The Hidden Epidemic: HIV/AIDS in Eastern Europe and Central Asia, Part 1

When HIV is discussed at the international level, let’s face it, most people think of Africa and Southeast Asia as the regions where HIV is spreading most rapidly. That is where most media, celebrity, and NGO attention is focused with regards to prevention and education. However, HIV/AIDS is spreading most rapidly in Eastern Europe and Central Asia [1]

To put this in context: between 2001 and 2011, the prevalence of HIV in Eastern Europe and Central Asia increased by 250%; during that same time period, prevalence fell by 0.8% in Africa and stabilized at 0.3% in Southeast Asia [2].  Yet despite this reality, the spread of HIV in this region receives little to no media coverage both domestically or internationally.

Due to the limited awareness and coverage on this, the SAN will be showcasing a blog series discussing the effects of stigma in Central and Eastern Europe, and what the world can do to make this problem better known. This first part of the series will serve to give you, our #StigmaWarriors, some background on the stats, policies, and social environment of Eastern Europe and Central Asia.

Knowing the Numbers

Approximately 1.4 million people (1% of the population) in Eastern Europe and Central Asia are living with HIV [3]. However, this is an estimate based on the current number of people who have been officially diagnosed with HIV. In reality the number may actually be higher due to underreporting, a direct result of stigma and discrimination people may experience around HIV testing and disclosure.

The countries with the largest populations of people living with HIV are Estonia, Russia, and Ukraine. Currently, Russia and Ukraine account for 90% of new cases each year in this region [4]. Below we have included a table of the HIV prevalence among adults in each country in this region.

HIV Prevalence in Eastern Europe and Central Asia:

Country	# of adults living with HIV	Prevalence
Estonia	9,900	1.3%
Russia	980,000	1.1%
Ukraine	350,000	0.8%
Latvia	10,000	0.7%
Belarus	13,000	0.4%
Kyrgyzstan	4,200	0.4%
Romania	15,000	0.3%
Tajikistan	10,000	0.3%
Armenia	3,500	0.2%
Georgia	2,700	0.2%
Kazakhstan	12,000	0.2%
Azerbaijan	7,800	0.1%
Bulgaria	3,800	0.1%
Hungary	3,300	0.1%
Lithuania	2,200	0.1%
Poland	20,000	0.1%
Turkmenistan	200	0.1%
Uzbekistan	16,000	0.1%

Source: [5]

In Eastern Europe and Central Asia, HIV/AIDS is currently concentrated, but not limited, among drug users and sex workers and their partners. Other populations affected are prisoners, MSM, and children who have parents living with HIV, but their numbers are small compared to the number of sex workers and drug users affected. 

Among drug users, approximately 20% are living with HIV, though the number could be even higher [6]. Furthermore one-quarter of the world’s injecting drug users live in Eastern Europe and Central Asia, and approximately 80% of new HIV cases are transmitted via injecting drug use [7]!  Among sex workers, 11% of this population are living with HIV [8].  It is even higher for sex workers who inject drugs; 43% for Ukrainian sex workers who inject drugs, compared to 8.5% for those who do not [9]. Lack of knowledge about the spread of HIV is a leading cause of high HIV prevalence among these groups. Only 8% of sex workers in Georgia know how HIV is spread, compared to 29% in Moldova and 36% in Uzbekistan [10]. It is also believed that the spread of HIV has been allowed to escalate due to very little funds targeting drug users, sex workers, and MSM, This is confirmed by UNAIDS Regional Program Adviser Roman Gailevich, who stated: "Governments everywhere are reluctant to spend money on sex workers, on drug users, but MSM comes at the top of the reluctance list. It is probably the last programs that the governments will start." [11]

Policy and Social Issues

Given the aforementioned statistics, it should come as no surprise that currently in Eastern Europe and Central Asia, HIV/AIDS is met with secrecy and derision , and HIV-related stigmas discourage testing and treatment – even at the policy level. Let consider the policies in Russia, for example. The Russian government does not allow harm reduction policies, such as needle-sharing programs because they claim it would threaten drug prevention programs by encouraging people to use injectable drugs [12]. Additionally, HIV treatment centers are separated from the rest of the medical community [13]. This is particularly troubling, not only because it inhibits individuals from receiving treatment, but as a result of the new gay propaganda laws, the threat of violence, social alienation, and arrest this has amplified individual’s concerns of being seen entering a HIV clinic and being perceived as gay.

These policies inform people’s perspectives on HIV and fuel stigma. Stigma is so prevalent that many of those who know their HIV status state that they do not fear dying as much as they fear the stigma associated with HIV [14]. The ugly reality for people living with HIV in this region, though it is applicable in other settings, is that they are more likely to be discriminated against when looking for employment, and there is a lack of confidential legal avenues for people living with HIV could to use to prevent such discrimination. As one man living with HIV in Georgia said:

"I know beforehand my status will certainly hinder the chance to get job or to be promoted… I do not search for a job as I think they will have a negative attitude towards me." [15]

Not even children are protected from HIV stigma. About 75% of parents of schoolchildren stated they would remove their child from school if they found out there was a child living with HIV attending the school [16], and one schoolteacher remarked:

 “Yes they [people living with HIV] are really dangerous. I think that such children [living with HIV] should not attend neither schools nor kindergarten as the other children will be safe”. [17]

Consequently, many children are forced to hide their status, until they are out-ed vis-à-vis a stamp on their national IDs that all people living with HIV are forced to carry [18].

This leads to much internalized shame and stigma, and explains why HIV is growing so rapidly in-country.

Until Next Time…

It is clear that there is a long way to go before the stigma facing people living with HIV in Eastern Europe and Central Asia is gone. The quality of life for those living with HIV is highly unstable, due to stigma and poor quality of medical care. This is a setback to the prevention of HIV, and to the quality of life for such individuals.

• What do you think about this issue?
• Why do you think HIV/AIDS in Eastern Europe/Central Asia hasn't been discussed much in the media?
• What do you think can be done to bring more attention to this?

Be sure to look out for our next post, where we will be discussing inter-country programs, and the various successes and failures of individual countries in implementing HIV prevention, treatment, and anti-stigma programs.

"Shuga" is Saving Lives in Nigeria - Mario Christodolou

Read the original post in its entirety here, at The Impatient Optimist: http://www.impatientoptimists.org/Posts/2014/01/Media-Can-Change-Lives-and-it-Can-Save-Lives

MARIO CHRISTODOULOU

January 06, 2014

Sophie has just had unprotected sex with her “Sugar Daddy” (a person who exchanges large amounts of money or gifts for sexual favours). While he goes to freshen up in the bathroom, she innocently snoops around the bedside drawer to reveal a box of pills—little does she know that they are antiretrovirals. She has unknowingly put herself at risk of HIV infection.

The scenario described above is from the new series of the MTV show Shuga, which has now landed in Nigeria. Condensed into this 60-second scene are issues related to transactional sex, negotiation of safer sex, HIV treatment, and HIV disclosure. But this depiction is just the tip of a gargantuan, mass-media behavior-change iceberg.

A scene from Shuga showing Sophie and Solomon in bed. Photo © MTV Staying Alive Foundation

Produced by the MTV Staying Alive Foundation in partnership with the Bill & Melinda Gates Foundation, US President’s Emergency Plan for AIDS Relief (PEPFAR), and the Nigerian National Agency for the Control of AIDS (NACA), the award-winning Shuga TV show has already had two hit seasons in Kenya. But Georgia Arnold, the Executive Director of the MTV Staying Alive Foundation and Executive Producer of Shuga, has a vision for the Shuga campaign in Nigeria that far exceeds anything attempted previously in Kenya.

“Shuga is a ground-breaking TV show that portrays the lives and loves of a group of young people. Seamlessly interwoven into the storylines are vital messages related to HIV and a wide range of other sexual health messages,” explains Arnold. “Alongside the TV series is a substantial mass-media campaign, which reaches our audience at all the points where they interact, improving their access to vital sexual and reproductive health messaging and directing them to the health services they need.”

As well as the TV show, the points of interaction that Arnold alludes to include a radio series, a mobile service (SMS), a comic book (focused on the domestic violence story line in the TV drama, aimed specifically at girls with low literacy levels), digital and social media, and a Skype service through which users can “call a character” from the show and share their thoughts.

Nii and Malaika in Shuga. Photo © MTV Staying Alive Foundation.

“The particular nature of stories and dramas not only deliver informational content but create emotional connections to characters and role models, which promote a better context for learning and behavior change than do factual presentations,” observes Victor Orozco, an economist at the World Bank and coordinator of their Africa HIV/AIDS Impact Evaluation Program. “TV could play an important role in introducing ideas to large segments of a society, especially segments where literacy is low and social norms discourage discussion of stigmatized issues such as HIV/AIDS and teen pregnancy.”

 Shuga series 3 aired for the first time on World AIDS Day, 2013, on more than 70 channels, with a potential audience of a half billion people.By keeping messages from the TV show at the forefront of people’s minds, the introduction of multimedia elements may have the potential to reinforce and promote positive behavior change. For example, sending weekly text messages can significantly increase adherence to antiretroviral treatment for people living with HIV. The Shuga campaign in Nigeria will aim to reinforce the messages of the Shuga TV show with a 360-degree campaign, including several social media and mobile components, such as text messaging and interactive voice recordings. Orozco is working with MTV to evaluate the behavior-change effects of the show and the additional impact of mobile messages through a randomized study.  

A character on the show is tested for HIV. Photo © MTV Staying Alive Foundation.

Shuga has made the journey from Kenya to Nigeria for several reasons. While some might argue that on the basis of prevalence, the need for a campaign like Shuga is greater in Kenya than in Nigeria—HIV prevalence in Kenya (6 percent) is double that of Nigeria (3 percent). However, Nigeria has the second highest number of people living with the disease, and while maternal mortality has significantly fallen since 1990 in the country, one in 13 women still die during childbirth. Additionally, of Nigeria’s burgeoning population of over 150 million, nearly a third are young people aged 10 to 24 years—a population that falls neatly into the MTV demographic and who will relate more closely with stories portrayed in Shuga.

These public health concerns are compounded by a severe lack of knowledge about HIV among young men and young women. “Comprehensive knowledge about HIV is defined as knowing that condom use and having just one HIV negative and faithful partner can reduce the chances of contracting HIV; knowing that a healthy-looking person can have HIV; rejecting the two most common misconceptions about HIV transmission—that HIV can be transmitted by mosquito bites and that HIV can be transmitted by supernatural means," explains Dr Emmanuel Alhassan, Director, Resource Mobilization at NACA. “However, only 22 percent of young women and 33 percent of young men [in Nigeria] have comprehensive knowledge about HIV.”

Shuga has the potential to displace the silence that has engulfed serious issues like HIV in Nigeria and beyond, and to fill the knowledge vacuum that such silence has created. Shuga series 3 aired for the first time on World AIDS Day, 2013, on more than 70 channels, with a potential audience of half billion people. With this kind of reach, the ability for this so-called entertainment education to inform, change attitudes, and even change behavior is undeniable.

However, Orozco notes that policy makers and funders might be seriously under-investing in such mass-media approaches due to lack of rigorous evidence. But with the support of the Gates Foundation and MTV Staying Alive, he and other researchers are remedying this by evaluating Shuga and creating a knowledge base of what methods works and what is worth scaling up in Nigeria and elsewhere.

“Our vision for Shuga is to see a transformation in attitudes about the way the world talks about sex, not as a dirty topic, or something that should be hidden, but something that is openly discussed: parent to child, peer to peer,” envisions Arnold. “Only by doing this will we see a real change in people’s attitudes about HIV and their knowledge about it. Only through open and honest dialogue can we can hope to save lives.”

Find links to the episodes that have aired so far here. 

Read the original post in its entirety here, at The Impatient Optimist: http://www.impatientoptimists.org/Posts/2014/01/Media-Can-Change-Lives-and-it-Can-Save-Lives

International Day of the Girl

International Day of the Girl encourages us to draw our attention to the inequalities facing young girls across the world. We are called to take a critical look at whether or not girls are given the same opportunities as boys in terms of access to education, financial stability, and sexual empowerment. Here at the Stigma Action Network, we are most concerned with how girls are affected by the HIV epidemic. After examining the data related to this topic, we ultimately found that:

• In sub-Saharan Africa, young women aged 15 to 24 are up to 8 times more likely than young men to be living with HIV.[1]
• Worldwide, young women account for 66% of young people living with HIV.[2]
•  Women living with HIV are more likely to experience violence as result of their status, than men living with HIV.[3]
• Prevalence of first forced sex among adolescent girls is as high as 48% in some countries, which further maintains the HIV epidemic.[4]

While these facts are indeed surprising, the factors that perpetuate them are even more alarming. Three of these most significant factors are outlined below.

• Girls’ Lack of Empowerment: According to global statistics, girls are significantly poorer, less educated, and as a result less financially and socially empowered than their male counterparts. This power imbalance reduces young women’s choices as they negotiate their sexual health and relationships, often giving them little choice in determining if and when to have sex, and in cases of consensual sex, whether that sex is safe. Furthermore, poverty prevents underprivileged girls from receiving adequate health care and education, and as such resources are essential in fighting the HIV epidemic, breaches in these areas may lead to HIV infection.

• Biology: The risk of becoming infected during unprotected sex is two to four times greater for women than for men, and for young girls, the risk can be even higher.[5] This biological disparity gives further evidence as to the importance of educating girls about their sexual health and rights, specifically as they relate to HIV.

• Culture: And lastly, cultural mores may encourage men to have many sexual partners.[6] This is particularly problematic surrounding the issue of child marriage, as such customs can facilitate the spread of HIV to girls in high-risk areas. And given that one-third of the world’s girls are married before they reach the age of 18, such practices can have quite widespread and devastating effects.[7]

As you can see, there are a multitude of socio-economic and biological factors that put girls at a higher risk of HIV. But what is the solution to this problem? And how can we curb these inequalities and give girls the power to take control of their sexual health?

Carol Bellamy, Executive Director of UNICEF offers up her thoughts:

“Education is crucial to success against the pandemic. 

In fact, UNICEF remains convinced that until an effective remedy is found,

 education is one of the most effective tools for curbing HIV/AIDS”

Luckily, the following organizations are contributing to the fight against HIV by educating girls about the importance of and how to protect themselves by engaging in safe sex! Here are a few #StigmaWarriors who are doing great work with girls on HIV education:

Girls Learn International, Inc

Girls Learn International, Inc. takes a unique approach to girls’ education by partnering American schools with schools in foreign countries where girls do not enjoy the same educational opportunities as boys. This organization functions as an after school program that offers service oriented learning to young girls. Participants in the US chapters learn of the challenges facing girls in their partner schools including child marriage, trafficking, poverty, sexual health, and educational disparities. Money that is raised domestically goes towards purchasing textbooks, teachers' salaries, meals, and transportation in partner schools. Girls Learn International, Inc. has 47 partnerships in the following countries where HIV rates are notably high: Afghanistan, Bangladesh, Cambodia, Ghana, India, Kenya, Nepal, Pakistan, Tanzania, Uganda, and Vietnam. Learn more about this organization and how you can help support the education of girls across the world. 

Maasai Girls Education Fund

On the Top 10 list of countries most affected by HIV/AIDS, Kenya comes in at #4. Girls living in poverty have less control over their sexual health, both because of lack of education and because of sexual abuse. "A large, national survey of secondary school girls in Kenya found that 40 per cent of those reporting sexual activity indicated that their first sexual experience was forced or that they were 'cheated into having sex.'"[8] The Maasai are nomadic pastoralists originating from the lower Nile valley with a strong traditional culture that often prevents females from receiving an adequate education. Only 48% of Maasai girls in Kenya enroll in school, and only 5% of those who enroll reach the secondary school level.[9] Such educational disparity can further facilitate the spread of HIV, as girls who remain uneducated are not only unable to make sexually sound decisions, but are also unable decisions that may secure a promising future. The Maasai Girls Education Fund works to combat this, however, by providing a safe environment where girls can receive a quality education. Donations to the Maasai Girls Education Fund go towards buying uniforms, books, and helping to pay tuition. What makes this organization stand out are their community workshops that attempt to reverse cultural beliefs and norms that discourage young girls from enrolling in and committing to school. And as enrollment in school is the best HIV prevention method available to girls (as noted by the World Bank), this organization’s work can surely make a difference.

Commit 2 Change

Young women are the victims of heavy abuse in India as well, in part because they are viewed as the less desirable of the two genders: over 25,000 of adolescent girls are malnourished and suffer from illness and medical neglect [10]. Commit 2 Change is dedicated to supporting female orphans in India by providing them with secondary education, with a particular emphasis on sexual health and HIV/AIDS prevention. Millions of children across the world have become orphaned after losing their parents to HIV/AIDS. Orphaned children are more likely to become impoverished and less likely to be enrolled in school as a result. A study done by UNICEF reveals that "the irony is that orphans are frequently deprived of quality education, which is the very thing they need to help protect themselves from HIV" [11]. India ranks #3 on the Top 10 countries most affected by HIV/AIDS.

The SAN congratulates the above-mentioned organizations (and others around the world!) who are doing great work to educate girls about safe sex and to prevent the spread of HIV among this particularly vulnerable population. However, The Girls Insights report conducted by the International Center for Research on Women found that "girls said they still lack even the most basic knowledge, autonomy and other assets critical for their health and empowerment." This demonstrates that even more must be done if we are to stop the spread of HIV and related stigma!

We hope that more organizations accept the challenge of incorporating sexual education, including education around HIV, into curriculum for young girls and adolescents. Programs must also be developed in a way that empowers girls to use this education to make sound decisions about their own sexual health. Together, with this sort of integrated approach, we can help girls gain control over their lives and futures, and help make a future without HIV a reality.

(Visit UNICEF for more details.)