14 February 2011
Latin America, HIV and Stigma
The number of people living with HIV in Latin America and the Caribbean has increased steadily since 1990. It is estimated that 2 million individuals are living with HIV/AIDS in the region 1 (Source: UNAIDS/WHO 2009 AIDS Epidemic Update) and the disease is most prevalent among at risk populations. Crime against key populations persists; violence, bullying, and generalised violations of rights create barriers to healthcare and information and undermine efforts to empower these groups.
As the HIV epidemic is worsening in many Latin American countries it is projected that the total number of people living with HIV in Latin America will increase in coming years. Although HIV affects millions of people’s lives, infection rates among the general population are modest. Rates of HIV infection in the region are far higher among specific, vulnerable populations. In spite of this, rather than receive greater attention within HIV campaigns and services, these populations have suffered the effects of stigma and discrimination and become further marginalised.
In the last 20 years of the AIDS epidemic, three population groups have consistently been identified as most vulnerable to HIV in countries with concentrated epidemics. They are sex workers, injecting drug users and men who have sex with men (MSM). The term MSM has been used to refer to all men who have sex with other men, regardless of whether they identify as gay, bisexual or heterosexual. Male-to-female transgenders, also referred to as transgender people, transgender individuals, transgenders and transgender women, have also been grouped together in this category, for having been born with, and, some still having, male genitalia. Yet the vulnerabilities to HIV faced by transgender people are often quite different to and, in some cases, far higher than those faced by self-identified men having sex with other men. A recent multi-centric study in Argentina puts the transgender prevalence rate at 35%. 2
Stigma and discrimination present many different problems for marginalised people, many of which exacerbate their vulnerability to HIV infection. For example, this list was generated by an Alliance / Atlacatl workshop in El Salvador:
- Discrimination and fear of discrimination from health service providers complicates access by transgender people, gay men and other men who have sex with men to condoms, counselling and HIV tests
- Acts of discrimination against PLHA and the transgender population by clinic staff, including physical aggression and attending them last
- Discriminatory laws that don’t recognise sex work as a profession, making it impossible for sex workers to make social security contributions, although sex work is not illegal, reducing access to social security-funded services
- Cases of violence by authorities and others against sex workers and transgender people (more than a dozen transgender people were killed in El Salvador in 2008)
- Available HIV information, education and prevention material does not take into consideration the needs of these key populations.
Positive Action is ViiV Healthcare’s global investment programme for communities affected by HIV and AIDS. It has now been running for nineteen years; in 2004, when it was a programme of GlaxoSmithKline, it began consultations in Latin America to identify a new project for the region. After deciding to focus initially on Mexico, Positive Action met with community leaders and AIDS Service Organisations to assess which needs it could meet in a new community-led HIV programme. While there had been progress in addressing stigma in some parts of Mexico, it was felt that many marginalised communities were unsupported in some of the country’s more conservative, central states.
Vida Digna (or “Life with Dignity”) was launched in Mexico in April 2005, the result of close collaboration between Positive Action, the Mexican HIV NGO Colectivo Sol and the International HIV/AIDS Alliance. The Alliance and Colectivo Sol developed a model for engaging the key populations worst affected by HIV-related stigma and discrimination: People Living with HIV (PLHIV), sex workers (SW), men who have sex with men (MSM), transgender people, and intravenous drug users (IDU).
This first phase Vida Digna was implemented in five cities in central Mexico – Aguascalientes, Leon, Irapuato, Queretaro and San Luis Potosi – selected as conservative areas where affected populations were struggling to self-organise or find concrete ways of addressing stigma and discrimination. Colectivo Sol worked with 13 community based organisations (CBOs) – some existing, some started from scratch – to define stigma and discrimination for their population, identify their impacts, and create individual projects, which were funded through Vida Digna’s small grants scheme, that could tackle stigma and its effects.
The external evaluation of the first three years of Vida Digna showed that the project had achieved changes in policy and programming, and had strengthened the capacity of civil society organisations, both of which contributed to the reduction of stigma and discrimination towards the key populations. One of the 13 implementing CBOs, FID, a transgender organisation set up with the support of Vida Digna in San Luis Potosi, received the special Red Ribbon Award on Human Rights during the World AIDS Conference, Mexico City in 2008 in recognition of their innovative work. Vida Digna has helped to raise awareness of HIV stigma and discrimination across Mexico; the project supported the creation of an HIV stigma and discrimination website where materials and experiences can be shared by campaigners and activists.
The success of Vida Digna helped it to achieve a high profile in the region and generated interest from organisations in other countries keen to adapt the model to their own contexts. In 2009, Positive Action agreed to support the Alliance and Colectivo Sol to work with Asociación Atlacatl Vivo Positivo in El Salvador on the next phase of Vida Digna. HIV prevalence in El Salvador is 0.9% with an estimated number of PLHIV of 36,000. But a multi-centric study carried out in 2003 with the participation of gay and bisexual men, heterosexual men and transgender people found that the HIV prevalence rate among transgender people was 25.0% and 23.7% among gay men 3. Prevalence among sex workers is 3.6%.
Colectivo Sol provided Atlacatl with the foundations of the model of community-based organisation (CBO) support they had developed for Mexico through a series of workshops and assisted with the design of their technical assistance strategy. Within a year Atlacatl has already achieved important steps in its work with these local organisations, including:
- technical assistance to CBOs for obtaining their legal registration;
- an increase in reporting of violations of Human Rights and providing legal assistance once this is done;
- promoting the work of the small grant recipients and making their work more visible; and
- concrete improvements in the NGOs’ and CBOs’ administrative and technical mechanisms.
The Next Steps
Now that Vida Digna has proved itself to be transferable, Positive Action and the International HIV/AIDS Alliance and their implementing partners in the region have agreed a strategy for expanding the model to other countries in Latin America. To facilitate the rapid roll out of the programme in five new countries the next phase of the project will focus on sex workers, including work with transgender sex workers. At the same time, Vida Digna’s work with other key populations started in El Salvador will be consolidated with Asociación Atlacatl Vivo Positivo, and Mexico’s Colectivo Sol will engage in some of the workshops of the regional programme to help ensure continuity with the original project.
Two new partners will bring their regional networks and national representatives into the project to deliver Vida Digna in Honduras, Panama, Costa Rica, Nicaragua and Guatemala. Redtrasex (the Latin American Network of Sex Workers) and Redlactrans (the Latin American Network of Transgender People).
Redtrasex is a network of female sex workers’ organisations from different countries across Latin America and the Caribbean. Established in 1997, the regional network is managed by the sex workers themselves, and has members in 15 countries. Redtrasex was created to defend the human and working rights of female sex workers (FSW), to eliminate the stigma and discrimination associated with sex work and to achieve participation and leadership of FSW in defining and implementing public policies and programmes which affect them, with a particular focus on issues relating to HIV. The stigma and criminalisation associated with sex work are a barrier to sex workers being able to access health systems, prevention, care and treatment programmes, which increases their vulnerability to HIV.
Redlactrans was established in 2005 in response to the lack of visibility and representation of the trans community in Latin America and today has representatives in 17 Latin American countries including Honduras and in the organisations Reinas de la Noche in Guatemala and Arco Iris in El Salvador. Since 2007 Redlactrans has received support from the Alliance on strategic planning and in strengthening its capacity and has received technical, administrative and financial support from Redtrasex. Redlactrans’ struggle for social inclusion and respect has influenced the creation of gender identity laws and there have been improvements in the health care, housing, employment and education options available to trans people. Redlactrans now has representatives on many national and regional bodies including AIDS programmes and Global Fund Country Coordinating Mechanisms.
The regional Vida Digna programme will work to avchieve four main objectives over the next three years (January 2011 – December 2013):
- To increase uptake of quality comprehensive services free of stigma and discrimination
- To strengthen the capacity of key population organisations and Retrasex country representatives in Central America to implement sustainable projects that increase access to and uptake of quality services
- To increase the influence and participation of Vida Digna partner CBOs and NGOs in international, national and local policy making and planning bodies related to HIV/AIDS and key populations
- To promote south - south exchange, and adaptation of the Vida Digna model between organisations in El Salvador and other Central American countries working to reduce stigma and discrimination towards sex workers in the region.
The project will retain Vida Digna’s emphasis on building local capacity, encouraging a participative approach to project planning and leadership, and facilitating local activity through a programme of onward grants. The time frame will allow the Vida Digna model in El Salvador to become sustainable and will produce results in removing stigmatising and discriminatory practices, policies and even legislation in the five new countries. This and the strengthening of sex worker and transgender organisations, their relations with health providers, and their own work on HIV-related factors will have begun to demonstrate real and health and welfare gains for the target populations by the end of 2013.
1 UNAIDS/WHO 2009 AIDS Epidemic Update
2 The Hidden HIV Epidemic, Transgender Women in Latin America and Asia, Javier Hourcade Belocq, The International HIV/AIDS Alliance Secretariat
3 HIV and STI and Behavioural Multi-Centric Study amongst MSM in El Salvador, 2003