Sexual Health Promotion with Sub-Saharan African migrants in

BelgiumChristiana Nöstlinger, Lazare ManirankundaInstitute of Tropical Medicine, Department

of Public Health

IAS 2014 - African Diaspora Networking Zone, Tuesday 22/07

Outline

1) Sub-Saharan African migrants (SAM) and HIV in Belgium

2) Epidemiological background3) Stigma as a barrier to effective HIV work with

communities4) Participatory approach to HIV prevention and sexual

health promotion (prevention continuum)5) Conclusion

Discussion and debate

1. Sub-saharan African migrants in Belgium• Minority– 175.000 SAM (1.60% of Belgian population)– Men/women ratio: 1.03– 15 - 49 years: 70%

• Heterogeneous population– 48 nationalities (ethnicity, cultures, religion, education)– Most affected communities: DRCongo, Cameroun,

Rwanda, Guinee, Burundi– Causes of immigration & residence permit

• Weak socio-economical status• Hard-to-reach group (languages, length of residence, mobile,

little social capital …)Source: Gegevens FOD 2010 Economie, KMO, Middenstand & Energie

2. Epidemiological background

3. HIV stigma as a barrier to HIV-related work with communities

Since we started our work in 1996, HIV-related stigma has been the most salient barrier to HIV prevention and sexual health promotion:

“Undesirable or discrediting attribute that person or group possesses…” (Goffman, 1963)

Stigma refers to process of devaluating, labeling, and stereotyping that are manifested in the loss of status, unfair, and unjust treatment, and social isolation of individuals or groups.

“Us” (stigmatizers, who don’t have the trait, power) versus “them” (stigmatized, carrying the trait)….

(Goffman E. Notes on the Management of a spoiled Identity. New York: Simon & Schuster; 1963, p. 5)

HIV stigma mechanisms

(Source: Earnshaw V.A.& Chaudoir SR, AIDS Behav, 2009)

4. Participatory approach to HIV prevention and sexual health promotion:

the prevention continuum

3.1. Primary HIV prevention and sexual health promotion

• WHY ONLY US? Fear of double stigma: as a migrant and

HIV

• SAM living with HIV are not visible, where they are? Doubt on statistics (immigration services)

• “Do you know what it means being labeled as HIV positive in our community?”

• Context: “Communities are not demanding HIV prevention, people need jobs…”

A network-based response

• HIV prevention networks (non-profit social cultural organizations): 3 regional networks and 9 “key-organizations”

Tasks of the HIV-SAM Project- Training /coaching/supervision- Providing free prevention materials (incl. condoms) to the

networks

Tasks of the networks:• Participating in regular meetings• Planning and implementing prevention activities (awareness raising at public events, condom distribution)• Evaluation

3.2. Promotion of HIV testing using a participatory approach

• It is better not to know, because… - “…you are going to die”- “…you will be rejected” - “…you will be deported”

• Low personal risk– “I’m married…”– “I have just been tested (or: my partner has just been

tested)”– “My wife has just given birth and delivered a baby…”– Assumption: “I have just done medical tests, blood works…”

Example of a prevention initiative: Promotion of HIV testing in the communities

• Community-based VCT, using low-threshold technologies: oral fluid testing in non-medical settings: cultural events, bars, talent evenings, church services, etc.• Prepared in collaboration with the prevention networks • Results communicated via a secured website or through personal counseling in a low-threshold sexual health clinic• Preparing with community promotion, leaders present, …• Group counseling before actual testing• Testing not fully anonymous to ensure linkage to care

Example: Promotion of HIV testing in the communities – some results

• 10 sessions: 780 people reached, 140 got tested for HIV• 56% opted for results collection via the website• 89% collected their results immediately• 30% tested for the first time• 1 in 5 had no family doctor• 3.5% had a reactive result confirmed as HIV+

Lessons learned so far:• HIV testing in the community was welcomed, but also raised some questions.• Needs careful preparation!

4.3. Positive prevention

Main concerns of SAM living with HIV:• Concerns about their future (death, unsecure life

makes coping difficult)• Great fear of being known as HIV positive or

breaching confidentiality– Huge impact on HIV disclosure fear of loss of control:

“How far will the information on one’s HIV status travel?” (Doyal & Anderson, 2005)

• Sexual and reproductive health: “Will I be able to find a partner? Will I be able to have a child?”

• Intersecting discrimination: migration context, HIV, socio-economic situation…

Some evidence: Discrimination in African migrants in France (VESPA II study, 2013)

• Women experienced more discrimination compared to heterosexual non-African man – Health services (OR:2.1, p<0.05)– Work environment (OR: 16.1, p<0.01– Public services (OR:5.5, p<0.01)– Job seeking (OR:2.3, p<0.05)– Family: (OR:2.2, p<0.05)

• Male SAM were discriminated at work environment (OR:7.4,p < 0.05)

*Marsicano et al, AIDS Impact Conference, Barcelona, 29/9 -2/10/2013

Some evidence: Psychological impact of an HIV diagnosis

• For African men an HIV diagnosis can be a blow to their masculine self-identity (having a job and being a hard worker versus being unable to work for health or legal reasons)

• For women, their identity as women and mothers is often jeopardized: child rearing is an important source of identity while women often do not want to put their partner or future child at risk of HIV infection ( disclosure!)

( Doyal et al. 2009)

Breaking the isolation – peer support groups

• Monthly meetings of two support groups (English and French-speaking)

• Exchange of life experiences, coping with HIV • Promoting healthy lifestyles• Recreative moments (patient weekends)

• Using creative art therapy to support PLHIV in coping with HIV, e.g. body mapping

“I always thought that only words that can be used to express oneself.

Now I know that pictures can speak louder than words"

Jimmy

“I always thought that only words can be used to express oneself. Now I know that pictures can speak louder than words!”

Body mapping

Challenges of living with HIV:

“I don’t have a house anymore, I’m living with compatriots in Brussels. These people don’t know my situation. They don’t know that I’m HIV. I have to hide my medication. If they find out, I’m dead… ”

Body mapping

Challenges of living with HIV:

“People think there is stigma only in Africa. Also here is discrimination. A nurse at the asylum centre told me not to share bread with others…”

Body mapping

Coping with HIV:

“In the beginning it was not easy. But when I met the people from the Muungano group, I heard the many stories and I said: “yes, I’m going to live…”

“My strength is my motherhood. When you want to climb, you need a strong belt. My belt is my child. I have responsibility, somebody who thinks that I am the world to him…”

Body mapping

Personal growth:

“HIV drew me out of my comfort zone, but gave me also leadership skills…I am know the strongest woman I know…

Breaking the isolation – peer support groups

• For health care provider it is important to understand the cultural meaning of disease and the coping strategies used, of which the body maps give vivid examples

• Tools such as body mapping help to express what cannot be verbalized through traditional professional support methods

• As a group-activity, it promotes role-models of people who are coping well and thus contributes to empowerment of people living with HIV

5. Conclusions• Participatory approach has helped to normalize HIV in the SAM

communities and to overcome resistance to HIV prevention• Settings approach needed to achieve behavioral change• Our limitation are where the environmental context is difficult to

change (e.g. legal conditions, migration policies)– Empowering PLHIV

• Better coping with HIV infection• Improving knowledge on laws against discrimination & aadvocating their

rights, e.g. univerals access to testing and tretment independent of legal status• Positive prevention, role models

– Reducing intersecting stigma• Multi sectoral interventions involving health, social welfare, migration policies• Participation of key populations in prevention, HIV testing & treatment policies

Thank you for your attention!

http://www.hivsam.be