The Hidden Epidemic: HIV in Eastern Europe, Part 2

Hello there, #StigmaWarriors!

We hope you enjoyed the first installation of “The Hidden Epidemic”, which discussed the prevalence and stigma surrounding HIV/AIDS in Eastern Europe and Central Asia. In Part 2 of the blog series we will discuss the effectiveness of HIV treatment and prevention policies in three former Soviet republics: Estonia, Ukraine, and Russia. These nations have the highest HIV prevalence of all the former Soviet republics combined. In fact, data suggests that Russia and Ukraine are responsible for up to 90% of new HIV infections in the region! 

Below, we take a look at HIV programs in all three countries from most comprehensive to least comprehensive, and explain how stigma affects the ways each country treats those affected with HIV in certain populations.

Most Comprehensive: Estonia

Prevalence: Estonia has the highest HIV prevalence in the European Union, at 1.3% [1]. As a result, preventing and treating HIV is a top priority for Estonia as well as the European Union. Given that half of IDUs in Estonia are either confirmed or suspected to be infected with HIV [2], public health officials are particularly focused on ensuring that the IDU population has easy access to needle exchange and drug treatment services.

Progress: Since 1992, when the first National AIDS Prevention Program was approved, Estonia has managed to reduce the number of new HIV cases per year [3] with such activities as:

• Increasing HIV/AIDS awareness among young Estonians [4];
• Providing needle exchange services to almost half of IDUs [5];
• Establishing an HIV testing and counseling system funded by the state [6];
• Providing those living with HIV with free antiretroviral (ARV) medication [7]; and
• Creating a high-level, multisectoral HIV and AIDS committee as an advisory body for its central coordination of the implementation, including representatives of all the relevant ministries, municipalities and counties; Parliament; the office of the Prime Minister; four thematic working groups; PLHIVs; and the youth organizations’ union [8]. 

Overview of the issues in context: where does stigma fit in?

• Funding: While HIV is a priority of the Estonian government and the European Union, there is still a lack of funds for HIV organization so any funding HIV organizations receive is inconsistent at best  [9].
• As a result, drug users cannot consistently use needle exchange programs because they are sporadically funded and supplies are limited. Additionally, most of the focus on needle-exchanges has been in the capital, Tallinn, leaving needle-exchange programs in other parts of Estonia to scramble for funding and services [10]. As a result many IDUs have stopped using these programs.
• Structure of National Health Programs: Local municipalities have no clear responsibility to cover health care expenditures and therefore financing varies widely between regions [11]. Many health care commissions in Estonia have limited their roles, which means monitoring of health services for PLHIVs is inconsistent [12]. Additionally, while testing services are offered, counseling services are not, meaning many people who are diagnosed with HIV are left to deal with the emotional ramifications on their own [13].

• The national HIV response is limited in geographical location, with many programs only available in the capitol of Tallinn and the north-east region of Estonia. That means those in other regions do not have the same access to prevention, education, testing, counseling, and treatment as those in Tallinn and north-east Estonia.
• Cultural Dynamics: The majority of Estonians living with HIV are not of Estonian ancestry, but Russian migrants looking for work or Estonians of Russian descent. Many of these people are either unable or unwilling to gain Estonian citizenship due to restrictive citizenship laws [14], and because of cultural stigma against "non-Estonians" the government is reluctant to fund programs that will be able to reach these populations. Thus, the needs of a large number of those at risk of acquiring or those already living with HIV remain unmet
• Intersecting Stigmas: Like in many other countries, Estonians are reluctant to fund programs for "deviants" such as sex workers and IDUs, despite the fact that 50% of all IDUs in Estonia are either confirmed or suspected to be living with HIV.

Where do we go from here?

• The Estonian government, with help from the EU, needs to focus more on working with the most affected populations (including those who are typically or nationally stigmatized - IDUs, members of the LGBT community, sex workers, and Russian migrants). One solution could be involving more community-based organizations in testing and treatment services, and implementing counseling services along with treatment services so that people newly diagnosed with HIV would be more willing to access health services than they currently are.
• To get to zero new infections, the government needs to recognize that while HIV rates are falling in Estonia, they still need to provide greater and more consistent funding to programs that are most in need of it, particularly creating more services around the country and not just in Tallinn.

Comprehensive National HIV Programming: Ukraine

Prevalence: Currently in Ukraine HIV prevalence is estimated at 0.8-1.3%, and is one of the fastest-growing HIV epidemics in the world [15].

Progress: While the Ukrainian government was slow to begin recognizing the vast impact of HIV on Ukrainian residents, things have been improving in terms of funding and treatment options. In 1999, the All-Ukrainian Network of People Living with HIV/AIDS (Всеукраинская сеть людей, живущих с ВИЧ) was founded, and in 2004 became the key distributor of the funds Ukraine was given by the Global Fund for HIV medication and treatments (previously, this money had been given directly to the Ministry of Health/MOH, but was later shifted to this organization because of government corruption) [16]. 

Furthermore, due to improvements in Ukraine’s economy and a renewed interest in improving Ukraine’s overall health systems during the 2000s, vast improvements were also made to the HIV health care system in Ukraine, including:

• In 2005, an advertising campaign was launched highlighting that eight Ukrainians die from HIV or AIDS every day [17];
• In 2007, methadone (a synthetic drug used to treat heroin addiction) was legalized and the criteria for who could receive treatment was relaxed [18];
• In 2008, a campaign aimed at students resulted in 15,000 free anonymous HIV tests and 100,000 students receiving information about HIV and about where they could be tested [19]; and
• By April 2010, there were HIV testing and treatment centers in all 27 Ukrainian oblasts (provinces), and thousands of IDUs were benefitting from methadone treatment [20].

Overview of the issues in context: where does stigma fit in?

• Funding: The Ukrainian government is bankrupt, and that is reflected in the subsequent dearth of funding for HIV prevention and treatment, especially harm reduction. Only 32% of IDUs, for example, are reached through HIV prevention programs, and less funding is allocated towards programs for sex workers [21]. 
• Corruption is an issue in the Ukrainian government as a whole, but much of the corruption directly affects HIV patients. In 2012, the MOH was accused of embezzling money earmarked for HIV/AIDS patients, and an internal investigation was launched to see if MOH officials were utilizing funds set aside for ARVs for other uses [22]. While there was no real judicial conclusion to the investigation, the officials accused of this were fired.
• Intersecting Stigmas: As is the case in many other countries around the world, Ukrainians – especially key populations within Ukraine living with HIV - experience high levels of discrimination because of the cultural and social stigma surrounding HIV. Those living with HIV in Ukraine, for example, are forced to have a special stamp on their national ID cards indicating that they are HIV positive [23], which forces them to (perhaps unwillingly) disclose their status and often causes them to experience additional stigma and discrimination in their daily lives.

Stigma against key populations further plays out in Ukraine in the following ways:

• Drug users wishing to receive methadone treatment (which is key in preventing HIV because it stops needle sharing) are placed on an official register that can be used to exclude them from certain professions, and confidential medical records for IDUs are often shared between medical professionals and law enforcement institutions in Ukraine [24]. Additionally, the police habitually raid drug treatment clinics [25]. As a result, IDUs avoid needle exchange programs and other drug treatment services.
• Unfortunately, stigma is also applied towards orphaned children living with HIV. Many are unable to find work after leaving the orphanage, which causes many orphans to turn to drug trafficking and sex work in order to survive [26].

Where do we go from here?

• The Ukrainian government needs to address HIV-related stigma and discrimination in the government, law enforcement, and in the general population so that those who need access to basic testing and treatment can receive it without fear of harm.
• More coordination between government agencies, law enforcement, and the All-Ukrainian Network of People Living with HIV/AIDS could help decrease stigma in Ukraine. 
• Airing media presentations on the harmful effects of HIV stigma and discrimination on those affected by HIV, with a particular focus on key populations, could also be beneficial.
• Most importantly, not just for PLHIVs but for all of Ukraine, the conflict between pro-Russian belligerents and the government in Kyiv must reach some sort of conclusion. Currently, the conflict is interrupting access to treatment and testing services in Eastern Ukraine, which has the highest prevalence of HIV in Ukraine.

Least Comprehensive HIV Programming: Russia

Prevalence: Russia currently has a 1.1% prevalence of HIV, and that number is reportedly increasing, with an average infection rate of 35.7 cases for every 100,000 people reported in 2013, an increase of 7% from the past year [27]. There would be a progress section in this area, but after looking at all the issues currently in Russia it seems as there has been no progress made in the fight against HIV. 

Overview of the issues in context: where does stigma fit in?

• Funding: There is a systemic reluctance to fund programs targeted towards groups at a high-risk of contracting HIV in Russia, and multiple NGOs have pulled financial support for HIV testing and treatment in-country.  In 2012, the Global Fund officially cut its aid to Russia after years of conflict with officials from the Russian MOH over HIV services and treatment policies [28]. Additionally, many NGOs are being forced to register as 'foreign agents,' which restricts the types of activities NGOs are able to carry out [29].
• Restrictive Laws: Currently, Russian law does not support and in some cases even bans harm reduction policies, claiming these policies threaten drug control. For this reason, for example, the Russian government banned methadone in 2005 [30], despite the fact that in some cities more than half of all IDUs are either confirmed or suspected to be living with HIV [31]. 
• Even worse, the Duma (Russia’s lower house of parliament) introduced a bill in April 2014 that would forcibly require any person living with HIV, even if they were foreign nationals, to be fingerprinted and be placed in a national database of those living with "dangerous diseases," [32].
• There are reports that IDUs have been harassed and arrested by police outside needle exchange programs and pharmacies where they have bought syringes, a practice that further deters other drug users from accessing them. These negative experiences with law enforcement when trying to access services drives IDUs away from initiatives that could avert the risk of becoming infected with HIV [33]. 
• Intersecting Stigmas: As with Estonia and Ukraine, drug users and sex workers are heavily stigmatized in Russia, and because IDUs most often seek out HIV testing and treatment programs, those living with HIV who are not IDUs are also stigmatized [34]. 
• Drug and HIV treatment centers also stigmatize patients as the centers are kept segregated from the rest of the medical communities, to prevent the perceived spread of HIV via doctor-to-patient contact [35].
• Furthermore, since drug use and sex work are taboo topics in Russia, educational programs in schools only provide a cursory overview of sex and drugs, which hinders what could be effective prevention programs for children [36].

Where do we go from here?

• Russia has a long way to go before any comprehensive HIV strategy can, or will, be implemented. This is because rampant homophobia and stigma against drug users and other populations vulnerable to HIV have and continue to impede any sort of progress. Thus, addressing homophobia and stigma against key populations should be the first issue tackled in Russia’s fight against HIV.
• Russia’s increasing hostility towards the West has impeded NGOs from working with people living with HIV in-country, and multiple NGOs have pulled funds for HIV-related services from Russia. While changing the nature of the political climate in Russia may not occur overnight, NGOs and native Russians alike could work towards making small changes in local HIV policies that could make a big difference for those living with HIV in Russia. 

Until the Next Time…

It is important to remember that all countries in Eastern Europe and Central Asia have unique HIV treatment and prevention programs, and that the current state of affairs in some countries is not indicative of programs or laws in other countries. However, HIV stigma and discrimination across the region is still prevalent, especially towards key populations like IDUs and sex workers, and these attitudes and actions hinder effective treatment for those who need it the most. Awareness about these issues makes us at the SAN wonder how the United Nations and other NGOs can help or put pressure on countries to reduce HIV stigma and improve their treatment programs. 

This information also raises these questions: 

• How can other countries help and be good examples for Eastern European/Central Asian 
• Should there be a joint focus on drug and HIV prevention?
• What do you think should be done to help people living with HIV in a tough political climate?

What do you think? As always, we’d love to hear your thoughts!

New Ugandan HIV and AIDS law jeopardizes health of women, men, and children

By Anne Stangl

*This blog originally appeared on ICRW and Thomas Reuters Foundation 

Last week, Ugandan President Yoweri Museveni signed into law a bill that will likely harm the health of Uganda’s men, women, and children for years to come and could set the country back decades in progress in reducing the transmission of HIV.

The new law, the HIV and AIDS Prevention and Control Act of 2014, criminalizes the transmission of HIV, makes it legal for doctors to disclose their patients’ HIV status to partners and families without consent, and, last but not least, calls for mandatory testing for pregnant women and their partners. To be blunt, it is nothing short of a major step backward for a country that, for 30 years, has been a leader in tackling HIV head on.

A doctor draws blood from a man to check for HIV/AIDS at a mobile testing unit in Ndeeba,
a suburb in Uganda's capital Kampala, May 2014. REUTERS/Edward Echwalu

While Ugandan legislators insist that the goal of the new law is to protect the public’s health, the new law, in effect, will do little more than stigmatize and discriminate against men and women living with HIV and will likely result in fewer women and girls – and men and boys – seeking and adhering to treatment that could literally save their lives. This will lead to a huge step back in any progress made in tackling the epidemic, which affects over 1.5 million Ugandans.

This law is simply unnecessary. The law mandates that pregnant women and their partners get tested, yet research shows that women are already getting tested and previous research has found that mandatory testing has actually been shown to lead some women to avoiding getting antenatal care all together.  This new law will serve as yet another repressive measure targeted at women, but ultimately affecting the health of men and entire families, including their children.

Researching HIV stigma in Uganda for my dissertation in 2005, I got to see up close the barriers and challenges that face people living with HIV on a daily basis. Yet, I also witnessed an amazing transformation in communities where, for the first time, people living with HIV were able to access life-saving antiretroviral treatment. As men and women who were on death’s door became healthy, they were able to begin working and could contribute to their families and communities again. No longer were they viewed as a burden. No longer were they feared. No longer were their opinions disregarded because they ‘would soon die.’ Neighbors, who had previously shunned them, began stopping by to ask: how had they become healthy again? Could their relative or friend also get access to these medicines? Communities wounded by years of losing so many to AIDS, struggling with stigma and discrimination, began to mend.

Following the roll-out of antiretroviral therapy in Uganda, increases in HIV testing and care-seeking were tremendous. Home-based testing campaigns achieved over 95% acceptance in most communities. Given the gains achieved from a supportive government response to the epidemic, which was lauded globally for its high involvement of people living with HIV, I find myself wondering why the Ugandan government would go backwards. Why risk these tremendous gains, and the very lives of their citizens, by passing such a discriminatory law? 

While researchers are working every day to discover new strategies and technologies to bring an end to HIV and AIDS, we already know what will not work: stigmatizing and discriminating against those living with HIV. We know that when individuals, communities, and, as is the case here, governments stigmatize and discriminate against those who are living with HIV, others decide not to seek out treatment or stop adhering to their medication, which contributes to the further spread of HIV. When laws mandate testing and criminalize HIV transmission, expectant mothers are likely to avoid seeking health care, putting their health – and their babies’ health – at risk.

To be sure, the signing of this bill marks a sad occasion. But this new law must not be the end of the story, especially when Ugandans lives hang in the balance.

Advocates, policy makers and researchers alike must work together to urge the Government of Uganda to weigh the risk of backsliding on hard-won gains against HIV, which could result from criminalization and mandatory testing under this law. We must urge the Government of Uganda to use all appropriate means to reconsider the law, including during the development of regulations for its implementation by the Minister of Health. And lastly, we must encourage the Government of Uganda to once again be a leader in the global response to HIV by championing evidence-based, inclusive and supportive HIV policies instead of policies driven by fear and stigma.

We’ve come too far in the fight against HIV to let discriminatory laws, such as this one recently signed by President Museveni, derail decades of progress and jeopardize the health of millions of women, men, and children.

Redoubling efforts to fight stigma and discrimination key to ending AIDS

By Anne Stangl
**This blog post originally appeared on Devex.com

It’s been 30 years since HIV was identified as the cause of AIDS, and since then we’ve made significant progress in fighting the epidemic.

The massive rollout of antiretroviral drugs worldwide has dramatically reduced AIDS-related deaths and prolonged the lives of millions of people. Innovative biomedical interventions — such as microbicides, male circumcision, universal testing and ARV prophylaxis for preventing transmission from mother to child — have greatly expanded our collective prevention toolbox. Great strides have also been made in understanding how to deliver services and motivate uptake and adherence, from home-based HIV testing to education entertainment programs like Soul City. And perhaps most importantly, the tremendous advocacy efforts of people living with HIV in countries like South Africa and the United States have ensured widespread access to affordable, lifesaving treatment.

Although we have a lot to celebrate, we must remember that we’re not even close to ending this epidemic.

This week, the 20th International AIDS Conference is taking place in Melbourne, Australia, under the theme “Nobody left behind,” which underlines the need to use a human rights-based approach to ensure that everyone — especially those who are most at risk and affected by HIV and AIDS — receives treatment. We cannot accomplish this without overcoming one of the most devastating barriers to prevention and treatment: stigma and discrimination.

The problem

Stigma and discrimination prevent millions of people, especially vulnerable populations like women and youth, from accessing the prevention and treatment they need.  

According to the 2014 Gap Report recently published by UNAIDS, more than half of those living with HIV globally do not know they have the virus because they have yet to get tested. Equally troubling, UNAIDS also notes that while more than 28 million individuals around the world need treatment, only 34 percent of these individuals had access to treatment. How does this happen? In many countries, the culprit is pervasive social stigma and discrimination in clinics and at both the local and national levels.

For example, a whopping 60 percent of countries around the world have laws, regulations or policies that prevent populations most at risk of HIV infection — like pregnant women, men who have sex with men, and people who inject drugs — from accessing these services. HIV transmission or the failure to disclose one’s HIV status to a sexual partner is criminalized in more than 60 countries. Additionally, 40 countries impose some form of restriction on entry, stay and residence of people living with HIV; 18 deport individuals whose HIV positive status is made public; and five countries have a complete ban on the entry and stay of individuals living with HIV.

Efforts to stigmatize and discriminate against populations living with HIV do nothing to reduce the rates of transmission. Instead, they keep people from getting tested for HIV and prevent people living with HIV from disclosing their status to partners, accessing care and adhering to treatment.

Small wins make a huge difference

Despite these worrying developments, organizations working to reduce stigma and discrimination have made significant progress over the past couple of years. For example, the 2014 Global AIDS Response Progress Report, which details the landscape of the epidemic around the world, now includes a section on measuring how many people hold discriminatory attitudes toward those living with HIV. Additionally, the U.S. State Department just released instructions on how embassies can work to track levels of HIV-related stigma and discrimination in countries as part of the department’s annual Human Rights report.

While these may seem like small wins, they’ll make a huge difference in measuring where stigma and discriminatory attitudes exist so that countries can better target their efforts to reduce these harmful social norms.

For far too long, gaps in data have prevented countries from truly understanding how stigma and discrimination prevent vulnerable populations from using needed health care services, and these efforts will help fill those gaps. The International Center for Research on Women is helping in this effort, undertaking important research on how HIV stigma and discrimination among health workers and communities in South Africa and Zambia influence the success of biomedical approaches to HIV prevention. This research will help inform how best to scale up new biomedical prevention strategies to ensure that the general population is open to accepting and adhering to them.

As the world’s attention turns to HIV and AIDS this week, we must redouble our efforts to ensure that sufficient attention is focused on how to reduce and overcome the stigma and discrimination that are impeding efforts to end AIDS. When we work together to end stigma and discrimination, we will be able to ensure that all people — regardless of their sexual orientation, race, age, gender or class — have access to vital HIV prevention, care and treatment services.

For more information on sessions and events at AIDS 2014 focused on stigma and discrimination, check out the Stigma Action Network's "stigma road map." 

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A Timeline for National HIV Testing Day

Happy National HIV Testing Day #stigmawarriors! Today we decided to present a timeline to show how far testing of HIV and AIDS has come in the United States, especially since there is a renewed effort by the LGBT community, HIV community, and the medical community to remove the stigma surrounding getting tested! 

The history of HIV testing is almost as old as the history of HIV in the United States, and since the 1980s the types of tests and how they detect HIV have changed so much. Let's take a look at how far HIV testing has come!

1980-1984:

• The City and County of San Francisco, working with the Shanti Project and the San Francisco AIDS Foundation, set up the San Francisco Model of Care in 1982, emphasizing home and community testing, care and treatment services [1]. 
• The following year, in May 1983, Congress passed the first bill that included funding specifically targeted at AIDS research, which lead to developments in testing and treatment [2].

1985-1989:

Between 1985, there was a lot of developments when it came to HIV testing! 

• The FDA licensed ELISA, the first commercial blood test which tested for HIV antibodies in the blood. Blood banks immediately began testing the US blood supply [3]. 
• Unfortunately, the Pentagon announced in the summer of 1985 that the military would immediately begin testing all new recruits for HIV infections, with the intention to reject anyone who tested positive. This policy sadly continues today [4]. 
• On December 6, 1985, the US Public Health Services issued the first recommendations for the prevention of mother-to-child transmission [5].
• In April 1987, the FDA approved the Western Blot Blood Test Kit, a more specific test for HIV antibodies [6]. 
• On August 14, 1987, the CDC issued the Perspectives in Disease Prevention and Health Promotion Public SafetyGuidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS [7].
• On August 18, 1987, the FDA sanctioned the first human tests of a candidate vaccine to prevent HIV [8]. 
• At the end of 1987, the FDA published regulations which required all blood and plasma collected in the US to be screened for HIV [9].
• IN 1988, the FDA doubled its efforts to test the US blood and plasma supply, and by the end of the year 100% of the US blood supply had been tested for HIV antibodies [10]. 
• More importantly, the first World AIDS Day took place on December 1, 1988 [11].
• In 1989, the FDA licensed the first diagnostic kit to test for HIV antigens. Prior to this all HIV tests had only tested for antibodies [12].

1990-1994:

• The early 1990s brought more new HIV tests and health regulations to the public. The first HIV test to test for both HIV-1 and HIV-2 antibodies was licensed in 1990 [13], and that same year the CDC adopted the HIV-prevention counseling model, a “client-centered” approach that focuses on the patient rather than the disease [14]. 
• On May 27, 1992, the FDA licensed a 10-minute diagnostic test kit which can be used by health professionals to detect the presence of HIV-1 [15]. 
• The following year, the FDA published an interim rule on December 14th establishing a requirement for certain infectious disease testing, donor screening, and record keeping to help prevent the transmission of HIV and Hepatitis B and C through human tissue used in transplantation [16]. 
• Later that month, on December 23rd, the FDA approved the first non-blood based collection kit utilizing oral fluid for use in the detection of the antibody to HIV-1 [17].

1995-1999:

• The National Association of People Living with AIDS launched the first National HIV Testing Day on June 27, 1995 [18]. 
• That same year, the FDA recommended that blood establishments should implement donor screening for HIV-1 antigen using licensed test kits [19].
• 1996 brought some of the biggest and quickest advancement in HIV testing to date. Within four months the FDA approved the first at-home testing and collection kit, a viral load test, and the first HIV urine test [20]. 
• In 1998, the FDA approved Cambridge Biotech HIV-1, a HIV-1 (Western Blot) test with a new indication for urine specimen testing [21].

2000-2004:

• The first National HIV Vaccine Awareness Day was observed in 2001, and the CDC announced an HIV Prevention Strategic Plan to cut annual HIV infections in the US by half within five years that same year [22]. 
• The following year, 2002, marked an important development in HIV testing. On November 7, the FDA approved the first rapid HIV diagnostic test kit for use in the United States that provides results with 99.6% accuracy in as little as 20 minutes. Unlike other antibody tests for HIV, this blood test can be stored at room temperature, requires no specialized equipment, and may be used outside of traditional laboratory or clinical settings, allowing more widespread use of HIV testing [23].
• HIV testing became even more widespread on February 3, 2003, when the Department of Health and Human Services expanded availability of the rapid HIV test from the current 38,000 laboratories to more than 100,000 sites, including physician offices and HIV counseling centers [24]. 
• In 2004, the first rapid oral fluid test and the first rapid-body test for plasma which detects HIV-1 and HIV-2 were approved by the CDC [25].

2005-2009:

• The CDC officially recommended routine HIV screenings in US health care settings for people aged 13-64, and yearly screening for populations considered to be "at-risk" in 2006. 
• The WHO and UNAIDS updated their global guidelines in 2007 to include that same recommendation [26]. 
• On December 30, 2008, the FDA approved the first nucleic acid test to detect the presence of two less common types of HIV, HIV-2 and HIV-1 Group O, in donated blood plasma and human tissue [27]. 
• The following year, in 2009, the FDA, CDC, and other federal agencies promoted National HIV Testing Day to increase awareness of the importance of HIV testing to help improve the health of those at risk for getting HIV and to prevent future infections [28]. 

2010-2014:

• In 2010, the CDC approved the first test which detects HIV antigens and antibodies [29]. 
• The first rapid oral fluid home test, Oraquick, was approved by the CDC in 2012 [30]. 
• And in 2013, the CDC approved the first rapid test that detects HIV antigens and antibodies, and distinguishes between acute and established HIV-1 infections [31]. 

What a trip! I learned so much about the history of HIV testing that I never knew before! I hope you did too! 

It shows just how far HIV testing really has come from the early days. With new testing technology people can even test inside the comfort of their own homes. Now the next step is removing the stigma surrounding HIV testing, which several public campaigns are striving to do. But the campaigns won't be successful without you, #stigmawarriors! Let's get out there today and every other day to reduce the stigma surrounding HIV testing, through our words and actions. That way, more people will feel encouraged and supported in taking charge of their health!

We hope National HIV Testing Day inspires you to get out there and be the best #stigmawarrior you can be!

Soccer: More Than Just a Game

By Anna Charles

At this time of year, soccer fans (or football fans, depending on where you are from)  around the world are turning their minds and their televisions to the 2014 FIFA World Cup. With millions across the globe tuning in to cheer for their favorite teams, many international health organizations are tapping into this soccer fanaticism, and employing soccer as an innovative medium to talk about HIV.  Soccer is one of, if not the most popular sport in the world, and groups such as UNAIDS and Grassroots Soccer are using the excitement around this sport to reach out to youth and to facilitate programs to educate them about HIV prevention and stigma reduction.

 At the Africa Cup of Nations in January 2013, UNAIDS presented their “Protect the Goal” Campaign, with goals of both preventing and raising awareness of HIV. HIV prevention information was posted on screens in the stadiums and prominent players backed the campaign by reading statements of support for this campaign before each game as they stood before their fans. With thousands of fans who look up to these teams and players, the campaign had a radically successful start [1]. A year and a half later, Protect the Goal has come to Brazil for the 2014 FIFA World Cup. Now backed by the President of Brazil, [2] Protect the Goal has been able to make an even greater impact, especially by offering free HIV tests to fans in Brazilian host cities. Renowned players like David Luiz are also joining the campaign and calling on their thousands of fans to join them in stopping the spread of HIV and stigma [3].

 Another organization, Grassroots Soccer, has taken a different approach to using soccer as a means of reducing HIV. They have built and refined a curriculum called “Skillz”, a new approach that uses soccer exercises to help kids learn about HIV risks and prevention.  For example, in one of their activities, called “Risk Field,” “participants dribble a soccer ball in between cones representing HIV-related risks—multiple partners, drug/alcohol abuse, sugar daddies, etc. If one player hits a cone, he and his teammates must complete 3 pushups, showing how the consequences of one person’s risk can not only affect him, but also his friends, family, and community" [4]. This is a revolutionary new way of educating kids, and allows the participants to feel more engaged in what they are learning.

Grassroots Soccer is using methods  that have proven results. One study in Zimbabwe found that, among many other encouraging statistics, students participating in the program who knew where to go for problems related to HIV increased dramatically, from 47% to 76% [5]. Like the Protect the Goal campaign, Grassroots Soccer is backed by a number of well-known players, such as AlexSong, Oguchi Onyewu, Christen Press, and more, [6] and is therefore able to reach a wide audience of fans that look up to and respect these players.

As evident by the campaigns and programs above, it is undeniable that sports have a great influence and can be used to unite and educate groups of people. Nelson Mandela said it best, “Sport has the power to change the world. It has the power to inspire. It has the power to unite people in a way that little else does. It speaks to youth in a language they understand. Sport can create hope where once there was only despair.” Soccer is more than just a game; it’s a powerful tool that can bring motivation, solutions, and hope to people around the world working to end HIV and the associated stigma and discrimination.


References:

1.http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2014/march/20140305prptg/

2.http://www.unaids.org/en/resources/presscentre/featurestories/2014/june/20140611ptgbrazilpresident/

3.http://www.unaids.org/en/resources/presscentre/featurestories/2014/june/20140610ptgbrazil/

4.http://www.grassrootsoccer.org/what-we-do/skillz/

5.http://www.grassrootsoccer.org/research-development/proven-results/

6.http://www.grassrootsoccer.org/who-we-are/pro-ambassadors/

HIV Care for Refugees

By Adriana Ganci 

Since 2001, June 20^th has been recognized as World Refugee Day.  A refugee is defined as someone who is forced to flee her country due to violence or fear of persecution due to reasons of “race, religion, nationality, political opinion or membership in a particular social group.”  [1]  Refugees face an array of difficulties in resettling. They are often hundreds or thousands of miles away from home, in a place where they know no one and in a culture of which they are not a part. Resettlement can be particularly difficult for those refugees and displaced persons living with HIV. They are subject to facing a variety of the stigma of being in a cultural or ethnic minority as well as  the stigma of living with HIV.

Luckily, there are agencies who make it part of their mission to guide HIV-positive populations to the proper resources and help ease their transition as much as possible. The UN Refugee Agency (UNHCR) has seven strategic objectives in their Strategic Plan for HIV and AIDS, these include:

1. Protection  
2. Coordination and Integration      
3. Prevention  
4. Care, Support and Treatment      
5. Durable Solutions 
6. Capacity Building  
7. Assessments, Surveillance, Monitoring and Evaluation and Operational Research

In setting these seven objectives, UNHCR supports and promotes HIV and AIDS programs which aim to reduce mortality and enhance the quality of life among refugees. The UNHCR works with many partners to ensure the best care for refugees, including governments, NGOs, and health care providers. [2]

Unfortunately, all HIV care for refugees is not created equally. The heath care the individual receives is obviously based on the country in which they have resettled. In the U.S., those with refugee status are given a caseworker that will set them up with Medicaid. In Canada they are enrolled in the Interim Federal Health Program, ensuring that they will receive the full gamut of HIV services. But if a refugee is resettled into Ethiopia their access to HIV care will be limited. Resettlement agencies will often try to take these caveats into consideration when placing a person or a family, but nothing is guaranteed. Organizations such as UNHCR and the International Organization for Migration work to advocate for refugees in order to find a home that can accommodate these needs. However, even if placed in a setting with a strong health care system, cultural differences may still pose additional challenges. For example, a traditional woman from Somalia might not be comfortable in an urban health clinic that is largely geared toward supporting homosexuals, indicating a strong need to guide refugees to culturally appropriate resources.  

Fortunately, policies regarding refugees and HIV are improving. In recent years, UNAIDS and the World Health Organization have come out against mandatory HIV testing of refugees, stating that it is a violation of human rights and leaves those living with HIV open to discrimination and persecution. [3] Hopefully, policies like this will continue to be made to improve the lives of refugees living with HIV. 


Furthermore, there have been more resources published for resettlement agencies, host countries, and for refugees themselves. The U.S. Committee for Refugees and Immigrants has included a guidebook for resettlement agencies serving refugees with HIV/AIDS.[4] The USCRI also has many toolkits for healthy living in many languages. They cover everything from mental health, to communicable disease, to cultural orientation, all of which are relevant to those living with HIV and can be found here.[5]  Canada’s Source for HIV and Hepatitis C Information also has lengthy information available for both refugees and immigrants living with HIV. [6] 

While it is fantastic that these resources exist, they are still limited. With over 15 million refugees in the world, many of whom come from high HIV prevalence areas, there needs to be more advocates for those living with HIV. Health care services can be complicated enough to navigate in one’s own country, let alone in a foreign setting, with the stigma of living with HIV and being  a national, ethnic, or religious minority posing an additional hurdle.  Many organizations suggest lawyers for those refugees living with HIV to ensure that they get the support they need. However, the burden cannot be on these populations who are already grappling with so many challenges and changes. We must urge governments, intergovermental organizations, NGOs, and other stakeholders to put their efforts into improving the lives of these refugees living with HIV so that they may lead the fulfilling life everyone deserves.

1.   http://www.unrefugees.org/site/c.lfIQKSOwFqG/b.4950731/k.A894/What_is_a_refugee.htm
2.  http://www.unhcr.org/488495642.pdf
3.  http://www.unfpa.org/emergencies/manual/5a1.htm
4.http://www.uscrirefugees.org/2010Website/5_Resources/5_1_For_Refugees_Immigrants/5_        1_1_Health/5_1_1_1_Healthy_Living_Toolkit/5_1_1_1_1_Communicable_Diseases/English_Guidebook_HIV.pdf
5. http://www.refugees.org/resources/for-service-providers/hiv-aids.html
6. http://www.catie.ca/en/practical-guides/managing-your-health/17