1. HIV STIGMA: FROM GLOBAL TO LOCAL Brandon Brown, PhD UCR SOM Department of Social Medicine and Population Health

2. Outline 1.HIV Background 2.HIV stigma 3.New epidemics 4.Positive outlook

3. zero new HIV infections zero discrimination zero AIDS-related deaths UNAIDS Goals

4.  Virus  Causes-transfer of: ◦ Blood ◦ Semen ◦ vaginal fluid ◦ pre-ejaculate ◦ breast milk Human Immunodeficiency virus  Destroys immune system ◦ Helper T-cells cant help ◦ Develop AIDS  What do you die from?  Opportunistic diseases

5. History/Emergence of HIV Developed countries (e.g. U.S.)- 1980s First identified among MSM Moved into drug-using populations leading to transmission via heterosexual sex Sub-Saharan Africa – mid-1990s to present Majority of HIV/AIDS burden Transmission attributed to heterosexual sex Southeast Asia, India, China & former Soviet Union Started primarily among intravenous drug users Male drug users subsequently infected FSWs  hetero

6. HIV ■37 million with HIV –60% Sub Saharan Africa –>50% don’t know + ■Prevention methods –PREP –Mother to child ■Labor ■breastfeeding –Condoms –Microbicides –Counseling and testing –Prevention with positives –Blood testing –ABCs

7. Issues with HIV eradication ■Sometimes difficult to recognize HIV infection –Common cold or flu ■Issues with testing –Window period –People don’t think they are at risk-stigma ■No vaccine-all failed ■Sexual behavior difficult to control ■Our best prevention-condoms –Don’t always work –Negotiation sometimes difficult ■Cultural factors

8. ■5 million ppl. infected per year –Majority heterosexual ■9/10 HIV+ children born in SSA ■Issue-difficult to change behavior –Depends on: 1.background characteristics 2.societal norms 3.attitudes towards new behavior AIDS and Behavior

9. ■ Former President of South Africa (Mbeki) – Denying HIV problem ■ ‘there is no such thing as HIV’ – HIV testing legally banned Context on changing behavior

10. HIV: Local In the US 1.1 million people living with HIV HIV is an urban disease African Americans most affected by HIV –12% of population, but 44% of new infections –Rate 8 times that of whites http://www.washingtonpost.com/national/health-science/southern-states-are-now-epicenter-of-hivaids-in-the-us/2014/09/22/9ac1525a-39e6-11e4-9c9f-ebb47272e40e_story.html

11. HIV: a higher impact on women 80% of new infections in Southern US Particularly black women What are the reasons for women being more prone? Where are they getting HIV from? Higher burden among women not unique globally

12. Women: Sub-Saharan Africa Nature of the transactional / polygamous relationships Older male partners with resources Women have limited rights & social power cannot insist on condom Stigma and blame in HIV testing Virgin myth If you have HIV, sex with a virgin will cure you

13. Age Group (Years) HIV Prevalence (N=1029) ≤168.4 17-1818.6 19-2025.4 21-2232.8 23-2444.8 HIV prevalence in young pregnant women in rural Vulindlela, South Africa (2009-2012) HIV continues to spread at high rates!

14. Young Women HIV in 15–24 year old men and women (2008–2011) women 8 X more HIV than men Source: Adapted from UNAIDS 2012 Zimbabwe

15. 15 World map --countries by land area

16. HIV/AIDS Deaths Globally http://www.worldmapper.org/display_extra.php?selected=374

17. Origin of HIV: revisited Developed countries (e.g. U.S.)- 1980s First identified among MSM Most believe still believe HIV is a disease of MSM and hyper sexual

18. What is the face of HIV? ■Sex workers? 18

19. ■Only among gay men?

20. ■Injection drug users

21. ■Or………. –Mothers, teachers, students 21

22. What is HIV Stigma? ■“An attribute that is deeply discrediting” ■Prejudice & Discrimination ■Negative Perceptions & Attitudes ■Abuse & Neglect ■Maltreatment ■…directed towards people living with HIV & AIDS and the groups and communities they associate with

23. Why is there HIV stigma? ■HIV/AIDS is a life-threatening disease ■People believe HIV infection is associated with behaviors that are already stigmatized –homosexuality, drug addiction, promiscuity ■Most people become infected through sex –Personal responsibility ■Inaccurate information about HIV transmission –http://www.youtube.com/watch?v=Ke2QKx26iNchttp://www.youtube.com/watch?v=Ke2QKx26iNc

24. Stigma in the News…cont Pastor Michael Jordan-Alabama

25. Talking about the news ■Charlie Sheen out as HIV+ –How does this impact HIV stigma? Charlie Sheen + goddesses

26. Impact of HIV-Stigma  Social isolation  Gender based violence  Decreased Access to Services  Reduced status Disclosure  Avoidance of Healthcare  Decreased HIV Testing  Mental Health Pathologies  Loss of employment  Decreased Negotiation of Safe Sex Practices  DEATH Larry Dunn and Cicely Bolden - Dallas

27. HIV Stigma reduction-Photovoice ■Recruited 10 women of color living with HIV ■Award winning photojournalist trained participants on photography and ethics ■Participants reflect on experiences with stigma –Took photos to bring reflections to life ■Discussed photos during focus groups & structured interviews Led by UCI PH Doctoral candidate Mariam Davtyan

28. Hospital visit-stethoscope

29. “Stay clear of my kids’ bathroom!”

30. “Taking labels off HIV pill bottles!”

31. “HIV-Stigma & Decay!”

32. “Pennies are more valuable than me!”

33. Inspot.org- confidential

34. Report official STD results and find partners who accept the ones you have

35. Visual Story of HIV-stigma ■Gay men’s CBO in Lima, Peru (Epicentro) houses our clinical studies “Peru was recently voted as the most Homophobic country in Latin America” http://uctv.tv/shows/HIV-Stigma-Personal-Stories-from-Gay-Men-and- Transgender-Women-in-Peru-A-UCI-GHREAT-Initiative-25898 ■ Opens up door to stigma globally

36. HIV-Stigma in the News Senator Morgan Femai

37. 64 countries: adult same-sex conduct is legal and protective laws in place 115 countries: adult consensual same-sex conduct is not a criminal offense 78 countries: adult consensual same-sex conduct is criminalized 7 countries: adult consensual same-sex conduct is illegal-punishable by death 7 countries: adult consensual same-sex conduct is illegal-punishable by death *Source: UNAIDS, 2013

38. Stigma in the news: Nigeria ■Last year –President Goodluck Jonathan signs same sex marriage ban bill into law ■Lynching, stoning MSM One man recently confessed to forced sodomy 7 years ago Judge spared him death sentence by stoning Lashed 20 times

39. Nigeria-new legislation The Same Sex Marriage (Prohibition) Act prohibits same sex marriage or civil union, and carries up to 14 years imprisonment Up to 10 years imprisonment for any persons who "support the registration of gay clubs, societies, organizations, processions or meetings". This provision poses a threat HIV organizations providing services to the LGBTI population

40. Not picking on Nigeria

41. Ebola and HIV stigma  Current Ebola epidemic raises HIV stigma similarities  Both divine retribution for past sins  propagandas for population control  Misconceptions that only (migrants, homosexuals, and sex workers) at risk  HIV stigma reduction programs may be applied to Ebola education programs

42. HIV and Ebola ■Recent Ebola seminar on HCW experience in Liberia –Children orphaned by Ebola shunned –Similar to HIV+ children shunned from orphanages in past ■Old news? –Last week Sierra Leone ■Ebola free then 2 more cases-stigma continues –New epidemics ■Zika virus

43. Study of MDs in Coachella Valley ■Provided HIV tests to 3% patients in past month ■How do we help them test more? –HIV testing literature for patients –better understanding of CDC recommendations ■Barriers? –other priorities at the patient visit (time) –discomfort on broaching the HIV topic ■What is the HIV testing recommendation by CDC? –Less than 50% agreed critical test http://www.ncbi.nlm.nih.gov/pubmed/26627106

44. New HIV prevention focus (PrEP)

45. More on PrEP ■Clinical trials around the world results 2010 –99% effective at preventing HIV if taken daily ■FDA approved in the US since 2012 –Most other countries not available not approved ■Even though studied there ■Just this year South Africa and Kenya ■Stigma for new intervention! –Party drug http://www.huffingtonpost.com/news/michael-weinstein-truvada-party-drug/

46. Stigma Trumps Prevention Options and Reachable Goals !!!! zero new HIV infections zero discrimination zero AIDS-related deaths

47. Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is focused on reducing sexual transmission Behavioural Intervention -Abstinence -Be Faithful -Condoms HIV Counseling and Testing Coates T, Lancet 2000 Male Condoms Female Condoms Treatment of STIs Grosskurth H, Lancet 2000 Male circumcision Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007 Treatment as prevention Donnell D, Lancet 2010 Cohen M, NEJM 2011 Microbicides for women Abdool Karim Q, Science 2010 Grant R, NEJM 2010 (MSM) Baeten J, 2011 (Couples) Paxton L, 2011 (Heterosexuals) Choopanya K, 2013 (IDU) Pre-exposure prophylaxis Post Exposure prophylaxis (PEP) Scheckter M, 2002 HIV PREVENTION

48. Hope/Progress ■https://www.youtube.com/watch?v=9eXlNn-C8BYhttps://www.youtube.com/watch?v=9eXlNn-C8BY ■Kami (HIV positive muppet) PrEP and now PEP New better drug therapy People living longer More availability-tests, therapy More media

49. Lifting Ban on lifetime blood donations

50. We are on the right track (UNAIDS) ■New HIV infections among adults and children were 2.3 million in 2012, a 33% reduction since 2001 ■New HIV infections among children have been reduced to 260 000 in 2012, a reduction of 52% since 2001 ■AIDS-related deaths have also dropped by 30% since the peak in 2005 as access to antiretroviral treatment expands ■By the end of 2012, some 9.7 million people in low- and middle-income countries were accessing antiretroviral therapy, an increase of nearly 20% in just one year ■Between 2005 and 2014, HIV diagnoses fell 40% among women, including 42 percent among black women. Diagnosis rate dropped 35% in heterosexuals and 63 percent among injection drug users (IDUs).

51. Preliminary Discussion Items 1.What can you do to help reduce HIV stigma? 2.What are some of your choices for HIV testing? 3.Challenge-come pick up a condom

52. Thank you Lookup: Great American condom campaign!! http://amplifyyourvoice.org/gacc/