1. STIGMA AND DISCRIMINATION REDUCTION AS AN ESSENTIAL PART OF COMBINATION PREVENTION Stefan Baral, MD MPH FRCPC Center for Public Health and Human Rights, Johns Hopkins School of Public Health

2. Outline  Background  Link between Stigma, Discrimination, and HIV  Prerequisites for HIV Prevention Research  Case Studies  Most At Risk or Key Populations Relationship Between Stigma and Prevention Research  Barriers to Prevention  Moving Forward

3. Reproductive Rate  Average number of secondary cases that will theoretically result from a sentinel case in the absence of immunity or interventions  R 0 = ß x C x D R 0 - reproductive rate of an infection ß - average probability of transmission per exposure to a susceptible contact C - average number of contacts per unit time D - average duration of infectiousness of the infection

4. Stigma, Discrimination, and HIV  Increased Acquisition and Transmission (ß)  Barriers to Accessing commodities condoms and condom compatible lubricants clean needles Information Services  Increased Exposure (C)  Eg. Coercion, sexual violence, rape as tool of war  Increased Duration of Contagiousness (D)  Eg. Treatment delays or gaps Forced detention Stigma in health care settings

5. Most At Risk or Key Populations  Specific populations that carry disproportionate burden of HIV  Three Universal Key Affected Populations Sex workers (SW) Gay Men and other Men who have sex with Men (MSM) People who use drugs (PUD)  Sentinel Population for Human Rights Contexts Criminalized in Many Countries Significant Social Stigma High Risk for HIV

6. Systematic Review of HIV Prevalence among Female Sex Workers Source: Baral, S et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet Infectious Diseases. 2012

7. Global HIV among MSM Evidence suggested four epidemic scenarios for LMIC MSM epidemics -Scenario 5 will come from MENA region: now largely “unavailable data” Beyrer C, Baral, et al, Epidemiology Reviews, 2010.

8. Combination HIV Prevention Research  Behavioural Interventions Increasing condom and lubricant use during sex Eg. Peer Education, Risk Reduction Counselling, Adherence Counselling  Biomedical Interventions Biomedical interventions aim to decrease transmission and acquisition risk of sex Eg. Oral or topical antiviral chemoprophylaxis, Treatment as Prevention  Structural Interventions Limited data because of complexity in study design to characterize efficacy and effectiveness of these interventions Eg. Decriminalization, Government-sponsored anti-stigma policy, Mass media engagement, Gender engagement programs, Community systems strengthening, Health Sector Interventions

9. Prerequisites for HIV Prevention Research  Identification  Must be able to Identify MSM and Sex Workers Willing to Self-Disclose  Risk Assessment  Must be able to appropriately stratify MSM and Sex Work according to risk Asked about risks in a competent and sensitive manner  Follow Up  Must be able to follow up participants to assess adherence and efficacy of intervention Safe Environment Community Group Client trust in health care facility

10. Case Studies  Combination HIV Prevention and Stigma  FSW in Russia, Swaziland  MSM in Gambia, Malawi

11. Case Study Russia Source: Decker, Wirtz, Baral, et al., Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. STI, 2012

12. Client Violence among FSW in Russia …sometimes I pull on a condom and he pulls it off right straight away, I pull it on once again and he can give me a punch for that. …I say to a client that I don’t practice anal sex and he replies that he doesn’t need it. When I come to him he just starts beating me up to make me do what he wants. Source: Decker, Wirtz, Baral, et al., Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. STI, 2012

13. Client Physical Violence & STI/HIV aOR=3.14, 95% CI 1.09, 8.99 Source: Decker, Wirtz, Baral, et al., Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. STI, 2012

14. Case Study - Swaziland Source: Central Statistical Office & Macro International, 2008, p. 222

15. Disclosure of Sex Work in Swaziland As a result of selling sex N=313 % Felt afraid to seek healthcare143 44.0 Experienced legal discrimination152 46.8 Been refused police protection160 49.4 Been blackmailed113 34.8 Verbal and physical harassment198 60.9 Have been tortured173 53.2 Have been beaten up125 38.7 Have been beaten up by Uniformed Officers (police, miltary, security)45 20.8 Family Member21 9.7 Regular Partner16 7.4 One time client11 5.1 Regular client, partner9 4.2 Manager/pimp6 2.8

16. Associations of Disclosure of Sex Work  Disclosure of Sex Work to  Family Member 30.3% (98/325)  Health Care Worker 25.9% (84/325)  Afraid to Seek Health Care  OR 3.5 (95% CI 1.3-5.6) disclosed sex work to HCW  OR 2.0 (95% CI 1.12-3.7) being treated for HIV

17. Case Study – Gambia

18. Gambia, 2012  20 men accused of attempting to commit unnatural offences

19. Gambia, 2012

21. Associations with Disclosure  Disclosure of Sexual Orientation to  Family Member 3.9% (8/205)  Health Care Worker 15.4% (84/205) Fear Denial VariableOR[95% CI]OR[95% CI] Disclosure of Sexual Orientation to Family or HCW 2.61[1.08-6.32]9.74[1.96-48.45]

22. Case Study - Malawi

23. Arrests in Malawi, 2010

24. Interrupting Structural Interventions, April, 2011

25. Malawi, May, 2011

26. Variable Fear of Seeking Health Care OR (95% CI) Denied Health Care Services OR (95% CI) Blackmailed OR (95% CI) Diagnosed with an STI2.4 (1.4-4.3) *6.9 (3.0-15.6) **1.5 (0.8-2.7) Treated for an STI2.8 (1.7-4.9) **7.3 (3.3-16.2) **1.5 (0.8-2.6) Received recommendation for an HIV test 1.9 (1.2-3.0) *2.2 (0.98-4.8)1.8 (1.1-2.8) * Ever tested for HIV1.1 (0.7-1.7)1.6 (0.7-3.7)1.0 (0.7-1.6) Self-Reported Diagnosis of HIV or AIDS 2.6 (1.1-6.5) *3.3 (0.9-12.1)2.7 (1.1-6.6) * Self-Reported Treatment for HIV 3.7 (1.6-8.6) *46.1 (17.3-122.8) **5.4 (2.2-13.2) ** HIV positive1.7 (0.9-3.2)1.2 (0.4-3.6)0.9 (0.5-1.6) Any interaction with health care2.6 (1.6-3.9) **6.4 (2.5-16.1) **2.1 (1.4-3.2) * Pooled Data from Three Countries * - p <0.05 ** - p <0.01 Source: Fay H, Baral S, Trapence G, Motimedi F, Umar E, et al. Stigma, Health Care Access, and HIV Knowledge Among Men Who Have Sex With Men in Malawi, Namibia, and Botswana. AIDS and Behavior, Dec 2010: 1-10. Associations between fear and experienced discrimination with sexual health and use of services among MSM in Malawi, Botswana, and Namibia.

27. Turning the Tide in Malawi?

28. Case Study Messages  Limited Capacity for HIV Prevention Research if Populations:  Live in fear  Live hidden  Have limited access to safe and effective clinical care

29. Prevention Expenditures for MARPS  Concentrated Epidemics  MSM and SW predominant risk groups 3.3% of non-treatment expenditures supporting MSM 2% of non-treatment expenditures support FSW  Generalized Epidemics  Emerging evidence of risk among MSM and SW < 0.1% of non-treatment expenditures supporting MSM and SW Many countries have invested 0% of national expenditures for the prevention needs for MSM and SW Source: Global HIV Prevention Working Group: Global HIV Prevention: The Access, Funding, and Leadership Gaps. 2009

30. Anti-Prostitution Loyalty Oath (APLO) aka Anti- Prostitution Pledge  All international organizations that receive PEPFAR funding to have a policy that explicitly opposes prostitution and sex trafficking  Signed by all USG funded programs in 2003 (PEPFAR v1 and also with PEPFAR v2 in 2009) limits comprehensive surveillance and service provision for sex workers  In combination with criminalization and stigma, the prostitution pledge has limited the understanding of the burden of HIV disease among female sex workers http://www.pepfarwatch.org/the_issues/anti_prostitution_pledge/

31. Global Fund Investments and Criminalization of Same- Sex Practices Source: amfAR, JHU. Achieving an AIDS-Free Generation for Gay Men and other MSM, 2011 Countries that Criminalize Consensual Same Sex Practices Seven of the ten countries receiving the greatest support from the Global Fund More than half of the 88 countries supported through PEPFAR * - Same-Sex Practices Criminalized

32. Conclusions  Stigma, Rights Violations, and HIV are intricately linked  To test combination HIV prevention strategies, stigma must be addressed  And for combination HIV prevention programs to have effectiveness outside of trial settings, stigma must be addressed  Addressing Stigma  Government and Funders  Anti-discrimination clauses in all policies, programs, RFP/RFA  Implementers (large and small) and Community  Engage media, engage government, engage religious leaders, engage target community, engage general community. Engage.  Find champions within target communities and in general community and empower them  Academia  All epidemiological research should include an assessment of enacted/perceived stigma  Linking HIV with UI, high numbers of partners, STI no longer contributes to our knowledge of risk  Use the opportunity of epidemiological assessments (size estimations, cohorts, cross-sectional studies, prevention studies, etc) to collect actionable data  Stigma manifests in different ways in different settings