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Research Article| Volume 78, P57-64, January 2019

Towards achieving the fast-track targets and ending the epidemic of HIV/AIDS in Ethiopia: Successes and challenges

Open AccessPublished:October 31, 2018DOI:https://doi.org/10.1016/j.ijid.2018.10.022
Towards achieving the fast-track targets and ending the epidemic of HIV/AIDS in Ethiopia: Successes and challenges
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      Abstract

      Background

      Ethiopia has adopted the global plan to end the epidemic of HIV/AIDS. The aim of this study was to assess the progress made towards achieving this plan.

      Methods

      A review and analysis of national population-based surveys, surveillance, and routine programme data was executed. The data analysis was conducted using Excel 2016 and Stata 14 (StataCorp LP, College Station, TX, USA).

      Results

      Between 2011 and 2016, the number of HIV-related deaths dropped by 58%, while that of new HIV infections dropped by only 6%. Discriminatory attitudes declined significantly from 77.9% (95% confidence interval (CI) 77.3–78.4%) in 2011 to 41.5% (95% CI 40.6–42.4%) in 2016. Around 79% of adult people living with HIV (PLHIV) were aware of their HIV status; 90% of PLHIV who were aware of their HIV status were taking antiretroviral treatment (ART) and 88% of adult PLHIV on ART had viral suppression in 2016. The proportion of people aged 15–49 years who had ever been tested for HIV and had received results increased from 39.8% (95% CI 39.2–40.4%) in 2011 to 44.8% (95% CI 44.2–45.4%) in 2016. This proportion was very low among children below age 15 years at only 6.2% (95% CI 5.9–6.5%). Among regions, HIV testing coverage varied from 13% to 72%. Female sex workers had lower coverage for HIV testing (31%) and ART (70%) than the national average in the adult population. International funding for HIV dropped from more than US$ 1.3 billion in 2010–2012 to less than US$ 800 million in 2016–2018.

      Conclusions

      Ethiopia is on track to achieve the targets for HIV testing, ART, viral suppression, and AIDS-related deaths, but not for reductions in new HIV infections, discriminatory attitudes, and equity. Ending the epidemic of HIV/AIDS requires a combined response, including prevention and treatment, tailored to key populations and locations, as well as increased funding.

      Keywords

      Introduction

      Concerted international solidarity and national efforts during the era of the Millennium Development Goals (MDGs) resulted in declining trends in AIDS-related deaths and new HIV infections (

      Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS report shows that 19 million of the 35 million people living with HIV today do not know that they have the virus; 2014. http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2014/july/20140716prgapreport.

      ,

      Joint United Nations Programme on HIV/AIDS (UNAIDS). Global AIDS update 2016; 2016. http://www.unaids.org/en/resources/documents/2016/Global-AIDS-update-2016. [Accessed 15 September 2017].

      ). The Sustainable Development Goals (SDGs), based on the lessons learned from the MDGs, aim to end the epidemic of HIV/AIDS by 2030 (
      • Sidibé M.
      The sustainable development agenda and the end of AIDS.
      Lancet. 2015; 386: 108-110
      ,

      United States Agency for International Development (USAID). Statement: 2016 United Nations political declaration on ending AIDS sets world on the fast-track to end the epidemic by 2030 8 June 2016. http://www.unaids.org/sites/default/files/20160608_PS_HLM_Political_Declaration_final.pdf. [Accessed 17 January 2018].

      ). This will result in a 90% decline in the number of new HIV infections and AIDS-related deaths between 2010 and 2030 (

      Joint United Nations Programme on HIV/AIDS (UNAIDS). 90–90–90 an ambitious treatment target to help end the AIDS epidemic; 2014. http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf. [Accessed 15 September 2017].

      ).
      The plan towards ending the epidemic of HIV/AIDS has three fast-track milestones to be reached by 2020: reduce new HIV infections and HIV-related deaths to fewer than 500 000 globally and eliminate HIV-related stigma and discrimination. The fast-track response also sets out targets on the HIV treatment cascade: 90% of people living with HIV (PLHIV) knowing their HIV status, 90% of people who know their status receiving treatment, and 90% of people on treatment having a suppressed viral load (

      Joint United Nations Programme on HIV/AIDS (UNAIDS). Fast-track: ending the AIDS epidemic by 2030; 2014. http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf. [Accessed 15 September 2017].

      ).
      Since the launch of this global plan, substantial progress has been made: in 2017, three quarters of PLHIV globally knew their HIV status and among those who knew their HIV status, 79% were accessing antiretroviral therapy (ART). Furthermore, 81% of people accessing ART had suppressed viral loads (

      Joint United Nations Programme on HIV/AIDS (UNAIDS). Miles to go: closing gaps, breaking barriers, righting injustices. Geneva: UNAIDS 2018.

      ). This contributed to a 37% global decline in HIV-related deaths and an 18% global decline in new HIV infections between 2010 and 2017 (

      Joint United Nations Programme on HIV/AIDS (UNAIDS). Miles to go: closing gaps, breaking barriers, righting injustices. Geneva: UNAIDS 2018.

      ).
      Ending the epidemic of HIV/AIDS has received significant support at the global and national levels, even though it is believed to be an ambitious goal. Ethiopia is one of the countries that has adopted this ambitious goal and developed an investment case towards achieving the fast-track targets and ending the epidemic of HIV/AIDS by 2030 (

      Federal Ministry of Health (FMOH). Health sector transformation plan, 2015/16–2019/20; 2015. https://www.globalfinancingfacility.org/sites/gff_new/files/Ethiopia-health-system-transformation-plan.pdf. [Accessed 23 March 2018].

      ). A recent study, reviewing the performance of the ART programme in Ethiopia, identified successes and challenges of the programme and recommended further and systematic analysis of the overall HIV/AIDS response in the country (
      • Assefa Y.
      • Gilks C.F.
      • Lynen L.
      • Williams O.
      • Hill P.S.
      • Tolera T.
      • et al.
      Performance of the Antiretroviral Treatment Program in Ethiopia, 2005–2015: strengths and weaknesses toward ending AIDS.
      Int J Infect Dis. 2017; 60: 70-76
      ).
      The objective of this follow on study is to review the progress made towards achieving the fast-track targets and ending the epidemic of HIV/AIDS in Ethiopia. It was hypothesized that there are lessons, in terms of both successes and challenges, which need to be identified and utilized towards ending the epidemic of HIV/AIDS in Ethiopia and other countries with a similar context.

      Methods

      Setting

      Ethiopia has a federal government structure consisting of nine regional states (Tigray, Afar, Amhara, Oromia, Somali, Southern Nation Nationalities and Peoples Region (SNNPR), Benishangul-Gumuz (BG), Gambela, and Harari) and two city administrations councils (Dire Dawa (DD) and Addis Ababa (the capital city)). More than 80% of the population live in rural areas. The proportion of rural population varies across regions, ranging from 75% in Tigray to 90% in SNNPR (

      Federal Democratic Republic of Ethiopia-Population Census Commission. Summary and statistical report of the 2007 population and housing census – population size by age and sex; 2008. https://searchworks.stanford.edu/view/8650186.

      ). The burden of HIV varies across these regions, with the highest prevalence in Gambela region (4.8%) and the lowest in Somali region (0.1%) (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      Since the first AIDS cases were identified in 1986, the HIV/AIDS epidemic has passed through various phases, from a concentrated epidemic among key populations (such as female sex workers (FSWs)), followed by rapid expansion into the general population, to the current phase of declining incidence (

      Berhane Y, Mekonnen Y, Seyoum E, Gelmon L, Wilson D. HIV/AIDS in Ethiopia—an epidemiological synthesis. Ethiopia HIV/AIDS Prevention & Control Office (HAPCO) and Global AIDS Monitoring & Evaluation Team (GAMET); 2008.

      ,
      • Kloos H.
      • Mariam D.H.
      HIV/AIDS in Ethiopia: an overview.
      Northeast Afr Stud. 2000; 7: 13-40
      ). The country has responded to the epidemic in phases (
      • Okubagzhi G.
      • Singh S.
      Establishing an HIV/AIDS programme in developing countries: the Ethiopian experience.
      AIDS. 2002; 16: 1575-1586
      ). The early phase of the response focused primarily on the health sector (
      • Kebede D.
      • Aklilu M.
      • Sanders E.
      The HIV epidemic and the state of its surveillance in Ethiopia.
      Ethiop Med J. 2000; 38: 283-302
      ). In the next phase (multisectoral response), the government issued a national AIDS policy in 1998 (

      Federal Democratic Republic of Ethiopia. Policy on HIV/AIDS of the Federal Democratic Republic of Ethiopia; 1998. http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_125382.pdf. [Accessed 25 November 2018].

      ), and established a National AIDS Council (NAC) and its Secretariat, the Federal HIV and AIDS Prevention and Control Office (FHAPCO) in 2000 (
      • Okubagzhi G.
      • Singh S.
      Establishing an HIV/AIDS programme in developing countries: the Ethiopian experience.
      AIDS. 2002; 16: 1575-1586
      ). Three consecutive 5-year strategic frameworks were developed and implemented to intensify the multisectoral response to HIV/AIDS: (1) strategic framework for the national response to HIV and AIDS in Ethiopia (2001–2005) (

      Federal HIV/AIDS Preventipn and Control Office (FHAPCO). Ethiopian strategic plan for intensifying multi-sectoral HIV/AIDS response (2004–2008); 2004. http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_125381.pdf. [Accessed 12 January 2018].

      ); (2) strategic plan for intensifying the multisectoral HIV/AIDS response in Ethiopia, SPM-I (2004–2008) (

      Federal HIV/AIDS Precention and Control Office (FHAPCO). Ethiopian strategic plan for intensifying multi-sectoral HIV/Aids response (2004–2008); 2009. https://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1151090631807/2693180-1151090665111/2693181-1155742859198/Ethiopia.pdf.

      ); and (3) strategic plan for intensifying the multisectoral HIV/AIDS response in Ethiopia, SPM-II (2010–2014) (

      Federal HIV/AIDS Prevention and Control Office (FHAPCO). Strategic plan II 2010/11–2014/15 for intensifying multisectoral HIV and AIDS response in Ethiopia; 2010. http://hivhealthclearinghouse.unesco.org/sites/default/files/resources/iiep_ethiopia_2010_strategic_plan_ii.pdf. [Accessed 15 January 2018].

      ). The response to the epidemic has also been guided by the health policy and the health sector development plans (I–IV) since 1997 (

      Federal Ministry of Health (FMOH). Health sector transformation plan-I annual performance report; 2016. https://www.itacaddis.org/docs/2017_11_10_09_46_13_HEALTH%20SECTOR%20TRANSFORMATION%20PLAN-I%20ANNUAL%20PERFORMANCE%20REPORT%20(ARM_2016).compressed.pdf. [Accessed 20 March 2018].

      ,
      • Assefa Y.
      • Kloos H.
      The public health approach to antiretroviral treatment (ART) service scale-up in Ethiopia: the first two years of free ART, 2005–2007.
      Ethiop Med J. 2008; 46: 401-406
      ).

      Study design

      A retrospective study was conducted to review and analyze national population-based surveys, surveillance, and routine programme data reported by the Federal Ministry of Health and its agencies. A set of complementary methods and a variety of nationally representative data sources were used, including the 2005 (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ), 2011 (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ), and 2016 (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ) Ethiopian Demographic and Health Surveys (DHSs). The standard DHS wealth index was employed to categorize the population into the five wealth quintiles (ranging from the lowest to the highest) (

      Rutstein SO, Johnson K, Measure OM. The DHS wealth index: ORC Macro, MEASURE DHS; 2004.

      ).
      Estimates for new HIV infections, HIV-related deaths, comprehensive knowledge, sexual activity, condom use, discrimination, HIV testing, ART, viral suppression, and funding for HIV were calculated. The data for new HIV infections and HIV-related deaths were extracted from estimates and projections conducted by the Ethiopian Public Health Institute (EPHI) and its partners (

      Ethiopian Public Health Institute (EPHI). HIV related estimates and projections for Ethiopia – 2012; 2012. http://files.unaids.org/en/media/unaids/contentassets/documents/data-and-analysis/tools/spectrum/Ethiopia2012report.pdf. [Accessed 15 March 2018].

      ,

      Ethiopian Public Health Institute (EPHI). HIV related estimates and projections for Ethiopia – 2017; 2017. https://www.ephi.gov.et/images/pictures/download2009/HIV_estimation_and_projection_for_Ethiopia_2017.pdf. [Accessed 15 March 2018].

      ,

      Federal HIV/AIDS Prevention and Control Office (FHAPCO). Single point estimate; 2007. http://www.etharc.org/aidsineth/publications/singlepointprev_2007.pdf. [Accessed 15 March 2018].

      ).
      The data came from different national offices (Federal Ministry of Health (FMOH), FHAPCO, EPHI, and the Ethiopian Central Statistics Authority) and global agencies (Joint United Nations Programme on HIV and AIDS (UNAIDS) and President’s Emergency Plan for AIDS Relief (PEPFAR)) working in Ethiopia. The data for population-level HIV prevalence and HIV prevention activities and testing services were acquired from the DHSs. The data for stigma and discrimination were obtained from the DHSs and reports from FHAPCO and UNAIDS. The data for HIV testing, treatment, and viral suppression were synthesized from programme reports on HIV testing and treatment from FMOH, FHAPCO, PEPFAR, and UN agencies. Table 1 below summarizes the indicators used in the study and the associated data sources.
      Table 1Indicators used in the study and the associated data sources.
      IndicatorsData sources
      New HIV infections and AIDS-related deaths
      Number of new HIV infectionsHIV-related estimates and projections
      Number of AIDS-related deathsHIV-related estimates and projections
      Stigma and discrimination
      Percentage with discriminatory attitudes towards people living with HIVDHS 2005, 2011, 2016
      HIV prevention
      Percentage with comprehensive knowledge of HIVDHS 2000, 2005, 2011, 2016
      Percentage who had 2+ partners in the past 12 monthsDHS 2000, 2005, 2011, 2016
      Percentage who had intercourse in the past 12 months with a person who was neither their husband nor de facto partnerDHS 2000, 2005, 2011, 2016
      Condom use at last higher-risk sex (with a non-marital, non-cohabiting partner)DHS 2000, 2005, 2011, 2016
      Percentage of adults age 15–49 years using condom with non-regular partner during the last sexual actDHS 2000, 2005, 2011, 2016
      HIV testing in the general population
      Adults tested for HIVDHS 2005, 2011, 2016
      Children tested for HIVDHS 2005, 2011, 2016
      Pregnant women tested for HIVDHS 2005, 2011, 2016
      People living with HIV: testing, treatment, and viral suppression
      Adults on ARTFMOH, FHAPCO, and PEPFAR
      Pregnant women on ARTFMOH, FHAPCO, and PEPFAR
      Adults on ART and with viral suppressionFMOH, FHAPCO, and PEPFAR
      DHS, Demographic and Health Survey; ART, antiretroviral therapy; FMOH, Federal Ministry of Health; FHAPCO, Federal HIV and AIDS Prevention and Control Office; PEPFAR, President’s Emergency Plan for AIDS Relief.

      Data analysis

      Data were entered and cleaned using Excel 2016. The data analysis was conducted using Excel 2016 and Stata 14 (StataCorp LP, College Station, TX, USA). Trends in coverage indicators and equity measures across wealth quintiles, regions, and residential groups were produced. Correlation analysis was conducted to estimate the association between coverage for HIV testing and other variables. The z-test was used, with statistical significance defined at a p-value of <0.05.
      Ethical approval for this study was obtained from the Scientific and Ethics Review Committee of the Ethiopian Public Health Institute.

      Results

      The findings of this study are organized to show levels and trends in (1) the number of PLHIV, new HIV infections, and deaths; (2) discriminatory attitudes; (3) fast-track targets; (4) inequity in HIV services; and (5) funding for HIV.

      Number of PLHIV, new HIV infections, and deaths

      The prevalence of HIV among 15–49-year-olds declined from 1.5% (95% CI 1.3–1.7%) in 2011 to 0.9% (95% CI 0.7–1.1%) in 2016 (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ). Figure 1 shows that there was a marked drop in adult PLHIV, new infections, and deaths between 2005 and 2011. New infections dropped by almost 90% (from 101 144 to 10 556) and deaths dropped by 54% (from 87 860 to 16 782) between 2005 and 2011.
      Figure 1
      Figure 1Estimated numbers of the adult population living with HIV, new HIV infections, and AIDS-related deaths in Ethiopia in 2005, 2011, and 2016.
      The estimated number of adult PLHIV continued to decline by 18% from 607 711 (95% CI 550 991–664 431) in 2011 to 495 720 (95% CI 429 624–561 816) in 2016. There was a small drop, by 6%, in number of new HIV infections from 11 228 in 2011 to 10 556 in 2016. On the other hand, the number of deaths dropped markedly, by 58%, from 40 082 in 2011 to 16 782 in 2016 (Figure 1) (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).

      Discriminatory attitudes towards PLHIV

      The plan to end the epidemic of HIV also aims to end discrimination. It was found that discriminatory attitudes declined significantly from 77.9% (95% CI 77.3–78.4%) in 2011 to 41.5% (95% CI 40.6–42.4%) in 2016 (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).

      Fast-track targets

      The proportion of PLHIV who already knew their HIV diagnosis increased significantly from 4.7% (95% CI 4.32–5.08%) in 2005 to 71.8% (95% CI 70.9–78.3%) in 2011 to 78.7% (95% CI 73.4–84.0%) in 2016. HIV testing services were targeting those at higher risk of HIV: 78.7% (95% CI 73.4–84.0%) of HIV-positive people knew their HIV status compared to only 44.8% (95% CI 44.2–45.4%) of HIV-negative people in 2016 (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      Close to 90% of adult PLHIV, who were aware of their HIV diagnosis, were taking ART in 2016. ART coverage among all adult PLHIV increased significantly from less than 1% in 2005 to 71% in 2016 (
      • Assefa Y.
      • Gilks C.F.
      • Lynen L.
      • Williams O.
      • Hill P.S.
      • Tolera T.
      • et al.
      Performance of the Antiretroviral Treatment Program in Ethiopia, 2005–2015: strengths and weaknesses toward ending AIDS.
      Int J Infect Dis. 2017; 60: 70-76
      ,

      Joint United Nations Programme on HIV/AIDS (UNAIDS). Ending AIDS: progress towards the 90–90–90 targets; 2017. http://www.unaids.org/en/resources/campaigns/globalAIDSupdate2017. [Accessed 12 January 2018].

      ). It was also found that 73% of HIV-positive pregnant women were receiving ART by 2016. Close to 88% of adult PLHIV taking ART had viral suppression, which was also equivalent to 63% of all adult PLHIV in the country (Figure 2) (
      • Assefa Y.
      • Gilks C.F.
      • Lynen L.
      • Williams O.
      • Hill P.S.
      • Tolera T.
      • et al.
      Performance of the Antiretroviral Treatment Program in Ethiopia, 2005–2015: strengths and weaknesses toward ending AIDS.
      Int J Infect Dis. 2017; 60: 70-76
      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      Figure 2
      Figure 2Fast-track targets for HIV testing, treatment, and viral suppression among the adult population living with HIV in Ethiopia, 2016a.
      aThe data for level of viral suppression are estimated from multi-site advanced clinical monitoring and nationwide treatment failure studies in Ethiopia: https://www.ncbi.nlm.nih.gov/pubmed/28465649.

      Comprehensive knowledge about HIV

      Comprehensive knowledge remained very low, although it increased from 19.8% (95% CI 19.24–20.36%) in 2005 to 27.9% (95% CI 27.4–28.4%) in 2016. Comprehensive knowledge increased from 15.8% (95% CI 15.2–16.4%) in women and 30% (95% CI 28.8–31.2%) in men aged 15–49 years in 2005 to 20.2% (95% CI 19.6–20.8%) in women and 38.3% (95% CI 37.4–39.2%) in men aged 15–49 years in 2016. Comprehensive knowledge among young people aged 15–24 years remained low, although it increased from 24% in 2005 to 31% in 2016. Urban youth (42% of women and 48% of men) were found to be more likely than rural youth (19% of women and 37% of men) to have comprehensive knowledge (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).

      Multiple sexual partners and condom use

      The proportion of people with multiple sexual partners remained low over time: 1.8% (95% CI 1.5–2.1%) in 2005, 1.8% (95% CI 1.65–1.95%) in 2011, and 1.7% (95% CI 1.55–1.85%) in 2016 (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ). Condom use at last sex with a non-marital or non-cohabiting partner was very low at 23.8% (95% CI 17.5–30.1%) among young women and was 54.5% (95% CI 49.6–59.4) among young men (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ). The percentage of women who had sexual intercourse before age 15 years was 22% among women with no education and 1% among those with more than secondary education (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).

      Inequity

      Discriminatory attitudes varied across regions with the lowest in Addis Ababa (18% of women and 17% of men) and highest in the Somali region (78% of women and 73% of men). Higher education, wealth, and urban residence were related to less discriminatory attitudes. For example, in 2016, 27% of women and 34% of men with a secondary education had discriminatory attitudes compared with 80% of women and 67% of men with no education (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      There were notable differences in comprehensive knowledge between women (20.2%) and men (38.3%). Comprehensive knowledge increased with education: 8% of women and 27% of men with no education demonstrated comprehensive knowledge compared to 51% of women and 58% of men with more than secondary education (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      It was found that the proportion of women and men who had been tested for HIV in the past 12 months was twice as high in urban areas (36% of women and 33% of men) as in rural areas (15% of both women and men). HIV testing coverage ranged from 13% in the Somali region to 72% in Addis Ababa (Table 2) (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      Table 2HIV testing coverage in Ethiopia in 2005, 2011, and 2016.
      Background characteristicsGeneral adult population tested for HIV and received results
      200520112016
      Urban16.6%

      (16.2–17.0)      		61.2%

      (60.6–61.8)      		66.7%

      (65.1–68.3)
      Rural1.0%

      (0.6–1.4)      		27.8%

      (27.2–28.4)      		38.2%

      (37.6–38.9)
      Somali region1.9%

      (1.5–2.3)      		10.6%

      (10.0–11.2)      		12.8%

      (12.2–13.4)
      Gambela1.0%

      (0.2–2.0)      		48.9%

      (46.7–51.1)      		64.3%

      (48.4–80.2)
      Addis Ababa26.5%

      (26.1–26.9)      		65.2%

      (64.6–65.8)      		71.6%

      (71.0–72.2)
      No education0.6%

      (0.2–1.0)      		24.1%

      (23.5–24.7)      		31.4%

      (30.8–32.0)
      Secondary and higher education20.8%

      (20.4–21.2)      		65.1%

      (64.5–65.7)      		57.6%

      (57.0–58.2)
      Lowest wealth quintile018.2%

      (17.6–18.8)      		21.2%

      (20.6–21.8)
      Highest wealth quintile12.5%

      (12.1–12.9)      		61.3%

      (60.7–61.9)      		64.1%

      (63.5–64.7)
      Total4.7%

      (4.32–5.08)      		39.8%

      (39.2–40.4)      		44.8%

      (44.2–45.4)
      HIV testing tended to increase with the level of education from 14% of women and 13% of men with no education to 44% of women and 39% of men with more than secondary education. Women who were living in urban areas, highly educated, and with the highest wealth quintile reported higher HIV testing prior to getting married or living with a partner than the other women (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      More than half of the women in urban areas (56%) had been tested for HIV and had received results compared to 14% of those in rural areas. HIV testing during pregnancy increased with education: 24% in women with no education and 88% in women with more than a secondary education (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      Only 6.2% (95% CI 5.9–6.5) of children below age 15 years (22% (95% CI 20.5–23.5%) in urban areas and 5% (95% CI 4.7–5.3) in rural areas) had been tested for HIV. HIV testing in children was highest in Addis Ababa (23%), followed by Tigray (14.6%), and lowest in Somali region (2%). Children born to mothers with more than a secondary education (28.6%) and in the highest wealth quintile (17.3%) were almost seven times more likely to have been tested for HIV than those born to mothers with no education (4.4%) and in the lowest wealth quintiles (2.8%) (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).
      A positive correlation was found between proportions of HIV testing and ART, with a Pearson correlation coefficient of 0.64 across regions in the country. On the other hand, a negative correlation was found between the proportions of HIV testing and the drop in number of PLHIV, with a Pearson correlation coefficient of −0.60 across regions in the country (
      • Assefa Y.
      • Gilks C.F.
      • Lynen L.
      • Williams O.
      • Hill P.S.
      • Tolera T.
      • et al.
      Performance of the Antiretroviral Treatment Program in Ethiopia, 2005–2015: strengths and weaknesses toward ending AIDS.
      Int J Infect Dis. 2017; 60: 70-76
      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ).

      Key populations

      FSWs are one of the recognized key populations in the country. In spite of the high HIV prevalence in FSWs (23%, 95% CI 19–28%), coverage of HIV testing and ART services in this population group were less than the coverage in the general population: only 31% of FSWs living with HIV were aware of their HIV status, and of those FSWs who knew their HIV status, close to 70% were taking ART (

      Ethiopian Public Health Institute (EPHI). Ethiopian national key population HIV bio-behavioral surveillance Round I, 2013 Report: EPHI; 2014.

      ).
      Other globally recognized key populations (people who inject drugs, transgender people, prisoners, and men who have sex with men, and their sexual partners) have not been studied and described in the country. There is indeed a lack of data on the epidemiology of and service delivery to these population groups.

      Funding for HIV

      External funding from the Global Fund and PEPFAR increased by almost two-fold from less than US$ 700 million in 2004–2006 to more than US$ 1.3 billion in 2010–2012. Since this significant increment, there has been a sustained decline since 2013, to less than US$ 800 million in 2016–2018. Furthermore, the recent national health account indicated that external funding for HIV dropped from 80% in 2007–2008 to 50% in 2013–2014 of the total resource for HIV/AIDS, which also dropped from 20% of the total health expenditure (THE) in 2007–2008 to 10% of the THE in 2013–2014 (

      Federal Ministry of Health (FMOH). Ethiopia health accounts, 2013/14; 2017. https://www.hfgproject.org/ethiopia-health-accounts-201314/.

      ,

      Glassman A. Ethiopia’s AIDS spending cliff; 2012. https://www.cgdev.org/blog/ethiopia%E2%80%99s-aids-spending-cliff. [Accessed 26 March 2018].

      ,

      Health Works Collective. PEPFAR funding allocations: FY2011–FY2013; 2012. https://www.healthworkscollective.com/wpcontent/uploads/2012/09/PEPFAR-Country-Allocations-FY11-131.pdf. [Accessed 27 March 2018].

      ). On the other hand, domestic funding for HIV and other health programmes has increased in Ethiopia over time (
      • Assefa Y.
      • Tesfaye D.
      • Van Damme W.
      • Hill P.S.
      Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia.
      Lancet. 2018; 392: 1473-1481
      ). However, more resources are still required to finance the implementation of the country’s investment case towards achieving the fast-track targets and ending the epidemic of HIV/AIDS (

      Federal HIV/AIDS Prevention and Control Office (FHAPCO). HIV/AIDS strategic plan 2015–2020 in an investment case approach; 2014. http://hivhealthclearinghouse.unesco.org/sites/default/files/resources/22292.pdf. [Accessed 26 March 2018].

      ).
      Figure 3 shows the funding for HIV from the Global Fund and PEPFAR in Ethiopia for the period 2004–2018.
      Figure 3
      Figure 3HIV funding from the Global Fund and PEPFAR in Ethiopia, 2004–2018.

      Discussion

      In this study, it was found that Ethiopia is on track to achieve the fast-track targets (HIV testing, ART, viral suppression) and reduction in AIDS-related deaths. However, achieving these targets is not sufficient to end the epidemic of HIV, as the country is lagging behind the targets for reductions in new HIV infections, discriminatory attitudes, and HIV prevention. Moreover, there is inequity in coverage of HIV services among populations and locations. International funding for HIV has also been declining recently. These successes and challenges are also present in other parts of the world (
      • Levi J.
      • Raymond A.
      • Pozniak A.
      • Vernazza P.
      • Kohler P.
      • Hill A.
      Can the UNAIDS 90–90–90 target be achieved? A systematic analysis of national HIV treatment cascades.
      BMJ Glob Health. 2016; 1e000010
      ,

      Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS data 2017; 2017. http://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf. [Accessed 10 January 2018].

      ).
      This study identified that there was a marked drop in HIV-related deaths from 40 082 to 16 782 between 2011 and 2016. This can be explained by the large-scale expansion of HIV testing and ART services in the country. On the other hand, a gap in HIV testing will definitely establish a gap in the fast-track targets, as HIV testing is an entry point for HIV-related care and treatment services. It was found that around 21% of PLHIV are not aware of their HIV status due to inadequacies in HIV testing, and this has contributed to 73% of the gap in ART coverage. As for many countries around the globe (
      • Cori A.
      • Ayles H.
      • Beyers N.
      • Schaap A.
      • Floyd S.
      • Sabapathy K.
      • et al.
      HPTN 071 (PopART): a cluster-randomized trial of the population impact of an HIV combination prevention intervention including universal testing and treatment: mathematical model.
      PLoS One. 2014; 9e84511
      ), addressing this limitation in HIV testing is, indeed, an ongoing challenge that requires urgent action.
      In general, multiple factors, including individual (
      • Underwood C.
      • Hendrickson Z.
      • Van Lith L.M.
      • Kunda J.E.L.
      • Mallalieu E.C.
      Role of community-level factors across the treatment cascade: a critical review.
      J Acquir Immune Defic Syndr. 2014; 66 (S311–8)
      ), societal (
      • Musheke M.
      • Ntalasha H.
      • Gari S.
      • Mckenzie O.
      • Bond V.
      • Martin-Hilber A.
      • et al.
      A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa.
      BMC Public Health. 2013; 13: 220
      ), and structural (
      • Group TAS
      A trial of early antiretrovirals and isoniazid preventive therapy in Africa.
      N Engl J Med. 2015; 373: 808-822
      ), can influence the uptake of HIV testing (
      • Bolsewicz K.
      • Vallely A.
      • Debattista J.
      • Whittaker A.
      • Fitzgerald L.
      Factors impacting HIV testing: a review—perspectives from Australia, Canada, and the UK.
      AIDS Care. 2015; 27: 570-580
      ). A range of interventions, such as information, education, and behavioural change programmes (
      • Musheke M.
      • Ntalasha H.
      • Gari S.
      • Mckenzie O.
      • Bond V.
      • Martin-Hilber A.
      • et al.
      A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa.
      BMC Public Health. 2013; 13: 220
      ), and innovative approaches addressing the complex intersection of individual, societal, and structural factors, including partner testing, opt-out testing, community-based testing, and self-testing, are required to address these factors (
      • Sabapathy K.
      • Van den Bergh R.
      • Fidler S.
      • Hayes R.
      • Ford N.
      Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis.
      PLoS Med. 2012; 9e1001351
      ,
      • Napierala Mavedzenge S.
      • Baggaley R.
      • Corbett E.L.
      A review of self-testing for HIV: research and policy priorities in a new era of HIV prevention.
      Clin Infect Dis. 2013; 57: 126-138
      ). In addition, to achieve high yield and impact, it is crucial that people are tested for HIV regularly (
      • Mayer K.
      • Gazzard B.
      • Zuniga J.M.
      • Amico K.R.
      • Anderson J.
      • Azad Y.
      • et al.
      Controlling the HIV epidemic with antiretrovirals: IAPAC consensus statement on treatment as prevention and preexposure prophylaxis.
      J Int Assoc Providers AIDS Care. 2013; 12: 208-216
      ,
      • Granich R.
      • Crowley S.
      • Vitoria M.
      • Smyth C.
      • Kahn J.G.
      • Bennett R.
      • et al.
      Highly active antiretroviral treatment as prevention of HIV transmission: review of scientific evidence and update.
      Curr Opin HIV AIDS. 2010; 5: 298
      ).
      Furthermore, HIV testing should be accompanied by strong linkage to care and ART provision (

      Olney JJ, Braitstein P, Eaton JW, Sang E, Nyambura M, Kimaiyo S, et al. Deciding the timing of home-based HIV testing in Western Kenya; 2016.

      ). It was found that 27% of the gap in ART coverage was due to inadequacies in linkage to care, pre-ART retention, and timely initiation of ART (
      • Assefa Y.
      • Damme W.V.
      • Mariam D.H.
      • Kloos H.
      Toward universal access to HIV counseling and testing and antiretroviral treatment in Ethiopia: looking beyond HIV testing and ART initiation.
      Aids Patient Care STDS. 2010; 24: 521-525
      ). Moreover, with an increasing patient caseload, both short- and long-term retention in care is crucial towards improved outcomes. These need appropriate models of care (
      • Assefa Y.
      • Lynen L.
      • Wouters E.
      • Rasschaert F.
      • Peeters K.
      • Van Damme W.
      How to improve patient retention in an antiretroviral treatment program in Ethiopia: a mixed-methods study.
      BMC Health Serv Res. 2014; 14: 45
      ), including differentiated care models (

      World Health Organization (WHO). A framing of differentiated service delivery 2016. http://www.differentiatedcare.org/Portals/0/adam/Content/FNGtNBkUYEK1Tj8eqFBO_A/File/A%20Framing%20of%20Differentiated%20Service%20Delivery%20[1].pdf. [Accessed 12 January 2018].

      ). These are critical steps that influence the treatment cascade from HIV testing to viral suppression (
      • Medley A.
      • Bachanas P.
      • Grillo M.
      • Hasen N.
      • Amanyeiwe U.
      Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence.
      J Acquir Immune Defic Syndr. 2015; 68: S286
      ,
      • Liau A.
      • Crepaz N.
      • Lyles C.M.
      • Higa D.H.
      • Mullins M.M.
      • Deluca J.
      • et al.
      Interventions to promote linkage to and utilization of HIV medical care among HIV-diagnosed persons: a qualitative systematic review, 1996–2011.
      AIDS Behav. 2013; 17: 1941-1962
      ), which, in turn, is a measure of success of ART programmes (
      • Camoni L.
      • Raimondo M.
      • Dorrucci M.
      • Regine V.
      • Salfa M.C.
      • Suligoi B.
      • et al.
      Estimating minimum adult HIV prevalence: a cross-sectional study to assess the characteristics of people living with HIV in Italy.
      AIDS Res Hum Retroviruses. 2015; 31: 282-287
      ) that leads to reduced HIV transmission (
      • Quinn T.C.
      • Wawer M.J.
      • Sewankambo N.
      • Serwadda D.
      • Li C.
      • Wabwire-Mangen F.
      • et al.
      Viral load and heterosexual transmission of human immunodeficiency virus type 1.
      N Engl J Med. 2000; 342: 921-929
      ) and related morbidity and mortality (

      Parra M. Initiation of antiretroviral therapy in early asymptomatic HIV infection: the INSIGHT START Study Group; 2016.

      ).
      It is equally important to note that the level of viral suppression was based on viral load measurements in PLHIV who were alive and taking ART. The level of viral suppression (88%) in the country, therefore, represents the level of viral suppression in PLHIV who have managed to survive and stay in care. The 88% level of viral suppression does not reflect the full picture as it does not take into account PLHIV who were dead or lost to follow-up. It is rather appropriate to report that 63% of all PLHIV had achieved viral suppression. This could be due in part to the limited access to treatment monitoring and second-line ART services in Ethiopia (less than 2%, contrary to the 12% treatment failure) (
      • Assefa Y.
      • Gilks C.F.
      • Lynen L.
      • Williams O.
      • Hill P.S.
      • Tolera T.
      • et al.
      Performance of the Antiretroviral Treatment Program in Ethiopia, 2005–2015: strengths and weaknesses toward ending AIDS.
      Int J Infect Dis. 2017; 60: 70-76
      ,
      • Assefa Y.
      • Gilks C.F.
      Second-line antiretroviral therapy: so much to be done.
      Lancet HIV. 2017; 4 (e424–5)
      ). It is imperative that the country invests in these services to gain maximally from the prevention and survival benefits of both first- and second-line ART.
      This study identified that the number of new HIV infections declined by only 6% (although it was expected to drop by 27%) between 2011 and 2016. This may be explained by the inadequate coverage of HIV prevention services, including low condom utilization (only 41% among adults 15–49 years of age who had sex with a non-regular partner) and low comprehensive knowledge on HIV prevention in 2016 (only 28%) (

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2005; 2006. https://dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2011; 2012. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. [Accessed 15 January 2018].

      ,

      Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016; 2017. https://dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm. [Accessed 23 February 2018].

      ). These data call for a much stronger combined HIV prevention response, including not only biomedical but also behavioural and structural dimensions. These need to be improved by providing consistent and tailored information, education, and behavioural change communication (
      • Musheke M.
      • Ntalasha H.
      • Gari S.
      • Mckenzie O.
      • Bond V.
      • Martin-Hilber A.
      • et al.
      A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa.
      BMC Public Health. 2013; 13: 220
      ). The scope of these services needs to be expanded enough so that they have an effect on reducing discriminatory attitudes towards PLHIV. Moreover, appropriate interventions that address structural issues, such as socio-economic status, that affect vulnerable population groups should be designed and implemented (
      • Abdul-Quader A.S.
      • Collins C.
      Identification of structural interventions for HIV/AIDS prevention: the concept mapping exercise.
      Public Health Rep. 2011; 126: 777-788
      ). The pre-exposure prophylaxis (PrEP) programme, which has not yet started in the country, could also be an option for HIV prevention in key populations (
      • Cowan F.M.
      • Delany-Moretlwe S.
      • Sanders E.J.
      • Mugo N.R.
      • Guedou F.A.
      • Alary M.
      • et al.
      PrEP implementation research in Africa: what is new?.
      J Int AIDS Soc. 2016; 19
      ).
      This study found that there was a huge inequity in service coverage among regions, socio-economic status groups, age groups, and the sexes. These equity gaps can be explained by differentials in access to and utilization of services due to discrepancies in health-seeking behaviour and health systems capacity (

      Ethiopian Public Health Institute (EPHI). Ethiopia service provision assessment plus survey 2014; 2015. https://www.washinhcf.org/fileadmin/user_upload/documents/Ethiopia_SPA-_Key-findings_Aug2015.pdf. [Accessed 25 March 2018].

      ). Services, therefore, need to be expanded with a focus on these special and key populations and locations by using appropriate models of service delivery that address the unique context and conditions of the locations and populations (

      World Health Organization (WHO). The world health report: health systems financing: the path to universal coverage; 2010. http://apps.who.int/iris/bitstream/10665/44371/1/9789241564021_eng.pdf. [Accessed 15 April 2018].

      ,
      • Marmot M.
      • Friel S.
      • Bell R.
      • Houweling T.
      • Taylor S.
      Closing the gap in a generation: health equity through action on the social determinants of health.
      Lancet. 2008; 372: 1661-1669
      ). On the other hand, the inequity in service coverage could also be due to variations in epidemiology of HIV; however, further analysis is required to validate this.
      This study identified that data on recognized key populations (FSWs, long-distance truck drivers, youth) are inadequate and that there is an absence of data on the epidemiology of HIV/AIDS and its response in globally recognized key populations (intravenous drug users, men having sex with men) in Ethiopia (

      Global Fund Observer. Newsletter. Issue 329 24 January 2018. http://aidspan.org/sites/default/files/gfo/329/English/GFO-Issue-329.pdf. [Accessed 15 April 2018].

      ). Therefore, an in-depth analysis of the epidemic in key populations and locations is of paramount importance for a targeted and effective response. Moreover, the goal of ending HIV/AIDS requires the recognition of key populations and the design of effective service delivery and monitoring and evaluation systems tailored to these population groups (

      World Health Organization (WHO). Consolidated strategic information guidelines for HIV in the health sector; 2015. http://apps.who.int/iris/bitstream/10665/164716/1/9789241508759_eng.pdf.

      ).
      Finally, the goal of ending HIV/AIDS requires increased funding now more than ever. However, the data show that there has been a declining trend in international funding for HIV over time. This needs due attention and urgent action so that sustained and reliable funding is available and used efficiently. This is possible with enhanced government leadership to increase domestic resources and sustained global solidarity towards ending the epidemic of HIV/AIDS.
      This study has both strengths and limitations. The strengths are (1) it is the first of its kind in the country that reviews the progress made towards fast-track targets and ending HIV/AIDS; (2) it used a variety of data sources; (3) it explored multiple programme components (prevention, treatment, new infections, death, and discriminatory attitudes); and (4) it assessed the progress across locations and population groups. The study also has limitations: (1) it is a retrospective observational study, based on secondary datasets, which may have inherent limitations related to data quality (including availability); however, these limitations are not systematic and will not affect the conclusions of the study; and, (2) it did not review the progress in children less than 15 years of age and pregnant women due to the lack of updated data on ART and viral suppression. Nevertheless, we argue that similar successes and challenges to those identified in this study could also be present in children and pregnant women. The following areas of future research are proposed: in-depth analyses of the epidemiology of HIV and access and utilization of services in key populations and locations, and a study to explain the variability in epidemiology of HIV and service delivery among regions in the country.
      In conclusion, Ethiopia is on track towards achieving the fast-track targets and reduction in AIDS-related deaths. However, there are gaps in reducing new HIV infections, discriminatory attitudes, HIV prevention, equity, and funding. The response to end the epidemic of HIV/AIDS should employ combination prevention and enhanced treatment approaches, tailored to key populations and locations. These require sustained and predictable funding from both international and domestic sources.

      Author contributions

      YA: conceived the research idea, designed the study, conducted data collection and analysis, wrote the first and subsequent drafts of the manuscript; CFG and PSH: participated in the research design; YA, CFG, JD, BT, ML, TTL, YG, WVD, and PSH: critically reviewed and provided extensive feedback on all drafts of the manuscript. All authors approved the final version of the manuscript for submission.

      Funding

      None.

      Data sharing

      Data are available from the corresponding author.

      Conflict of interest

      None.

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      Article info

      Publication history

      Published online: October 31, 2018
      Accepted: October 26, 2018
      Received in revised form: October 25, 2018
      Received: August 24, 2018
      Corresponding Editor: Eskild Petersen, Aarhus, Denmark

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      DOI: https://doi.org/10.1016/j.ijid.2018.10.022

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      © 2018 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

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