Beletu Hailemariam, 32, is HIV-positive and knows she should avoid contracting opportunistic infections that could further compromise her immune system. But she lives in one of poorer suburbs of Ethiopia's capital, Addis Ababa, and has to share a toilet with dozens of people and walk long distances to access clean water. A year ago, she was diagnosed with typhoid.
"At that time, I didn't know how an easily curable disease like that... put my life at risk. The doctors told me it has to do with me having the virus in my blood that makes me too weak to cope with the disease," the mother of seven told IRIN/PlusNews. "They told me to be cautious and make an effort to avoid other opportunistic infections for a second time."
Opportunistic infections reduce one's quality of life and can speed the progression of HIV to AIDS, resulting in premature death.
Since her recovery, Hailemariam says she is being "extra careful" not to contract another illness. However, her access to safe water and sanitation has not improved, leaving her at continued risk of waterborne diseases.
"The nearest communal toilet and water points are several minutes' walk away... Twenty-seven households share this dirty toilet, while 11 families share the communal water point," she said.
Beletu is too weak to work, and her husband's US$16-a-month pension is insufficient to pay for the construction of a private latrine or for piped water.
"Health workers have taught me how to protect myself using a simple but efficient way," she said. "I clean my hands with soap after using the toilet. I always treat the water my family drinks... I know not doing this could risk me getting diarrhoea and other opportunistic diseases."
Health workers say a lack of information on the prevention of common opportunistic infections means many Ethiopians living with HIV continue to contract easily preventable diseases.
"Most of them reach our hospital's emergency outpatient department after opportunistic diseases - such as diarrhoeal diseases and typhoid fever - have compromised their immune system," Daniel Teshome, a public health officer at Zewditu Memorial Hospital in Addis Ababa, told IRIN/PlusNews. "They have little knowledge of what caused it, though."
Access to water
According to the NGO Wateraid, people living with HIV are often unable to access community water sources or latrines because of stigma and discrimination.
Although patients usually recover with treatment, many will get repeat infections unless their access to safe water is improved. A 2009 assessment of the water and sanitation situation of HIV-positive home-based care clients in Addis Ababa found that only 62.5 percent had access to improved sanitation, only 6.9 percent had access to bathing facilities and only 4.3 per cent had access to hand-washing facilities near latrines.
The assessment found that the water, sanitation and hygiene needs of home-based care clients were not met, and that safe water, sanitation and hygiene should be essential components of basic preventive care packages for home-based care clients at policy, service provision and community levels.
Experts say HIV-positive children are particularly vulnerable to waterborne infections. "HIV-infected children are at higher risk of getting infectious diseases often associated with poor hygiene and sanitation conditions," said Muhammad Irfan, a water sanitation and hygiene specialist with the UN Children's Fund (UNICEF) in Ethiopia.
More than 180,000 Ethiopia children are infected with HIV, according to Ethiopian government statistics, and according to the 2011 Demographic and Health Survey (DHS), about 60,000 children under the age of five die due to diarrhoea every year in Ethiopia.
Safe water is especially important for people on life-prolonging antiretroviral (ARV) drugs. According to Wateraid, ARVs must be taken with at least 1.5 litres of safe water a day to be effective.
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"By reducing risk factors for diarrhoeal diseases, people living with HIV retain more nutrients, allowing ARVs to be more effective," a Wateraid factsheet indicates.
Experts are calling for water and sanitation issues to be addressed by the country's HIV care and treatment programmes and the country's national HIV policy. "Integrating these special needs of people living with the virus in various policies is critically important now," said Mahider Tesfu, a water and sanitation expert with Wateraid.
The Ethiopian government appears to be doing just that. It has laid out ambitious plans for water, sanitation and hygiene through its Universal Access Plan II, which seeks to reach 98.5 percent of its population with access to safe water and 100 percent with access to sanitation by 2015.
The country is also drafting a document called "Guidelines to Integrate Water, Sanitation and Hygiene into HIV Programmes", which lays the groundwork for incorporating safe water, sanitation and hygiene practices into all HIV care services being delivered at all levels.
According to UNICEF, the implementation of simple steps such as treating water and washing hands with soap can have a significant impact on prevention of waterborne diseases. "Handwashing with soap has been shown to reduce the incidence of diarrhoeal disease by over 40 percent," said UNICEF's Irfan.
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions