country with an especially strong record battling HIV/AIDS is Eritrea. Located in the fractious Horn of Africa, Eritrea is on pace to achieve the UN’s Millennium Development Goal related to combating HIV/AIDS, malaria, and other diseases.[5] Further, Eritrea’s figures are distinguished as amongst the best, both within the region and comparatively across the continent (see Table 1). At the same time, the potentially devastating consequences posed by HIV/AIDS – in terms of severe human toll and national developmental disaster – mean that Eritrea has little room for complacency. Rather, the country must augment existing programmes and continue to promote effective initiatives and interventions in order to control and reduce the harmful impact of HIV/AIDS.

The first documented case of HIV/AIDS in Eritrea dates back to 1988, during the latter stages of the independence struggle (Muller 2005).[6] In subsequent years, the number of infections steadily increased, to such a degree that by the early new millennium, HIV/AIDS was Eritrea’s second leading cause of death among patients over five years of age.[7]

During this period, prevalence was ~2.0%, ~30000 Eritreans were infected, and there were ~1900 new infections annually (UNAIDS 2013).[8]  Though the figures were “relatively low” in comparison to other countries in Africa, the situation was serious enough for UNAIDS to warn that Eritrea was “…[facing] a rapid expansion of the HIV/AIDS pandemic within the next few years.”[9] However, in stark contrast to the dire projections, Eritrea currently has a prevalence rate of ~0.6% (WHO 2011),[10] one of the lowest in Africa, and records less than 500 new infections annually (UNAIDS 2013). An examination of Eritrea’s achievements – made in spite of a multitude of challenges – finds that they have been the result of a wide array of efforts.

Table - 1
Table – 1

Notably, some of the success may relate to Eritrea’s targeting of traditional and patriarchal stereotypes and practices, many of which can serve to increase HIV/AIDS risk factors. For example, in several countries throughout the region, child or adolescent marriage is still quite common. In addition to representing a significant child rights issue, the practice is thought to increase HIV/AIDS prevalence via several mechanisms.[11] Importantly, Eritrea has made child and adolescent marriage (under 18) illegal,[12] and remained committed to enforcement, especially within rural areas. Accordingly, the outcome is that one potential risk factor for HIV/AIDS has been averted.

As well, female genital mutilation (FGM)[13] – a harmful traditional practice found in parts of Africa and the Middle East – was outlawed in 2007,[14] although efforts to eradicate were in place during Eritrea’s pre-independence era.[15] Like child marriage, not only is FGM a women’s, child, and human rights issue, it can place females at a high risk for HIV/AIDS through several causal pathways.[16] Beyond abolishment, Eritrea has also promoted support, awareness, educational, prevention, and recovery programs in both urban and rural areas.[17] Consequently, FGM prevalence rates have decreased, women’s and children’s rights have been better protected, and potential risk factors for HIV/AIDS have been prevented.[18]

Last, gender equality has been a central focus in the country, potentially providing the foundation for continued positive outcomes in battling HIV/AIDS. No less an authority than the WHO has claimed that gender discrimination and violence render females far more vulnerable to infection.[19] Further, the feminization of poverty places women at a tremendous risk for HIV/AIDS since “above all… poverty limits people’s options for protecting themselves and forces them into situations of heightened risk.”[20] Through improving gender equality, a key driver of the HIV/AIDS epidemic may be controlled since women will face fewer barriers in accessing HIV prevention, treatment and care services due to limited decision-making power, lack of control over financial resources, restricted mobility, or unbalanced child-care responsibilities.[21]

Eritrea’s efforts at improving gender equality and decreasing the burden of poverty borne by women include, inter alia: ratifying several relevant international rights instruments, including The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW 1979);[22] making gender equality a fundamental component of the National Education Policy[23] and national poverty reduction strategies; issuing Labour and Land Reform Proclamations to secure the equal status of women in society; and working closely with the National Union of Eritrean Women (NUEW) to coordinate, monitor, and implement gender-equality programs and policies across all sectors of society.[24]

Though gender equality is yet to be achieved and several challenges remain, the efforts represent steps in the right direction, both for the status of women and in terms of fighting HIV/AIDS.

In addition to the broad societal and legal factors contributing to the nation’s HIV/AIDS response, Eritrea’s national public health measures have proven quite effective. Like other countries that have made successful responses, commitment has come from the highest level, starting with President Afwerki, who states, “[i]t is our timely duty, more so than at any other time, to go beyond control, to eradicate this disease from the face of the earth and to defend ourselves against it.”[25]

Eritrea’s Ministry of Health (MoH) has been central within the national response. Specifically, it established a national HIV/AIDS policy that, amongst other things, provided guidelines on preventative activities, the provision of treatment and care, and securing the rights and dignity of people living with HIV/AIDS. A notable, tangible outcome of the policy was the implementation of the HAMSET programme, which seeks to reduce the economic, social and health burden caused by HIV/AIDS, Malaria, Sexually Transmitted Infections (STIs) and Tuberculosis. Particular features of the programme include data collection, upgrading resources, expanding and enhancing facilities, and improving health management structures (Muller 2005).

A useful illustration of the MoH’s commitment to the health of citizens living with HIV/AIDS is the national provision of antiretroviral therapy (ART). Figures available from UNAIDS for 2012 show that estimated total ART coverage (as a percentage) in Eritrea had recently risen to 73%. For comparative purposes, other countries in the region posted the following figures: Ethiopia – 60%; Djibouti – 31%; Kenya – 73%; South Sudan – 8%; Uganda – 64%; and Africa as a region – 57%.

Table - 2
Table – 2

National institutional efforts, particularly the establishment of Voluntary Counseling and Testing (VCT) and Prevention of Mother to Child Transmission (PMTCT) centers, have also been critical within Eritrea’s response. There are two types of VCT sites: free standing and integrated VCT sites located inside health facilities. VCTs offer rapid testing and pre- and post-test counseling, are staffed with trained counselors, and they operate according to national guidelines. PMTCT centers chiefly focus on pregnant women, offering testing services and supporting those found HIV positive in preventing the transmission of HIV to their children.[27]

Impressively, while in 2001, there were a mere 19 VCTs (18 integrated and 1 free standing), by 2011, there were 239 VCTs dispersed throughout the country (228 integrated and 11 free standing). Regarding PMTCTs, whereas in 2002 there were a total of 3 located in Eritrea, by 2011 there were a total of 198 PMTCTs found across the country. Consequently, Eritreans have received greater access to better quality care (quite important for rural populations), as well as training, education, and support.[28]

Table - 3
Table – 3

Another important component of the nation’s response has been the National Union of Eritrean Youth and Students (NUEYS), which has promoted education and awareness of HIV/AIDS across all demographic groups. First beginning its activities in the 1990s, NUEYS has been vigorous and effective in the social marketing of condoms, communicating safe practices, offering awareness and educational programs, and providing youth or peer counseling. As a result, awareness of HIV/AIDS [is] nearly universal [in Eritrea]” (Muller 2005).

A unique and highly effective element within Eritrea’s HIV/AIDS response has been the use of the Rapid-Results approach in implementing the country’s long-term HIV/AIDS strategic plans. The Rapid-Results approach focuses on “introducing highly choreographed 100-day projects into large-scale programs and projects, in ways that create local ownership and accountability for results, and that inspire innovation and collaboration among stakeholders at the local level.”[30] The use of several Rapid-Results based projects saw tremendous expansion in the utilization of VCTs and safer practices exhibited amongst at-risk populations. Further, new health programs were implemented in schools across the country, where the foci included life skills and safe behaviors.[31]

Any discussion of HIV/AIDS responses must also consider the issues of stigma and discrimination. The two topics present basic rights challenges and arouse questions of human dignity, while also potentially influencing the spread of HIV/AIDS since they represent disincentives for testing. Importantly in this regard, Eritrea has established The Association of People Living with HIV/AIDS (BIDHO). The organization combats stigma and discrimination, offers supportive measures for people living with HIV/AIDS (including micro-finance programmes), and gives care equal importance with prevention (Muller 2005).

Building on the work of BIDHO, The Good Samaritan Programme has also been a useful initiative in reducing stigma. Coordinated with the Catholic Church, the programme offers home-based care, as well as spiritual and psychosocial counseling to patients. Additionally, it assists people living with HIV/AIDS to access ART and follow up care, thus supporting them in maintaining employment, schooling, or other important activities.[32]

Though the initiatives have witnessed positive results, it is acknowledged that stigma in Eritrea is still “widespread… [and]…discourages people from undergoing testing.”[33] Accordingly, one potential step Eritrea can take to further combat stigma and discrimination is to enact national laws or proclamations that protect people living with or affected by HIV/AIDS.[34]

Most recently, the 2009-2012 period witnessed Eritrea collaborate with the UNDP to offer intervention programmes targeting the workplace. Specifically, the interventions upgraded and developed workplace policies and programs to address HIV/AIDS in the workplace. Resultantly, there are now HIV/AIDS workplace awareness and prevention programmes in many sectors.[35]

According to Piot and Quinn (2013: 2216), “‘[t]here is consensus that no single intervention can stop the spread of HIV and that combination prevention is the best approach. Effective biomedical interventions coupled with behavior and structural approaches may now successfully reduce the incidence of HIV infection to very low levels and ultimately control the epidemic.”[36] The preceding discussion outlines that Eritrea’s response has been multisectoral and has also involved the targeting of harmful social behaviors and traditions. As a result, Eritrea has witnessed significant progress combatting HIV/AIDS within a short time period. Considering its figures and improvements in the context of its various socio-economic, development, and regional challenges or in comparison to other countries throughout Africa, Eritrea’s success becomes particularly striking. Potentially serving as a model for Africa, Eritrea’s HIV/AIDS response also illustrates what can be achieved with a self-reliance approach, a capacity to adapt, effective coordination, and cost-effective projects.[37]

Nonetheless, Eritrea must still confront several challenges: there have been slow behavioral changes regarding safe practices amongst some segments of the population, stigma is still readily apparent,[38] women’s equality remains an ongoing struggle, and expansions of care and treatment (such as for pregnant women) are required. To overcome current challenges and build upon past success, Eritrea should maintain its prioritization of health, continue to work with the UN and other development partners, and further promote the eradication of HIV/AIDS throughout the country.

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[1] {LINK}

[2] {LINK}

[3] {LINK}

[4] {LINK}

[5] a) {LINK} and b) {LINK}

[6] Muller, T. 2005. “Responding to HIV/AIDS Epidemic: Lessons from the Case of Eritrea.” Progress in Development Studies. 5: 199-214.

[7] {LINK}

[8] UNAIDS Report on the Global AIDS Epidemic. 2013. Avialable at: {LINK}

[9] {LINK}

[10] {LINK}

[11] a) Laga, M., B. Schwartlander, E. Pisani, P. Sow, and M. Carael. 2001. “To Stem HIV in Africa, Prevent Transmission to Young Women.” AIDS. 15: 931-934.

b) Bruce, J. 2007. “Child Marriage in the Context of the HIV Epidemic.” Population Council. September (11): 1-4.

[12] {LINK}

[13] Coming to a consensus on how to refer to the practice has been a challenge. At various times, the practice has been referred to as: a) female genital cutting; b) female genital circumcision; c) or female genital mutilation. Here I use female genital mutilation as that is the term utilized by the World Health Organization {LINK} . At different times, Eritrea has referred to the term as female genital mutilation or cutting.

[14] Proclamation 158/2007: A Proclamation to Abolish Female Circumcision. Available at:{LINK}

[15] a) EPLF initiatives: {LINK} b) pre-2007 initiatives: {LINK} c) also see: Keneally, T. 1990. To Asmara: A Novel of Africa. London: Grand Central Publishing.

[16] a) Brady, M. 1999. “Female Genital Mutilation: Complications and Risk of HIV Transmission.” AIDS Patient Care and STDs. 13 (12): 709-716.

b) UNFPA. 2013. “Promoting Gender Equality: Female Genital Mutilation/Cutting.”UNFPA: Population Issues. Available at: {LINK}

c) Yount, K. and B. Abraham. 2007. “Female Genital Cutting and HIV/AIDS among Kenyan Women.” Studies in Family Planning. 38(2): 73-88.

[17] {LINK}

[18] {LINK}

[19] WHO. 2000. “Violence Against Women and HIV/AIDS: Setting the Research Agenda.” Gender and Women’s Health Meeting Report. 23-25 October 2000. Geneva, Switzerland.

[20] Irwin, A., J. Millen, and D. Fallows. 2001. Global AIDS: Myths and Facts – Tools for Fighting the Global AIDS Epidemic. Cambridge, MA: South End Press.

[21] {LINK}

[22] a) {LINK} and b) {LINK}

[23] {LINK}

[24] {LINK}

[25] {LINK}

[26] Figures for each country referenced: {LINK} and for the Africa regional average:{LINK}

[27] {LINK}

[28] {LINK}

[29] {LINK}

[30] {LINK}

[31] {LINK}

[32] WHO. “Best Practices in HIV/AIDS Response in Eritrea.” Report. Available at:{LINK}

[33] {LINK}

[34] {LINK}

[35] {LINK}

[36] Piot, P. and TC. Quinn. 2013. “Response to the AIDS Pandemic: A Global Health Model.” The New England Journal of Medicine. 36(23): 2210-2218.

[37] {LINK}

[38] {LINK}