Christiana Nöstlinger, HIV SAM Project, Institute of Tropical Medicine, discusses a Participatory Network Approach. This presentation was given at the Under the Baobab African Diaspora Networking Zone at the International AIDS Conference, AIDS 2014.

1. Sexual Health Promotion with
Sub-Saharan African migrants in
Belgium
Christiana Nöstlinger, Lazare
Manirankunda
Institute of Tropical Medicine, Department
of Public Health
IAS 2014 - African Diaspora Networking Zone, Tuesday 22/07

2. Outline
1) Sub-Saharan African migrants (SAM) and HIV in
Belgium
2) Epidemiological background
3) Stigma as a barrier to effective HIV work with
communities
4) Participatory approach to HIV prevention and
sexual health promotion (prevention continuum)
5) Conclusion
Discussion and debate

3. 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

4. 2. Epidemiological background

5. 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)

6. HIV stigma mechanisms
(Source: Earnshaw V.A.& Chaudoir SR, AIDS Behav, 2009)

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

9. 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…”

10. 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

11. 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…”

12. 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

13. 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!

14. 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…

15. 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

16. 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)

17. 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

18. “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!”

19. 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… ”

20. 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…”

21. 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…”

22. 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…

23. 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

24. 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

25. Thank you for your attention!
http://www.hivsam.be