HIV/AIDS IN NICARAGUA: Establishing the Need for Action and Critically Assessing the National Responses to the Epidemic
Linn Dahlman BA (Honours) Latin American Development Studies University of Portsmouth School of Languages and Area Studies Faculty of Humanities and Social Sciences April 2006
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ABSTRACT This dissertation will address the HIV/AIDS epidemic in Nicaragua. In addition to establishing the general population’s vulnerability to HIV infection, with a special focus on women and young people, it will assess governmental and NGO responses to the epidemic. In a HIV/AIDS context, Nicaragua might not seem very interesting at a first glance with the lowest prevalence rate in Central America of only 0.2 per cent. However, a closer look reveals a country that has experienced a rapid increase in HIV incidence during the last 7 years. We argue that the numerous vulnerability factors present in the Nicaraguan society such as poverty, machismo and the Catholic Church’s influence on sexual education, all contribute to increased susceptibility to HIV infection, while particularly putting women and young people at risk. This is evident as the male to female ratio has gone down from 7:1 to 2.5:1 in a few years, and a large number of AIDS cases are found among young people. Confronting this situation the government and civil society have made advances in the fight against HIV/AIDS during the last few years. Political and legislative frameworks have been made and treatment is expanded. Civil society is also offering a wide range of prevention and support services. Through the use of general literature on HIV/AIDS, information from MINSA, interviews with people working in this area and the experience of working in a Nicaraguan NGO dedicated to the fight against HIV/AIDS (SI Mujer), we have come to the conclusion that there are still shortcomings and obstacles that need to be dealt with, such as a lack of commitment and will from the government, a lack of organization and weak implementation of policies, and furthermore, NGOs need to consolidate their efforts and should focus more on men’s role in gendered approaches.
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ACKNOWLEDGEMENTS I would like to take the opportunity to give thousand thanks to Dr Andy Thorpe for his invaluable help and support throughout the research and writing process. I would also like to express my gratitude to Dra Ana Evelyn Orozco (SI Mujer) for her support during my stay in Nicaragua, and to Lic Xiomara Luna (PAJ) for her kind help with arranging the interviews. In addition, all my friends and colleagues at SI Mujer and PAJ deserve to be mentioned for making my work experience memorable. Furthermore, I am grateful to my interview objects (see appendix B) for expanding my understanding of the HIV/AIDS situation in Nicaragua and for making time for me in their busy schedules. I would also like to express my thanks to the staff at CISAS who were most helpful in letting me use their research centre; Richard Pilgrim for proof reading my work and Craig Hull for help with the graphs. Finally, to my friends and family in Norway, Nicaragua and England, who have been most supportive, I would like to say: Takk. Gracias. Thank you.
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TABLE OF CONTENTS ABSTRACT
III
ACKNOWLEDGEMENTS
V
LIST OF ABBREVIATIONS AND ACRONYMS INTRODUCTION
IX 1
1 THE GLOBAL THREAT OF HIV/AIDS (PLACING THE NICARAGUAN EPIDEMIC INTO CONTEXT) 3 1.1 INTRODUCTION 1.2 WHAT IS HIV/AIDS? 1.3 THE GLOBAL SPREAD OF HIV/AIDS 1.4 HIV/AIDS IN LATIN AMERICA 1.5 THE SITUATION IN NICARAGUA 1.6 CONCLUSION
3 4 4 6 6 8
2 VULNERABLE GROUPS IN A VULNERABLE SOCIETY (ESTABLISHING THE NEED FOR ACTION)
11
2.1 INTRODUCTION 2.2 RISK AND VULNERABILITY FACTORS 2.2.1 POVERTY 2.2.2 MIGRATION AND MOBILITY 2.2.3 MACHISMO AND GENDER BASED VIOLENCE 2.2.4 THE CATHOLIC CHURCH 2.2.5 LOW LEVELS OF EDUCATION 2.2.6 LACK OF PERCEPTION OF RISK 2.2.7 HIGH RATES OF STIS 2.3 VULNERABLE GROUPS 2.3.1 WOMEN 2.3.2 ADOLESCENTS AND YOUNG PEOPLE 2.4 CONCLUSION
11 11 11 12 16 17 18 18 19 19 19 21 22
3 FIGHTING THE HIV/AIDS EPIDEMIC (PRESENTING THE NATIONAL RESPONSES)
25
3.1 INTRODUCTION 3.2 PREVENTION 3.2.1 GOVERNMENTAL RESPONSES 3.2.2 NON GOVERNMENTAL ORGANISATIONS
25 26 27 29
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3.3 TREATMENT AND CARE 3.3.1 GOVERNMENTAL RESPONSES 3.3.2 NON GOVERNMENTAL ORGANISATIONS 3.4 CONCLUSION
31 31 32 33
4 NOT QUITE THERE YET… (A CRITICAL LOOK AT RESPONSES)
35
4.1 INTRODUCTION 4.2 ASSESSING THE GOVERNMENTAL RESPONSES 4.2.1 PREVENTION STRATEGIES 4.2.2 TREATMENT AND CARE 4.3 NGO INITIATIVES 4.4 CONCLUSION
35 36 36 38 40 41
CONCLUSION
43
POLICY SUGGESTIONS AND FURTHER RESEARCH
44
BIBLIOGRAPHY
47
APPENDICES
55
APPENDIX A APPENDIX B
57 59
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LIST OF ABBREVIATIONS AND ACRONYMS AIDS
Acquired Human Immunodeficiency Syndrome
ARV
Antiretroviral
ASONVIHSIDA
Asociación de Personas que viven con VIH/SIDA
CEPRESI
Centro Para la Educación y Prevención del SIDA
CEPS
Centro de Estudios y Promoción Social
CISAS
Centro de Información y Servicios de Asesoría en Salud
CNLS
Comisión Nacional de Lucha Contra el SIDA desde la Sociedad Civil
CONFER
Campaña Costeña de Lucha contra el SIDA
CONISIDA
The Nicaraguan AIDS Commission
CSW
Commercial sex workers
ENDESA
Encuesta Nicaragüense de Demografía y Salud
FAO
Food and Agriculture Organization of the United Nations
GBV
Gender-based violence
Global Fund
The Global Fund to Fight AIDS, Tuberculosis and Malaria
HIV
Human Immunodeficiency Virus
ICAS
Central American Health Institute
IDU
Injecting drug users
IEC
Information, Education and Capacitation
INSS
Instituto Nicaragüense de Seguridad Social
Ley 230
Ley de Reformas al Código Penal para Prevenir y Sancionar la Violencia Intrafamiliar
Ley 238
Ley de Promoción, Protección y Defensa de los Derechos Humanos ante el SIDA
MECD
Ministry of Education, Culture and Sports
MINSA
Ministry of Health
MSM
Men who have sex with men
NGO
Non Governmental Organisation
NORAD
Norwegian Agency for Development Cooperation - ix -
PAHO
Pan American Health Organization
PAJ
Programa para Adolescentes y Jovenes
PASCA
Proyecto Acción SIDA de Centroamérica
PLWHA
People living with HIV/AIDS
RAAN
Región Autónoma del Atlántico Norte
RAAS
Región Autónoma del Atlántico Sur
SILAIS
Sistemas Locales de Atención Integral en Salud
SI Mujer
Servicios Integrales para la Mujer
STI
Sexually transmitted infections
UN
United Nations
UNAIDS
Joint United Nations Programme on HIV/AIDS
UNDP
United Nations Development Programme
WHO
World Health Organisation
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INTRODUCTION The HIV/AIDS epidemic in Nicaragua is characterized as nascent, with an estimated prevalence rate of 0.2 per cent (United Nations Development Programme [UNDP], 2005, p.248). However, since 1999 the number of people living with HIV/AIDS (PLWHA) has been increasing rapidly, and the HIV virus is spreading among the general population, with more and more women and young people becoming infected (Nicaragua, 2004). It seems crucial to create a set of responses that can adequately contribute to reduce vulnerability for these groups, and control the further spread of the virus, while also improving the situation for those already living with HIV/AIDS. During the last few years, responses to fight the HIV/AIDS epidemic – both from the government and civil society – have improved, although there are still challenges to be met and obstacles to overcome. The aim of this dissertation, then, is two fold. Firstly, it seeks to analyse some risk and vulnerability factors present in Nicaragua, and to identify certain groups susceptible to HIV infection so as to establish the need for a committed and focused response to the HIV epidemic. Our main focus is on women and young people as these groups constitute a large part of the general population. Secondly, it aims at identifying and assessing some of the national responses in the fight against HIV/AIDS, considering both governmental and Non Governmental Organisation (NGO) initiatives. These issues will be addressed through four main chapters: The first aims to give a general overview over the HIV/AIDS situation and its global spread, whilst putting Nicaragua into context and describing some of the characteristics of the nature of the epidemic. The second chapter will analyse the risk and vulnerability factors present in the country, and identify two of the most vulnerable groups within the general population, women and young people, as they are increasingly becoming infected with the HIV virus. In the third chapter, some of the initiatives from the government and NGOs in the fight against HIV/AIDS are presented such as normative frameworks and national plans to draw out the responses. The country’s numerous NGOs are working in -1-
different ways to educate and inform about HIV/AIDS, and are also providing services such as the testing and treatment of other STI’s, as well as providing support to people living with HIV/AIDS. The fourth and last chapter will look at some of the shortcomings in governmental initiatives, such as problems with the Church’s interference in education, and the need for expanded treatment, decentralisation, and better organisation and implementation of policies. In addition, NGOs need to consolidate their responses, and should further broaden gendered prevention methods. They are also in need of more assessment. The concluding chapter will sum up our findings, and will also put forward some suggestions for further policymaking and research.
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1 THE GLOBAL THREAT OF HIV/AIDS (Placing the Nicaraguan epidemic into context)
1.1 Introduction Since the first cases of Human Acquired Immunodeficiency Syndrome (AIDS) were discovered [1981], and the Immunodeficiency Virus (HIV) was identified [1983] (Adler, 2001, p.1), the number of people living with HIV/AIDS (PLWHA) has rapidly increased in many parts of the world, especially in developing countries, with Africa being the region hardest hit by the epidemic. Yet not only does it affect PLWHA in a physically, psychologically, socially and economically devastating way, it also affects society as a whole for the highest proportion of PLWHA is concentrated in the working age group (between 15 and 49). Both the number of deaths resulting from AIDS, and the number of people who are too ill to work, lowers the production capacity of society (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2002b). In addition health care costs are high as treatments require expensive drugs that need to be taken continuously once treatment is started (Pizarro, 2004c, p.5). There is still no cure for the virus, and so the focus remains on controlling the spread of the HIV virus, and on controlling the development of AIDS related illnesses. However, while this requires much effort on global, national and regional levels, the national responses to the situation vary both qualitatively and quantitatively from country to country, depending on the number and type of groups of PLWHA, the differences in how nations perceive the threat, and in their funding resources (United Nations [UN], 2003). This chapter will provide an introduction to the global HIV/AIDS situation. Firstly, we will look at what HIV/AIDS is, and how it can spread, before we look at the development of the global epidemic. Then we will look at the diverse nature of the epidemic in the Latin American region, before we introduce the HIV/AIDS situation in Nicaragua.
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1.2 What is HIV/AIDS? AIDS is defined as being “an illness characterised by one or more indicator diseases” (Adler, 2001, p.1). The virus that causes these illnesses is the Human Immunodeficiency Virus which attacks the CD4 cells, (the ‘helper T-cells’ of the immune system) whose job it is to destroy infections in the body. It reproduces within these cells and as it gradually destroys them, the immune system responds by generating more antibody cells to fight the virus. These antibody cells cannot eliminate the virus and, with the immune system so weakened that it can no longer fight off even - under normal circumstances - quite harmless diseases1, this is when the condition has progressed to AIDS. It normally takes about 10 years to develop AIDS once a person is HIV infected, the time depending on treatments and lifestyle - among other factors (Irwin, Millen & Fallows, 2003, p.xxv). The virus is highly concentrated in certain body fluids such as semen and blood, and transmission from one person to another occurs through either sexual intercourse, (both vaginal and anal); blood transfusions - or other ways that contaminated blood can enter a healthy persons blood stream (needle sharing among drug users for example); and from mother to child in utero, at birth or through breast milk. The first method is, however, the most common, and it is estimated that 70 to 80 percent of transmissions worldwide happen through sexual intercourse (Adler, 2001, p.2).
1.3 The global spread of HIV/AIDS “AIDS is unique in human history in its rapid spread, its extent and the depth of its impact” (UNAIDS, 2004, p.13). Since the 1980s the virus has spread rapidly in the world resulting in an estimated 40.3 million people living with HIV at the end of 2005 (UNAIDS/WHO, 2005, p.1), and every day more people are becoming infected. Estimates further suggest that during 2004 there were 14000 new infections per day - a yearly total of 4.9 million worldwide (UNAIDS/WHO, 2004). The cumulative number of AIDS related deaths was estimated 1
These infections are called opportunistic infections (UNAIDS, 2002a, p.46).
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to be more than 25 million by the end of 2005, and during 2005 alone, 3.1 million people passed away (UNAIDS/WHO, 2005, p.2). Since the end of 1997, there has been an increase of about 8 million PLWHA. More than 95 percent of PLWHA are found in developing countries, and the region that has been hardest hit by the epidemic is Sub-Saharan Africa, where the number of people infected is said to be 25.4 million (64 percent of total cases), as can be seen in figure 1.1. The region further accounts for about three quarters of the number of deaths worldwide since 1981 (UNAIDS/WHO, 2000, p.11).
Out of the total number of PLWHA, 2.2 million are children. And, of the adults that are infected, a growing percentage is women who are more vulnerable to the epidemic for many reasons, as shall be discussed later on. While in 1997, 41 per cent of the adult population affected by HIV were women, by 2002 the figure had grown to almost 50 percent (UNAIDS, 2004, p.22), with 17.6 million women affected at the end of 2004 -5-
(UNAIDS/WHO, 2004). Alongside women, the group within the general population that is experiencing a rapid increase in HIV infection is that of adolescents and young people (almost 50 per cent of new infections are found in the age group between 15 and 24) (UNAIDS/WHO, 2004). Other groups that are more vulnerable to the HIV epidemic either because of risky behaviour, or because they are more physically or socially vulnerable include marginalised groups such as men who have sex with men (MSM), commercial sex workers (CSW) and injecting drug users (IDU) (Abreu, Noguer & Cowgill, 2003, pp.7-8).
1.4 HIV/AIDS in Latin America The Latin American region has only 4 per cent of the global population of PLWHA with 1.8 million people affected (see fig. 1.1) (UNAIDS/WHO, 2005, p.59), but has prevalence rates ranging from over 5 per cent in Haiti to 0.1 per cent in Bolivia and Cuba (UNDP, 2005, pp.246-249)2. However, there are huge problems with underdiagnosis and underreporting, which makes it difficult to get an exact overview of the situation (Abreu et al., 2003, pp.3-5). The nature of the epidemic in the Latin American region moreover is very complex, and differs from country to country. Mexico for example, has the highest prevalence of HIV transmission among high risk groups such as MSM, (47 percent), while in Central America, the most common mode of transmission is through heterosexual sex (72 percent of the transmissions). In Brazil the picture is less skewed; MSM transmission accounts for 30 percent, heterosexual transmission 27 percent, and IDU and contaminated blood products each account for 19 percent of infections (Abreu et al., 2003, pp.1-48).
1.5 The situation in Nicaragua While three of the six Central American countries, Belize, Guatemala and Honduras are among the countries with the highest estimated HIV prevalence in the Latin American region – with over 1 per cent of the adult population being HIV infected – Nicaragua is the Central American country with the lowest HIV prevalence at an estimated 0.2 per cent (UNDP, 2005, pp.246-249; World Bank, 2003, p.1). The total number of PLWHA 2
See Appendix A for a list of prevalence rates in Latin America.
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registered by the Ministry of Health (MINSA) (Nicaragua, 2004) from 1987 to 2004 was 16073. The first AIDS case discovered in Nicaragua was in 1987 – which was late in relation to other countries – but since that year, the number of PLWHA has been growing rapidly (see fig. 1.2), and now, around one new case per day is reported (Nicaragua, 2004; C. Quant, personal communication, January 28, 2005)4.
The most common mode of HIV transmission in Nicaragua is through sexual relations, of which 67 per cent are heterosexual, and 33 per cent are between MSM (UNAIDS, 2002a, p.12). There are different reasons why Nicaragua is an interesting country to look at in relation to HIV/AIDS. First of all on grounds of the qualitative and quantitative changes occurring in the epidemic – such as the increasing number of young people becoming
3
UNAIDS, however, has estimated that there were more than 6000 people living with HIV at the end of 2003 (UNAIDS, 2004, p.202). 4 See Appendix B for a complete list of personal communications.
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infected, and also its rapid feminization (Nicaragua, 2004). Second, when it comes to HIV/AIDS, Nicaragua is a country with many risk factors present, including high rates of STIs, high levels of poverty, the geographical position of the country situated as it is between neighbouring states with a high HIV ratio, and a high level of human mobility through the country (Nicaragua, 2000, p.72). In addition, socio-cultural factors such as machismo; (a disturbingly high rate of) gender-based violence (GBV); the inadequacy of sexual education; low rates of condom use and low perception of risk within the general population are among other factors that make the population vulnerable (Nicaragua, 2000, p.31; Low et al, 1993, p.695) as we discuss in Chapter 2.
Fig. 1.3 Men who Have Sex with Men (MSM) MSM is a high-risk group in relation to HIV/AIDS. HIV prevalence among MSM in Nicaragua is estimated to be around 9 per cent (UNAIDS, 2004, p36). It is increasingly recognized that MSM serve as a bridge between homosexual and heterosexual infection, as it is common for MSM to have sex with both men and women (Stillwaggon, 2000, p.994). MSM are at greater risk of HIV infection for several reasons: physiologically, practices such as unprotected anal sex increase the chance of contagion. However this group also suffers social and cultural marginalisation – stigma resulting from machismo and religious intolerance is widespread in Nicaragua (Abreu et al., 2003, pp. 29-30; UNAIDS, 2000, p.67), and homosexual relationships are also forbidden by law (article 230 of the Penal Code) (Sånchez et al., 2000, p.10). These factors can hinder the openness of MSM, and the fact that not all MSM consider themselves gay can make it difficult to reach them as a risk group in prevention efforts (World Bank, 2003a, p.3).
1.6 Conclusion The world has seen a rapid spread of HIV/AIDS and, in its wake, severe and devastating consequences. Throughout the world there is a growing consensus that rapid and efficient
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responses and commitment are urgently needed. The Sub-Saharan continent is most adversely affected, whilst on the Latin American continent the epidemic is diverse and complex in its nature, differing both quantitatively and qualitatively. Nicaragua is still a country with low rates of HIV, where heterosexual relations is the main mode of transmission, but there are several aspects that make the situation increasingly serious, such as a rapid spread of the virus and a number of vulnerability factors present. In the next chapter these risk and vulnerability factors will be examined in more detail, alongside two vulnerable groups; women and young people.
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2 VULNERABLE GROUPS IN A VULNERABLE SOCIETY (Establishing the need for action)
2.1 Introduction Nicaragua is a country with a low prevalence of HIV/AIDS. However, according to the World Health Organisation [WHO] (2005, p.1), there is a great risk that infections will continue to increase sharply. Subsequently, in this chapter we draw attention to some of the principal conditions that might contribute to a further rapid spread, such as high levels of poverty; migration and mobility; cultural and religious influences; lack of sexual education; lack of perception of risk and high rates of STIs. Further, we examine two of the most vulnerable groups within the general population, namely women and young people.
2.2 Risk and vulnerability factors HIV risk is defined as the probability that a person may acquire HIV infection, due to risk-taking behaviour (UNAIDS, 1998, p.5), while the term vulnerability refers to those environmental and societal factors that might increase the susceptibility of certain groups to infection (Shaw & Aggleton, 2002, p.6). The scope of this chapter is not to test and confirm any causal relationships between factors, however, but rather to simply identify the presence of the most significant ones.
2.2.1 Poverty Nicaragua is the second poorest country after Haiti in the Latin American region, with 45.1 per cent of the Nicaraguan population living in extreme poverty and 79.9 per cent living in general poverty in 20015 (Nicaragua, n.d.; UNDP, 2005, p.228). It is widely recognised that poverty and HIV/AIDS are interrelated; an epidemic can create and/or intensify conditions of poverty, but it can also be fuelled by poverty itself (Stillwaggon, 2000, p.988; UN, 2005, p.3). Living in conditions of poverty can contribute to 5
According to World Bank definitions, those in extreme poverty live on less than US$1 a day, while those in general poverty are living on less than US$2 a day.
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vulnerability in many ways; firstly, people who live in poverty often have poorer health (UNAIDS, 1998, p.7), while common results of poverty are malnutrition and parasitosis, which, according to Stillwaggon (2000, pp.991-992), can increase the susceptibility to HIV infection6. Estimates from 1997-1998 showed that 31 per cent of the Nicaraguan population were malnourished (Food and Agriculture Organization of the United Nations [FAO], 2001, p.5), and particularly vitamin A deficiency7 is widespread in children, students and women (FAO, 2001, p.4; Stillwaggon, 2000, p.998). Secondly, poverty may be linked to problems such as alcoholism and drug use, which can lead to an increase in risky behaviour such as practising unsafe sex, and/or sharing of needles when injecting intravenous drugs (Abreu et al., 2003, p.7; Nicaragua, 2000, p.29). Prostitution, which puts people at risk of infection due to the frequency of unprotected sex with multiple partners, can also be seen as a result of poverty (Stillwaggon, 2000, p.1002), and in relation to drug addiction, either as a last resource to earn a living, and/or to fund drug use (Sánchez, Shedlin & Araica, 2000, p.9; Shaw & Aggleton, 2002, p.2). Furthermore, poverty restricts access to (adequate) health services, and can limit the ability to fund prevention such as the purchase of condoms (Shaw & Aggleton, 2002, pp.6, 8). Temporary labour migration is another result of poverty (Stillwaggon, 2000, p.1000), and migration and mobility are linked to HIV infection, as we shall see below.
2.2.2 Migration and mobility It is increasingly recognised that migration and mobility contribute to the spread of HIV/AIDS, as mobile populations might find themselves in vulnerable situations and/or engage in risky behaviours8 (UNAIDS, 2001, pp. 2, 5). In Nicaragua, internal migration and mobility is high, while international mobility – especially to and from Honduras in the north and Costa Rica in the south, countries that 6
Stillwaggon (2000, p.1006) argues that malnutrition and parasitic diseases increase the risk of HIV infection as they depress the body’s immune responses. 7 Vitamin A is essential for immune response (Thakore, 2003). 8 For a detailed overview of risk and vulnerability factors affecting migrant and mobile populations, see Population, Mobility and AIDS (UNAIDS, 2001).
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have much higher rates of HIV/AIDS – is also significant (Pan American Health Organization [PAHO], 1998, p.383; Nicaragua, 2000, p. 72). Several factors contribute to this migration/mobility: Firstly, the Pan-American Highway runs through Nicaragua (see fig. 2.1) and is the only conduit for heavy transport to travel between the north and the south of Mesoamerica. Secondly, temporary labour migration – such as to Costa Rica – is frequent (PAHO, 1998, p.383; Sánchez et al., 2000, p.iii), and furthermore, as a consequence of the Sandinista government’s defeat, many Nicaraguans returned from the United States in the 1990s (Nicaragua, 2000, p.30; Sánchez et al., 2000, p.2). These situations can contribute to an increasing number of HIV infections, as people that were infected when staying abroad can pass it on when they return to Nicaragua (Stillwaggon, 2000, p.1005).
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Fig. 2.1: Map of Nicaragua. Source: UN, 2004.
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Internally, many people migrate from rural areas to Managua9, the country’s capital, in search of employment and a better life. However, many end up unemployed and living in poor conditions (PAHO, 1998, p.383). This, in addition to the capital being one of the most important connection and communication points – both domestically and internationally – for buses, flights and transport, contribute to its high number of PLWHA (see fig. 2.2) (Proyecto Acción SIDA de Centroamérica [PASCA], n.d., p.1). Chinandega has the second highest number of PLWHA in Nicaragua, arguably due to its maritime port and because it is situated next to the border with Honduras, which has the highest PLWHA ratio in Central America (UNAIDS, 2002a, p. 24). León’s numerous HIV cases are a result of the city being an important transit point for heavy transport; the active prostitution industry, and the fact that it is sharing border with Chinandega (PASCA, n.d., p.1). The two autonomous regions on the Atlantic coast (RAAN and RAAS) – with important maritime borders – have high levels of internal and external migration, and have further become a corridor for drugs, which contribute to the high
9
It is estimated that 40 per cent of internal migrants come to Managua (PAHO, 1998, p.383).
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HIV ratios. Moreover, cultural diversity10; marginalisation; low levels of education, and extremely high levels of poverty are some of the causes that make people in these two regions vulnerable to HIV infection (Camaroni & Roos, 2005, p. 5; Nicaragua, 2002, p.8; UNAIDS, 2002a, p.12).
2.2.3 Machismo and gender based violence “Machismo (…) kills us. It can kill us instantly, or slowly. It can kill not only our bodies, but also our feelings, our hopes, our ideas and dreams, our dignity; at last, the right to live our own life, and enjoy it”. (Puntos de Encuentro, 2004, p.3, the translation is ours).
Machismo-related behaviour and way of thought is broadly present in the Nicaraguan society. While machismo is considered to be universal, it is also most closely identified with societies in Latin America (Machismo, 1999, p.873). It is a term which is defined in many different ways, with definitions of machismo indicating: “a strong or exaggerated sense of masculinity stressing attributes such as physical courage, virility, domination of women, and aggressiveness” (American Heritage Dictionary of the English Language, 2000), or a “joint set of ideas, attitudes, habits and traditions which maintain that men are superior to women” (Puntos de Encuentro, 2004, p.2, the translation is ours). The machismo factor is especially evident in the socialisation of children in Nicaragua; boys and young males are taught to be strong, active and dominant, and are encouraged to engage in activities that demonstrate these qualities. These might be actions such as drinking, gambling, fighting, and having several sexual partners; all which are meant to assert masculinity (Lancaster, 1992, pp.40-44; Puntos de Encuentro, 2004, pp.2-5). Sexual roles are strongly influenced by machismo; boys are encouraged to have sexual relations at an early age and with as many partners as possible, and vulnerability to HIV infection is a result of men’s multiple sex partners, and the low rate of condom use (Nicaragua, 2000, p.31; PAHO, 2004). The role of women is that of subordination, and in sexual relationships they are supposed to be passive (see section 2.3.1)(Centro de Información y Servicios de Asesoría en Salud [CISAS], 2004, p.15).
10
RAAN and RAAS is the home of different indigenous and minority populations (including Miskito, Rama, and Criollo), with different languages and religious beliefs (Nicaragua, 2002a, pp.7-8; Sánchez et al., 2000, appendix D).
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One of the most serious ways in which machismo is manifested is through Gender Based Violence (GBV). A large part of GBV takes place in intimate relationships (Heise, Ellsberg & Gottemoeller, 1999, pp.1-2); statistics from the 1998 ENDESA national survey11 in Nicaragua showed that 29 per cent of women had experienced violence in a close relationship (Pizarro, 2004c, p.5). GBV includes physical, sexual, psychological and economic abuse towards women, and studies show that the risk of getting infected with HIV is increased among women who are experiencing GBV (PAHO, 2004; UNAIDS/WHO, 2005, p.10).
2.2.4 The Catholic Church Even though the Nicaraguan state is secular according to the constitution, Catholic values have always heavily influenced government policies (Pizarro, 2004c, pp.2-3; Sánchez et al., 2000, p.8). Regarding HIV prevention, the Catholic Church is counteracting the control of HIV/AIDS as it is firmly opposing the use of condoms as a first choice of protection, while advocating instead Abstinence and Fidelity (Pizarro, 2004c, p.5). Further, representatives of the Church, such as Fader Eddy Rojas, indirectly condemn those who have been infected, when claiming that: “the causes of AIDS infection is the lack of Christian values; lack of knowledge about the ways of transmission of the disease; infidelity and promiscuity” (Chamorro, 2005, the translation is ours). Such statements are stigmatising, and contribute to fuelling the HIV epidemic, as stigma can for example lead to a fear of being tested, and to admitting that one is HIV positive (UNAIDS, 1998, pp.7-8; UNAIDS/WHO, 2005, p.10). Rojas’ statement also suggests that moral values are the best way to fight AIDS; and this leads us to the next vulnerability factor, namely the lack of adequate sexual education.
11
The Encuesta Nicaragüense de Demografía y Salud (ENDESA), 1998, gives general information about knowledge, attitudes and practices among the population in the area STI/HIV/AIDS (Nicaragua, 2002, p.5).
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2.2.5 Low levels of education Educational attendance in Nicaragua is low: In 2000 it was estimated that primary enrolment was 80.7 per cent, but only 54.2 per cent of those enrolled completed five years (Nicaragua, n.d.). Education can reduce risk-taking behaviours, and more so in the case of sexual education (based on scientific and objective information), both through expanding knowledge about STIs and how to prevent them, but also through enhancing awareness and the perception of risk in the population (see section 2.2.6) (Abreu et al., 2003, p.92; Nicaragua, 2000, p.29; UNAIDS, 1998, p.5). (Unfortunately), Nicaragua lacks this kind of information, as the Church’s influence is seen in educational policies, such as when the Ministry of Education, Culture and Sports (MECD) had to modify the suggested manual for sexual education, after the government experienced pressure from religious groups in 2003 (Navas, 2005; Pizarro, 2004c, p.3).
2.2.6 Lack of perception of risk Another factor that puts people at risk is their lack of perception of being susceptible to HIV infection. HIV/AIDS is something that has commonly been believed to only affect marginalised groups such as MSM, CSWs and IDUs (L. ArgĂźello, personal communication, February 24, 2005)12. In a country where stigma and discrimination prevails, and HIV infection is associated with promiscuous behaviour, it might be hard for people in the general population to recognize that they too are prone to HIV infection. This is especially clear in relation to housewives for example (C. Espinoza, personal communication, September 23, 2004). Most Nicaraguans have heard about AIDS and how to prevent it (Nicaragua, 2002, p.5), but we can see that there is also a discrepancy between those who know about condom use (and believe it is the best way of preventing HIV infection), and those who actually use it. In the ENDESA-98 survey, almost all of those questioned had heard about AIDS, yet only 59.1 per cent of the women, and 25 per cent of men sampled altered their behaviour to prevent them contracting it (Nicaragua, 2000, p.30). Furthermore, when asked if they believed they had a chance of getting infected, 64.6 per cent of women and 41.4 per cent of men answered that there was no possibility of them getting infected (Nicaragua, 2000, p.31).
12
See appendix B for a complete list of personal communications.
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2.2.7 High rates of STIs There are not only socioeconomic, cultural and cognitive factors that may put people at risk, but physical factors can also play a part; for example, other STIs apart from HIV, make people become more susceptible to HIV infection (World Bank, 2003a, p.3). One reason for this is that some STIs (such as genital herpes) can lead to open sores and ulcers, which allow the HIV virus to enter the body more easily (UNAIDS/WHO, 2005, p.12). The registered cases of STIs are high in Nicaragua (Abreu et al., 2003, p.187): MINSA reported 3121 cases of gonorrhoea; 1428 cases of genital warts; and 673 cases of syphilis in 2001 (Nicaragua, 2002, p.9). However, there is also likely to be a large number of unreported cases, as many choose not to get tested when they suspect the have an STI, partly due to fear of being judged (Nicaragua, 2000, pp.16-17, 41).
2.3 Vulnerable groups Although one of the most important messages to spread in the fight against HIV/AIDS is that everyone can be infected, some people are more vulnerable to infection than others. The Nicaraguan epidemic is mainly general in scope affecting people other than those considered to be marginalised (MSM, CSWs and IDUs). We will in this section take a look at two groups within the general population, which are especially vulnerable to infection.
2.3.1 Women The male to female ratio has gone down dramatically from 7:1 at the beginning of the epidemic, to 2.6:1 in the first part of 2005 (Nicaragua, 2005), with the largest numeric group of PLWHA being housewives (see fig. 2.3). The feminization of the epidemic is especially worrying because of the possibility of mother-to-child transmissions: Vertical transmission accounted for 3 per cent of HIV infections in 2005, and the figure is expected to rise (Linneker & VĂquez, 2005, p.23; Nicaragua, 2005, pp.1-2).
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One of the reasons why women are especially vulnerable is, as suggested above, the machismo factor (and the resulting GBV), which either manifests itself directly through sexual violence, or more indirectly –as women have less power in decision-making, such as deciding on the use of condoms, and/or whether to be sexually abstinent13 (CISAS, 2004, p.15; PAHO, 2004). A study showed that even when women believed that their husband or boyfriend had extramarital sex, condom use was low (Claeys, Gonzalez, Gonzalez, Van Renterghem & Temmerman, 2002, p.206), and the ENDESA-98 Survey found that only 2.7 per cent of married women used condoms as protection (Nicaragua, 2000, p.31). Women are also more biologically susceptible to HIV infection than men. Research suggests they have a two to four times greater chance of contagion because the vagina has a larger area of mucous membrane through which the virus can more easily pass into the bloodstream (PAHO, 2004). Younger girls are especially more vulnerable, becoming
13
If women take the initiative to suggest using a condom, they can be perceived as cheap, unfaithful and so on, and might be punished physically or verbally (Nicaragua, 2000, p.31).
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infected five to ten years earlier than men14 (see fig. 2.4), with Reid & Bailey (1992) suggesting that there is “a biological, immunological and/or virological susceptibility in women which changes with age”. In relation to GBV, it is also suggested that younger women are at greater risk of sexual and physical violence than older women, as they have less autonomy (Morrison, Ellsberg & Bott, 2004, p.6). However, as both sexes are increasingly becoming infected at an earlier age, age and adolescence are also correlated with vulnerability.
2.3.2 Adolescents and young people A large part of the Nicaraguan population is young, as 43 per cent are under 15 years of age (Sánchez et al., 2000, p.iii), and when looking at the HIV/AIDS statistics from MINSA, it is striking that the most affected groups are those between the ages of 20 to 39 (Nicaragua, 2004). Furthermore, as it normally takes about ten years from when a person has been infected with the virus to the development of full-blown AIDS, infection clearly takes place at a very early age (Nicaragua, 2002, p.12). Some of the reasons that contribute to this situation are the early age at which young people initiate their sexual relationships15 and furthermore, because of the lack of scientific and objective sexual education available to them (CISAS, 2004, p.15). This can also been seen as fertility rates are high16 –especially among adolescents with low levels of education (World Bank, 2003b, p.7). Low levels of condom use also indicate that there is a lack of perception of risk among young people: A study in Jalapa17 found that out of the three quarters of the sexually active boys surveyed who said condom use was the best prevention against HIV, only 33 per cent of them reported actual condom use –while out of the 50 per cent of (sexually active) girls who reported condom use as the best method of prevention, just 27 per cent reported using it (Red Cross Nicaragua, Red Cross Italy, CIET Nicaragua & UNICEF, 2003, p.6). The study also found that perception of risk was higher among male participants than female participants (Red Cross Nicaragua et al., 2003, p. 44). 14
70 per cent of girls living with AIDS were to be found in the age groups up to 30 years old, while only 42.8 per cent of men were found in the same age group (Nicaragua, 2004). 15 More than half of young men and 16.6 per cent of girls have had sex before the age of 16 (CISAS, 2004, p.15). 16 In the period 1998 to 2001 the fertility rate was 119 births per 1000 women in the age between 15 and 19, which was the highest adolescent fertility rate in Latin America (World Bank, 2003b, p.7). 17 The study included 758 young persons aged 15 to 19.
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2.4 Conclusion In the context of HIV/AIDS, Nicaraguan is a vulnerable society. In this chapter we have seen that factors such as widespread poverty is making people vulnerable, while cultural factors such as machismo and the Catholic Church’s dominance influence the way sexual relations, and prevention strategies are perceived and promoted. Although there is a lack of objective and scientific educational information, most people have heard about AIDS and ways to prevent HIV infection. However, there is a discrepancy between knowledge and behaviour, and condom use is not high within the population. Furthermore, migration and mobility are factors that create vulnerability to HIV infection. These risk and vulnerability factors are interrelated, and although anyone can get infected, we have identified certain groups who are more susceptible than others, such as women and young people. Prevention policies need to be directed towards these groups and have to focus on the complex risk and vulnerability factors to be able to curb further rapid spread of the - 22 -
HIV virus. However, it is also important to dedicate resources to the treatment and care of PLWHA. We shall present some of the current responses both in relation to prevention, and to treatment and care in the subsequent chapter.
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3 FIGHTING THE HIV/AIDS EPIDEMIC (Presenting the national responses) “In the context of HIV/AIDS, the ultimate aim of risk and vulnerability reduction is to enable people to exert control over their own risk by a process of individual and collective empowerment as well as to develop societal responses that create an environment in which safer and protective behaviour can be practised� (UNAIDS, 1998, p. 9).
3.1 Introduction Dedicated and focused action is needed to counter a rapidly expanding HIV epidemic. We have already identified some of the most important vulnerability factors and susceptible groups in Nicaragua, which should be targeted when countering the epidemic. The UNAIDS Global Report (UNAIDS, 2000) identifies several common features of effective national responses in the fight against HIV/AIDS; political leadership and the will to fight the epidemic is crucial, but a strategic response involving different government departments, the private sector, the mass media and civil society is also necessary. Furthermore, effective efforts require long-term commitment, with initiatives ranging from national to community level and policies drawn from previous responses which have proven to be successful. The importance of focusing on combating stigma is also emphasized, as is the need for social policy reforms to address the complex vulnerability factors within society (UNAIDS, 2000, pp.108-115). When HIV prevention strategies are developed it is equally important to include treatment, care and support for those people already living with HIV/AIDS, as both areas are seen as mutually reinforcing to counter the epidemic (Irwin et al., 2003, p.60; Salomon et al, 2005). The aim of this chapter is to present the different responses to the HIV/AIDS epidemic in Nicaragua. Many are a result of cooperation between government and civil society, and involve financial aid and support from external donors (such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and various foreign embassies). To ease the progress of this chapter, however, the responses will be presented as follows: - 25 -
Firstly, we will examine the different governmental prevention strategies. Then we present the methods of promoting HIV prevention of two NGOs (Servicios Integrales para la Mujer (SI Mujer) and Puntos de Encuentro), and a voucher programme led by the Central American Health Institute (ICAS). Subsequently, we take a look at treatment and care, (where the focus is on strategies aimed at countering stigma and discrimination and on treatment and care for PLWHA). This section is also divided into governmental and NGO activities, (the NGOs being the Asociación de Personas que viven con VIH/SIDA (ASONVIHSIDA) and Fundación Nimehuatzin).
3.2 Prevention The most common prevention strategies are based on programmes of information, education and communication. They have the promotion of safe sex and the use of condoms as their main focus, and are especially targeted at certain vulnerable groups. Investigation is also central, so as to shed more light on the nature and scope of the epidemic (Nicaragua, 2000, p.4). Prevention strategies in Nicaragua are a result of governmental and NGO initiatives, or collaboration between these two: One of the most important joint initiatives has been the creation of CONISIDA (The Nicaraguan AIDS Commission), a platform to facilitate dialogue and the sharing of knowledge and experiences, under Ley 238: Ley de Promoción, Protección y Defensa de los Derechos Humanos ante el SIDA (the Law of Promotion, Protection and Defence of Human Right in the Presence of AIDS) (UNAIDS, 2002a, p.26). CONISIDA is made up of members from different governmental departments, NGOs working in the area of HIV/AIDS and a health worker representative18.
18
The current representatives are from MINSA, MEDC, the Ministerio de Trabajo, the Ministerio de Gobernación, INSS, NGOs working in the area of HIV/AIDS, Comisión de Salud de la Asamblea Nacional, Commissions for Human Rights and one representative from the health workers organisation (Ley 238, A32).
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3.2.1 Governmental responses Governmental responses in Nicaragua vary from policies aiming at reducing and controlling HIV, to legal frameworks that directly and indirectly support HIV prevention, together with free services (such as HIV testing) offered to the public. The political plans and legal frameworks target, in most cases, both prevention and treatment and care, but here we have attempted to present these areas separately. The government has, since the first AIDS cases were discovered, incorporated strategies aimed at controlling HIV/AIDS into its political agenda. This can most clearly be seen in the National Programme to Prevent and Control STI/HIV/AIDS (Nicaragua, 2000, p.43). The programme aims to facilitate control, prevention and surveillance of the spread of HIV through policymaking and the creation of sectoral benchmarks (CISAS, 2004, p.8). In addition, other government programmes such as the Programme for Adolescents’ Reproductive Health; the Model for Women’s and Children’s Integral Attention, and the Model for Adolescents’ Integral Attention are other programmes aimed at reducing vulnerability among specific groups (Nicaragua, 2000, p.43). A pivotal political plan, which emerged as a product of cooperation between the government and civil society19, was the National Strategic Plan to fight STI/HIV/AIDS. This document not only expresses political commitment to the fight against HIV/AIDS and other STIs, it also identifies and incorporates most of the strategies proposed by UNAIDS into a national plan to counter the epidemic. The main objective of the plan is “to contribute to a reduction in the incidence of STI/HIV/AIDS, by promoting behavioural changes towards more healthy lifestyles through “multisectoral participation” so as to reduce vulnerability for the Nicaraguan population, and to offer treatment and care to PLWHA” (Nicaragua, 2000, p.67, the translation is ours). It is to be achieved by following eight broad strategies20, which include several practical activities (Nicaragua, 2000, pp.74-78). The
19
The Plan was elaborated by members of the government and several NGOs. In addition, individual experts on HIV/AIDS and institutions and organisations were consulted in the process (Nicaragua, 2000). 20 The strategies focus on political commitment and collaboration; increased funding and budget allocations to HIV/AIDS programmes; information, education and communication campaigns to reduce the incidence of STI/HIV/AIDS; better practices for blood screening and surveillance, and treatment and care for PLWHA (Nicaragua, 2000, pp.74-78).
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Plan forms the basis for the HIV/AIDS component of the proposal made to the Global Fund (see section 3.3.1). The government has also created a legal obligation for information and communication institutions to include and promote HIV prevention (Ley 238). Article 12 of the law establishes the state’s responsibility for facilitating access to scientifically accepted methods of prevention. Other laws, although not directly related to the work against HIV, can further contribute towards preventing HIV infection – for example, Ley 230: Ley de Reformas al Código Penal para Prevenir y Sancionar la Violencia Intrafamiliar (the Law of Reforms to the Penal Code to Prevent and Sanction Domestic Violence) gives legal protection to victims of domestic violence and allows for the imposition of restraining orders. It also expresses the right of the victims to receive psychological and medical attention if needed (Centro de Mujeres: Masaya, 2004). Chapter VIII of the Penal Code deals with rape and sexual abuse, and acknowledges it as an aggravating circumstance when the violator is the carrier of a serious STI (A195). Although not directly dealing with HIV prevention, this kind of legislation contributes to reduction of women’s vulnerability21 by creating a legislative and normative foundation for the sanctioning of violent acts towards women (Morrison et al., 2004, p.16, citing Larraín, 1999). Adolescents and young people’s health is also targeted in existing legislation: In 2002, Ley de Promoción del Desarrollo Integral de la Juventud (the Law for the Promotion of Youth’s Integral Development) was created. It establishes young people’s right to health services in order to reduce immunological diseases. Furthermore, it indicates that information about sexual and reproductive health should be provided for young people with a special focus on “teenage pregnancies, unwanted pregnancies, abortion in risk conditions and HIV/AIDS” (Pizarro, 2004a, p. 65).
21
See Chapter 2, sections 2.2.3 and 2.3.1
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In addition to providing a political and legislative structure, the government also provides free health services related to HIV prevention; at the MINSA headquarters in Managua, the Elisa Blot HIV test is offered to anyone for free (Pizarro, 2004a, p.80). HIV testing is one of the most important prevention strategies as it helps provide a more precise overview of the epidemiological situation and hence, allows for the creation of more efficient responses (Abreu et al., 2003, pp.50-51). In addition to governmental responses in the fight against HIV/AIDS, civil society is also playing an important role, offering a wide range of prevention initiatives.
3.2.2 Non Governmental Organisations Although most NGOs have a broad program agenda that includes issues such as (for example) gender equality, children’s rights and violence, HIV/AIDS prevention strategies within civil society are manifold. Certain NGOs focus on supplying information about HIV/AIDS to specific groups (Centro Para la Educación y Prevención del SIDA (CEPRESI)22), some offer information and support through hotlines (Xochiquetzal) and others offer free contraceptives (SI Mujer, CEPRESI), HIV testing (SI Mujer) and treatment for STIs (Xochiquetzal and SI Mujer). Some organisations operate in several parts of the country (such as CISAS) while others mainly work within one area (Campaña Costeña de Lucha contra el SIDA (CONFER) works exclusively on the Atlantic coast). There are also networks within the country working with HIV/AIDS, which strengthen and coordinate NGO responses such as the Comisión Nacional de Lucha Contra el SIDA desde la Sociedad Civil (CNLS) (C. Espinoza, personal communication, September 23, 2004; Sánchez et al., 2000, appendix D). One of the most reputed Nicaraguan NGOs in terms of HIV prevention is Puntos de Encuentro, which was founded in 1991 and is based in Managua. Puntos is a nongovernmental organisation whose main target groups are women and young people. It aims to change those attitudes, values and actions that establish power relationships within society; to counter discrimination and machismo; and to promote young people’s
22
CEPRESI is a group aimed at MSM.
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right to make decisions about their sexual behaviours, among other things (Bradshaw, 2005, p.2; Weinberg, 2006, p.38). Puntos de Encuentro uses the media to inform and educate, and its message reaches out to a large part of the country’s population through its national radio and TV programme, el Sexto Sentido. While the radio programme invites people to ring in and discuss different issues, the TV show is a soap opera that covers topics such as drug abuse, homosexuality, sexual violence, abortion, and HIV/AIDS, and has been a major success in Nicaragua (Bradshaw, 2005, pp.6-7; Weinberg, 2006, p.38). Another NGO, SI Mujer, also targets vulnerable groups – women, young people and those living in poor areas – but adopts a different approach. Its focus is on sexual and reproductive health and rights, and its services include medical, legal and psychological attention in addition to information, dissemination and education. SI Mujer has two branch offices in Managua, the SEDE Central and the Programa para Adolescentes y Jóvenes (PAJ), in addition to a small medical post in Ciudad Sandino (just outside Managua). One of the strategies used sees local women and adolescents visit poor areas where they give talks and distribute flyers concerning issues such as violence, prevention, STIs and HIV/AIDS. SI Mujer also participated in the civil society project “A mí me puede afectar el SIDA” 23, a three year project (January 2003 to December 2005) partly funded by the Norwegian Agency for Development Cooperation (NORAD) (Carola Espinoza, personal communication, September 23, 2004; Norwegian embassy, 2003)24. Activities undertaken included the organisation of conferences on bio security, meetings with journalists and health workers to raise awareness about Human Rights for PLWHA and Ley 238, and conferences to focus on the lack of perception of risk among young people. Other initiatives from civil society include for example a voucher scheme led by ICAS, which has involved several NGOs in the free provision of sexual and reproductive health care services to poor adolescents (aged 12-20) in Managua and other cities. The vouchers 23
The NGOs participating in the Project are CISAS, Centro de Estudios y Promoción Social (CEPS), Fundación Xochiquetzal, SI Mujer and CNLS (Norwegian embassy, 2003). 24 See appendix B for a complete list of personal communications.
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are distributed to adolescents who (within 3 months) can come for a free consultation and follow-up appointment in any of the health clinics involved in the project (SI Mujer being one), and in addition they are given free condoms and complementary sexual information (Meuwissen, Donaire, Medina, Segura, & Gorter, 2004).
3.3 Treatment and care Treatment and care for PLWHA is an important tool in the fight against HIV/AIDS, not only because it enhances the quality and length of their lives and reduces the number of deaths, but also because it is an essential component of prevention – and a combined prevention/treatment response gives better results (Salomon et al., 2005, p.0050). Treatment, care and support for PLWHA include the promotion and protection of human right for PLWHA, so that they can live their lives in dignity, free from stigma and discrimination. It also includes the right to medical attention and access to antiretroviral (ARV) treatment. When it becomes clearer that being diagnosed with AIDS is not a death sentence, more people will want to be tested, and stigma and discrimination will be reduced (WHO, 2003, p.5). In areas where both testing and treatment is available, there is generally a higher number of people who get tested than in areas where treatment is not available (Global Fund, n.d., p.13).
3.3.1 Governmental responses Ley 238 is the most important legislation on the statue books to ensure the rights of PLWHA. The law declares that the state should provide counselling, consultancy, support and treatment for PLWHA (A19). It further establishes the right to non-discrimination against PLWHA in labour, education, sport and recreational activities (A22; A24; A25); the right to confidential and voluntary HIV testing (A5-7); and that they should not be isolated for other reasons than the protection of their health when in hospital (A28). The law also states the obligation of governmental as well as private institutions and organisations to promote the participation of PLWHA in HIV prevention initiatives in their communities or organisations (A9). This law is a crucial instrument to fight stigma and discrimination; Fundación Nimehuatzin describes the case of a man who had a serious STI and died as a result of doctors fearing to operate thinking he was HIV positive – although, it turned out he was not (UNAIDS, 2002a, p.37). - 31 -
The coverage of ARV treatment has improved in the last two years, with 154 people now receiving treatment (Global Fund, 2006). A five year long plan funded under the Global Fund started in October 2003, and is based on the main strategies from the National Strategic AIDS Plan. Its aim is to reduce the number of new HIV cases and prolong the lives of PLWHA (Global Fund, 2003, p.22). The goal stated in the plan is to increase the percentage of PLWHA who receive treatment from 0 per cent in 2002 to 60 per cent in 2008. Other specific goals to improve treatment and care for PLWHA include the provision of prophylactic treatment25, educating more health personnel to attend PLWHA, and expanding the number of hospitals equipped to offer treatment and care to PLWHA (Global Fund, 2003, p.2).
3.3.2 Non Governmental Organisations “[The PLWHA](…) we are not the problem, we are the solution” (Flor de María Alvarado, UNAIDS, 2002a, p.35, the translation is ours). Civil society does not only work in the area of HIV prevention, but is also aimed at the people already living with HIV/AIDS. ASONVIHSIDA is perhaps one of the most important and influential organisations that work to support PLWHA. The NGO started out as a self-help group for PLWHA in 1996, with just 18 people. However, it grew rapidly and currently has 152 members with branch offices in four departments: Chinandega, Granada, Masaya and Managua (V. Rivera, personal communication, January 12, 2005). It collaborates with other NGOs, networks and through international cooperation (UNAIDS, 2002a, p.35), and its president, Arely Cano Meza is one of the representatives in CONISIDA (V. Rivera, personal communication, January 12, 2005). One of its principal objectives is to promote and defend human rights for PLWHA, and to ensure compliance with Ley 238 (ibid.). It is also a place where those who have discovered they are HIV positive can come for support, advice and counselling. It aims to raise awareness about HIV/AIDS discrimination and human rights of PLWHA within society by holding workshops for institutions and in schools (ibid.), such as those
25
Prophylactic treatment prevents AIDS related diseases in a HIV positive person.
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workshops held with employees of the Hospital Roberto Calderón (C. Quant, personal communication, January 28, 2005). Fundacíon Nimehuatzin (funded in 1990) is another NGO working for the rights of PLWHA. This NGO was one of the principal organisations advocating for the creation of Ley 238, and is also involved in research, training and education in prevention and care issues (Sánchez et al., 2000, p.14, appendix D).
3.4 Conclusion In this chapter we have identified how UNAIDS suggests countering an expanding HIV epidemic and the different responses adopted to prevent HIV transmission in Nicaragua. The government’s prevention strategies include policymaking including the National Strategic Aids Plan, and also programs that more indirectly can reduce HIV transmission such as health plans aimed at women and young people. The strategies have also legal frameworks that target HIV/AIDS directly and indirectly by reducing the vulnerability of certain groups, and service provision. Furthermore they have also formed an intersectoral commission (CONISIDA) with members from both government and civil society to strengthen responses to the epidemic. Civil society also has a wide range of NGOs that are offering their services in the fight against HIV/AIDS; the NGO Puntos de Encuentro uses radio and TV as forums to change attitudes and behaviours in the population, while SI Mujer offers integral attention (medical, psychological and legal) to women and youth, and supports community work as a way of informing the poorer parts of the population on sexual health issues. In addition, a voucher programme has facilitated the access to sexual and reproductive health services for poor adolescents. Besides prevention strategies, treatment and care responses are also important in fighting discrimination and stigma; Ley 238 targets human rights for PLWHA, and the government has (since gaining the support of the Global Fund) expanded ARV treatment. The NGO ASONVIHSIDA complements this by offering support and advice for PLWHA, and is an influential voice in promoting the rights of PLWHA, while Fundación Nimehuatzin has been an active advocate in for creation of Ley 238. All these efforts are important advances in the fight against HIV/AIDS. However, in the next chapter, we shall take a
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closer look to see what might be the shortcomings in the efforts of both the government and civil society, as there are several areas that need further improvement.
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4 NOT QUITE THERE YET… (A critical look at responses)
4.1 Introduction HIV/AIDS was not seen as an important focus area in Nicaragua, especially not from the government’s side, until recently. However, due to a sharp increase in the incidence of HIV/AIDS after 1999 (Nicaragua, 2004; UNAIDS, 2002a, p.13), more attention was directed towards the epidemic. Not only the increasing number of infections, but also growing pressure from the international community, including the Global Fund’s support contributed to this interest (C. Quant, personal communication, January 28, 2005)26. When talking to people involved in the fight against HIV/AIDS, both from the government and Civil Society, there is a widespread view that many efforts have been made by NGOs in this fight, there is also recognition that there are still many obstacles to overcome, and they all recognise the need for an increased commitment (C. Espinoza, personal communication, September 23, 2004; M. Román, personal communication, February 17, 2005). The aim of this chapter is to examine in more detail some of the responses to the HIV epidemic. Firstly, we see how there is a lack of transparency about the HIV/AIDS situation and responses, which hampers the government’s role in prevention, and how information and education efforts have been influenced by pressure from the Church. Secondly, we argue that HIV testing services need to be expanded further and treatment implemented universally to improve prevention, surveillance and the situation for PLWHA. Furthermore, we will look at how, while the Global Fund’s contribution has led to expanded coverage in treatment, hospitals still lack certain resources to provide full assistance. Finally, we will look at some of the problems faced by NGOs.
26
See appendix B for a complete list of personal communications.
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4.2 Assessing the governmental responses When examining the governmental responses to the HIV/AIDS epidemic, there are a few fundamental problems that become clear: Firstly, the lack of political will and commitment (indicated by the continuous influence of the Church in policymaking, and the responsibility for treatment being left in the hands of the Global Fund). Secondly, efforts are undermined by poor organisation (in sharing of information about the HIV epidemic and financial resources) and thirdly, implementation (of policies and legislation; of universal access to treatment; and of the proposed decentralisation process) has been weak.
4.2.1 Prevention strategies One major problem in Nicaragua is the lack of information on the nature of the epidemic, the programmes aimed at HIV/AIDS and their budgets. The information is fragmented and hard to get hold of (Orozco, 2006). It is especially difficult to know the real amount spent by the government on HIV/AIDS as there are no specific budget allocations for the national HIV/AIDS programme (CISAS, 2004, pp.21-25; Hofbauer & Lara, n.d., p.308). Consequently, spending on HIV/AIDS has to be worked out by MINSA (with the support from SIDALAC and PAHO27) through analyses of the health budget (CISAS, 2004, p.23; Hofbauer & Lara, n.d., p.309). It also appears that a large part of HIV/AIDS funding comes from external sources (see fig. 4.1), and this, and the lack of specific budgetary allocations points to insufficient transparency is one of the grounds on which the government is being questioned regarding its commitment to the fight against HIV/AIDS (Orozco, 2006). As we have seen in Chapter 3, the government is committed to developing policies to fight HIV/AIDS, with the most explicit one being the national AIDS plan. However, the mere presence of policies does not necessarily result in action and, to date, the implementation of the national AIDS plan has been rather limited (Orozco, 2006). This 27
The last budgetary information we have been able to find is from 2002.
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can perhaps most clearly be seen in relation to HIV education and information as the plan’s strategy includes the design and implementation of an Information, Education and Capacitation (IEC) plan to prevent STI/HIV/AIDS (Nicaragua, 2000, p. 75).
Provision is also mainly as a priority, to include the subject in the curriculum at all educational levels (Nicaragua, 2000, p.65). Nevertheless, despite the plan establishing the right to objective and scientific information and education about HIV/AIDS, there have been problems due to the MECD and Church’s emphasis on “moral education” – notably abstinence and fidelity as the best methods of HIV prevention – and their reluctance to include information on the use of condoms in education and campaigns (Hofbauer & Lara, n.d., p.313; Nicaragua, 2000, pp. 46, 52; Sánchez et al., 2000, p.8). While some MINSA officials do not admit to the Church being an obstacle in the fight against HIV/AIDS (M. Román, personal communication, February 17, 2005), the separation of state and Church is seen as a fundamental need (Pizarro, 2004c). Although the influence of the Church on governmental policies is a clear obstacle, the Church has (after international pressure) expressed its concern about the HIV epidemic. It has also taken some steps to join in the fight against HIV/AIDS, such as having Cardinal Miguel - 37 -
Obando pose on a poster promoting abstinence, fidelity and contraceptives as means of prevention, with members of ASONVIHSIDA (V. Rivera, personal communication, January 12, 2005). This is an important move, because the Catholic Church has not only a strong influence on the government, but also on the population. HIV testing is, furthermore, a crucial element for HIV prevention and surveillance. Underreporting is high in Nicaragua – it was estimated to be around 60 per cent in 2001 (Abreu et al., 2003, p.190) – and there is a need to promote the HIV test, as many do not know whether it costs money or where to get it done (V. Rivera, personal communication, January 12, 2005). It is important to identify those who need treatment, and the testing of pregnant women can contribute to reducing mother-to-child transmission. Furthermore, more widespread testing creates a good opportunity to communicate information about HIV prevention (Global Fund, n.d., p.13) as many do not find out about their status until they have developed full-blown AIDS, when it is already too late (Camaroni & Roos, 2005, p.27; C. Quant, personal communication, January 28, 2005). Unfortunately, there is a problem as free HIV testing has only a limited coverage with only 7 out of 17 local health units (SILAIS) having available HIV testing services (Hofbauer & Lara, n.d., p.313).
4.2.2 Treatment and care Universal access to treatment has not been fully implemented (Hofbauer & Lara, n.d., p.312), despite Ley 238 and the national AIDS plan both guaranteeing it. Some claim that the government has neglected to provide ARV treatment, and that instead they are relying fully on the Global Fund for this (Hofbauer & Lara, n.d., p.309). Less than 20 AIDS patients were receiving treatment sponsored by the government at the end of 2002, and this only after ASONVIHSIDA took its case to the Inter-American Court of Human Rights (A. Cano, personal communication, January 12, 2005; Pizarro, 2004c, p.5). However, after Nicaragua received funds from the Global Fund, the number has increased drastically (C. Quant, personal communication, January 28, 2005), with 154 people on treatment as of December 1, 2005 (Global Fund, 2006). However, as it is only a short term programme scheduled to end in 2008, this makes people ask themselves
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what will happen when the funding stops (V. Rivera, personal communication, January 12, 2005). Furthermore, the (public) use of ARV treatment is so far limited to hospitals in Managua. This centralisation makes it difficult for people outside Managua (especially those living in rural areas) to access treatment, and those who do receive it will have to spend a lot of time and financial resources to get to Managua28 (Camaroni & Roos, 2005, p.30; Hofbauer & Lara, n.d., p.312; Orozco, 2006). During the author’s field research, one AIDS patient from Chinandega (receiving treatment in the Managua hospital Roberto Calderón) explained how he had had to get money from an NGO to be able to travel to Managua, as he himself could not afford it. While PAHO and MINSA met in 2005 to discuss decentralisation of treatment (PAHO, 2005; M. Román, personal communication, February 17, 2005), little decentralisation has taken place (Orozco, 2006). Equally, the services that presently exist within the hospitals are somewhat incomplete: there is a problem with the ARV cocktails (certain components are sometimes missing) and there is a lack of drugs for opportunistic infections (Camaroni & Roos, 2005, p.30; C. Quant, personal communication, January 28, 2005). Furthermore, there has been a problem with laboratory equipment, as the hospital is lacking (for example) a microscope, and most importantly, equipment to check the viral load29, which means the doctors have had to send the samples to Guatemala30. Dr. Quant explains that this is especially serious for pregnant women who are HIV positive, because if the result does not come back until after they have given birth, the test will have to be redone (ibid.). Another shortcoming mentioned is the number of staff working with HIV/AIDS patients, as enough funds have not been directed at human resources (Camaroni & Roos, 2005, p.30; C. Quant, personal communication, January 28, 2005).
28
Another problem is that the journey can be an uncomfortable one to make for those who come in with symptoms such as diarrhoea. 29 The viral load is the quantity of HIV virus in the blood. 30 This has led to a delay of up to two months in receiving the results (Camaroni & Roos, 2005, p.30; C. Quant, personal communication, January 28, 2005).
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4.3 NGO Initiatives As mentioned in Chapter 3, Nicaragua has many NGOs working in the area of HIV/AIDS throughout the country. However, even though CONISIDA and the CNLS are working to consolidate NGO efforts, some reports mention the lack of coordination and cooperation between NGOs due to competition for funding (Orozco, 2006; Sánchez et al., 2000, p.24). During her stay in Nicaragua, the author experienced how NGOs work from the inside: SI Mujer’s community work, in which youth were trained to inform about HIV/AIDS (amongst other subjects), reached many poorer areas in Managua, however it could sometimes seem as if the number of flyers distributed during community work (25 per person) was more important than either the quality of the work and/or the oral information given31. The need to challenge cultural attitudes and beliefs is essential in the fight against HIV/AIDS, and NGOs are important in this sense as we can see from the success of initiatives such as Puntos’ soap opera el Sexto Sentido. However, it would be beneficial to expand the methods used; many NGOs work from a feminist point of view, where the empowerment of women is seen as crucial for them to negotiate safer sex, for example. This is indeed important, but the problem should perhaps also target the cause (not only the effect), meaning that there should be more attention directed towards sensitising young boys and men to the idea of gender equality and oblige them to change their attitudes and behaviours (PAHO, n.d; UNAIDS/WHO, 2005, p.10). This approach has been used (albeit not widely), by for example the NGO, CANTERA32, which helps men discuss and reflect upon the concepts of gender and masculinity (CANTERA, n.d.).
31
In need to meet donor’s goals, the stakeholders will need to complete a report at the end of each year to demonstrate how funds has been spent, such as for example having distributed a specific number of flyers (C. Espinoza, personal communication, September 23, 2004) . This leads us to the question of how cost effectiveness and the impact of NGO work is being assessed, as there seems to be little focus on this (Abreu et al., 2003, p. 105). 32 CANTERA is an NGO whose main focus is on gender relations.
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4.4 Conclusion In this chapter we have looked at how despite countless efforts to advance HIV/AIDS prevention, treatment and care, there are still weaknesses and shortcomings that need to be addressed. There is a lack of transparency in information related to the epidemic and the responses, and there is a need for the further separation of state and Church if objective and scientific information is to be spread effectively. HIV testing should also be promoted better and the expanded coverage to aid surveillance. ARV treatment, as we have seen, has improved after the Global Fund came onto the scene(although this is only a five year long programme), but there are still distributional problems due to its highly centralised provision allied to the lack of specialized equipment and medication at the hospitals. Civil society presently seems to be fragmented in its HIV/AIDS efforts, and should develop stronger cooperation. In addition, there is a need to assess the work done by NGOs, as there currently seems to be little information on the cost effectiveness of initiatives, and further, there should also be more focus on the changing of male behaviour in addition to the empowerment of women in gendered HIV/AIDS initiatives.
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CONCLUSION HIV/AIDS has emerged as a serious health threat, affecting over 40 million people worldwide and having killed more than 25 million since its start. The virus, which has no cure, has had its most devastating impact so far on the Sub Saharan continent, where 64 per cent of all cases are found, and where it has seriously disrupted not only the lives of those people affected, but also the society as a whole. Nicaragua however, is a different story: With an estimated prevalence rate of 0.2 per cent, its HIV epidemic is characterized as nascent. Nevertheless, we have seen in Chapter 2 that there are factors present in the country that indicate the epidemic will develop rapidly if serious action is not taken to halt the spread of the virus. The number of HIV infections has increased rapidly during the last 7 years, with the main mode of transmission being sexual intercourse, and today around 1 case per day is reported. An interplay of risk and vulnerability factors is responsible for this increase: High levels of poverty, migration, machismo, the Catholic Church’s influence, lack of sexual education, low perception of risk, and high levels of STIs are all important to consider when trying to explain the HIV situation in Nicaragua. There are several groups that are more vulnerable to HIV infection such as MSM, CSWs and IDUs. However, in this dissertation we have focused on women and young people, as these are the groups within the general population that we consider to be most susceptible to infection. The male to female ratio has gone down from 7:1 to around 2.6:1 in only a few years, and the share of young people with HIV/AIDS is high. In Nicaragua, HIV/AIDS has become a more important focus area during the last years, and both governmental and private initiatives are increasingly involved in the fight against HIV/AIDS. MINSA has set up an AIDS programme, and has created a national AIDS plan to counter the epidemic. In addition, a legal framework has been created with the most important law being Ley 238, which addresses both prevention and treatment, care, and Human Rights issues for PLWHA. The number of PLWHA on treatment has also increased since Nicaragua received the financial support from the Global Fund. - 43 -
However, despite these efforts, there are still many shortcomings to deal with as indicated in Chapter 4. It can be argued that there is lack of will and commitment from the governments side as, on the one hand, the Church is still influencing educational policies, and hence, limiting young people’s access to objective and scientific sexual information. On the other hand, the responsibility for treatment and care has been left almost entirely in the hands of the Global Fund, whose short term programme leaves people to question what will happen after 2008, when the funding stops. Treatment is also far from being universal, as is indicated in Ley 238. Furthermore, treatment and other services have limited coverage, as most facilities are highly centralised. This makes it difficult for people, especially those with limited financial resources, to access it. It is also said that accessibility to information about the epidemic, its responses and resource allocations is limited. This needs to be made more transparent and organised. As we have seen in Chapter 3, civil society has played an important role in the fight against HIV/AIDS. Its responses are manifold with strategies including information campaigns, the distribution of condoms, treatment of STIs, and support services for PLWHA, to mention a few. However, despite the existence of a national AIDS network (CNLS), NGO responses are fragmented, and need to consolidate their efforts.
Policy Suggestions and Further Research Confronting this situation it seems crucial to strengthen implementation of existing policies – especially in relation to sexual education – and the government should do more to mark the separation of state and Church. Decentralisation of HIV testing and treatment should also be prioritized, especially to rural areas, whilst training of both hospital staff and administrative staff to improve existing treatment facilities is necessary. Information on HIV/AIDS spending should be made more easily available, and furthermore, a national information system on HIV/AIDS to which governmental departments as well as NGOs and research institutions can submit their information should be created. This could facilitate research as well as mapping of responses to - 44 -
detect more easily the areas that need more focus, and it could help NGOs working in the same areas to join forces and share information. NGO work should focus more on gender initiatives directed at young men to change their attitudes and behaviours, which currently are leaving women (and also themselves) vulnerable to HIV infection (among other negative effects). Further research needs to be aimed at NGO initiatives, their results and cost effectiveness.
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APPENDICES
APPENDIX A: HIV prevalence in Latin America and the Caribbean
48
APPENDIX B: List of personal communications
49
APPENDIX A
HIV Prevalence in Latin America and the Caribbean33
Haiti Trinidad and Tobago Guyana Belize Honduras Dominican Republic Suriname Jamaica Guatemala Panama Argentina Brazil Colombia El Salvador Venezuela Costa Rica Paraguay Peru Chile Ecuador Mexico Uruguay Nicaragua Bolivia Cuba
5.6 3.2 2.5 2.4 1.8 1.7 1.7 1.2 1.1 0.9 0.7 0.7 0.7 0.7 0.7 0.6 0.5 0.5 0.3 0.3 0.3 0.3 0.2 0.1 0.1
Source: UNDP, 2005, pp. 246-249
33
Percentage of ages 15-49 (2003).
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APPENDIX B
Personal Communications Here is a list of people (presented in alphabetical order) involved in the fight against HIV/AIDS in Nicaragua, with whom the author conducted interviews during her stay in Managua (from September 2004 to May 2005) to enhance her understanding of the HIV/AIDS situation in the country.
•
Arana, Rafael Dr. – HIV/AIDS coordinator, NICASALUD (principal recipient for funds from the Global Fund). January 13, 2005 Managua, Nicaragua.
•
Argüello, Leonel Dr. – Director, CEPS February 24, 2005 Managua, Nicaragua.
•
Bonillar, Sergio – PLWHA, ASONVIHSIDA January 12, 2005 Managua, Nicaragua
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Cano Meza, Arely – President, ASONVIHSIDA January 12, 2005 Managua, Nicaragua.
•
Espinoza, Carola – Norwegian Embassy September 23, 2004 Managua, Nicaragua.
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Riveras, Victor – Legal adviser, ASONVIHSIDA January 12, 2005
•
Román, Matilde Dra. – Director, STI/HIV/AIDS Programme, MINSA February 17, 2005 Managua, Nicaragua.
•
Quant, Carlos Dr. – Head of the Office of Epidemiology, Hospital Roberto Calderón January 28, 2005 Managua, Nicaragua