Progress & Note on HIV/AIDS Stigma

I have had a very productive week here especially in terms of organizing and completing all the data summations for the 2008 year for my partner organization's outreach work. I added all the necessary missing forms and compiled all the summed data for each month into an excel file. Now they have ready data which they can present concerning the amount of materials distributed and the number of field visits done and clients seen. I also compiled all the data for new clients who have to fill out a longer form. Some interesting trends I have seen that I believe are very positive is that almost half of the people have been tested for HIV and about 70% of sex workers have been tested for various STDs. However, for intravenous drug users, a large portion (close to 90%) have shared their equipment with others in the past. In addition to organizing the data, we spent a whole day preparing materials for the EXIT show which is a four day music festival with multiple stages in whichbands from all over the world play held in Serbia over this weekend. They saythat during the event there is a lot of drug use, especially ecstasy, and an increased engagement in risky sexual behavior. Each year Juventas has a booth there at which high school students volunteer to distribute condoms and educational materials. Therefore, we spent a whole day packing condoms into custom made boxes which have quotes on them such as "reduce the risk" and counting and packaging brochures into boxes so they can be transported to

Serbia.

In addition to office work, I have gotten much more involved in the outreach work this week. I went out 3 nights this week and have started leaving the van more often to interact with and meet the clients. I have also learned how to put together the packages of needles, syringes, condoms, etc. that we give to the clients and am learning what specific things known clients typically ask for. It has been great getting to hear the client's stories as we distribute the materials. There is really no set profile for either intravenous drug users or commercial sex workers. They all come from so many different backgrounds and each has a unique life story. In one night, we met with 15-16 year old boys who just started experimenting with drugs most likely because they were bored, with a guy in his twenties who had finished his second year of law school and is very intelligent and well- spoken, and with an older man who has been using

heroine for a long time and started because all his brothers had been doing it. They come from both families who are well off with regard to this area and from poor families who are refugees from areas such as Kosovo. The sex workers are mostly younger women and they say that 90% of them come from Serbia. Initially, it was very hard for me to talk with them as I just did not know what to say or what I could ask and what I couldn't. The commercial sex workers especially are very open about everything they say and they often make statements I just do not know how to respond to especially in Serbo-Croatian. They definitely talk about a world with which I have had very little experience so it is hard for me to relate and to find things to talk about. However, I have seen that they are all actually very open about their experiences and are willing to talk about themselves and their lives more so than I expected. Each time I become more relaxed and find it easier to talk with them. Also, I am starting to see the same clients over again so it makes it easier. Also, for the first time I saw one client ask the doctor we have go with us about Hepatitis C symptoms and such and then ask for which doctor he could visit to set up a treatment for quitting. It was interesting to see how she advised him on everything and we gave him the phone number of the doctor with which Juventas collaborates. They say that it is an extremely positive sign when they even begin to talk about quitting as they do not typically do this unless they are seriously considering it.

As for the data collection during the outreach work, I have been observing how they fill out the forms during the night to see what would be the best areas for improvement. I really think that there is a way to change the form a little to make it much easier to fill out in a uniform manner and to make the final summations much easier to do. This I believe would solve many of the problems in the most efficient way. Next week a lot of the Juventas staff will be gone for a seminar so the one outreach group will have to go out each night. As they are going to be very busy, I offered to go along and to help with recording the data. I will then try to set up the form in the way I envision and take down the data in that manner and then I will see what they think. I believe it is going to help a lot with making it easier to quickly record the necessary information in a way that will be easily accessible for calculating total sums and finding the necessary information for the data organization I have been doing this week.

I was also able to set up a visit to the voluntary counseling and testing center here in Podgorica and met with one of their counselors this week. The center opened about five years ago and early on very few people visited but now there are about 3 visits per work day. They are open Mondays and Tuesdays from 4-8pm and patients can pick up their test results on Wednesdays. However, the counselor I met with is a doctor who works in the clinic every day so she usually will also take clients in on other days if they can not come in. Also, since this clinic opened, 4 others have opened in Montenegro, most of which are in coastline cities that have large tourist industries. She explained how a typical counseling session goes during which she discusses their engagement in risky behavior, assesses how much they know about HIV, Hepatitis, STDs, and any other disease at which they may be at risk of contracting, and discusses with them what would happen if they were positive and who they would have to go to for support. This last part she says is most important as many come without having considered this at all and really become

reflective during such questions. At the end of the session she asks them if they would like to be tested and they can get tested right there for HIV and Hepatitis. Throughout this counseling and testing process, the patients can remain anonymous and they need not give their name or reveal any personal data. However, here, once a patient has been found to be positive for HIV, their name must be put in the registry and revealed. They are then sent to various doctors in infective disease and such and thus those doctors plus all the nurses that work in those units know the name of the positive patient. As this is in general a small town which is known for gossiping, it does not take much for the information that so and so is positive to get out. Unfortunately, with a

small population, everyone knows each other so the information can quickly get to friends and family. While all the hospital staff is expected to follow a confidentiality code, miscommunications can happen. Therefore, she also discusses this with the patients before they get tested saying that they do everything possible to maintain confidentiality but that that can't be guaranteed at this time. Despite this problem, she also spoke with me about a very interesting phenomena that exists here in Montenegro but that she did not see in other areas of the world. When a family member is found to be positive for HIV, rather than throwing him/her out or isolating him/her,

the whole family (here, this includes a much more extended family than would be typical in the US) really sticks by him/her and goes out of their way to help him/her. She said that she observes this most when patients come for check ups during which she says almost always at least 5-6 people from the family call to see how they are doing and someone always accompanies them. While the patient will undoubtedly face stigma from the society here, it is interesting to see how much the family takes care of one of its members during a difficult time. This comes from the general culture here in which family is the most important thing and everyone is expected to do everything they can to help any family member no matter how distant. She said that she hoped research studies could be done to statistical show this as she believes it is something very different and positive that would be exciting to show the rest of the world. In general, the stigma here comes some from the belief that those infected with HIV must either be very promiscuous, involved with drugs, or must be homosexual all of which are things that the culture here looks down upon. However, she says that in general people know about the disease and its transmission and understand that it is a global epidemic. They are now looking at ways in which they can educate the incoming tourists and the tourist workers about safe behavior. Overall, it was a great experience being able to speak with her and see the center. I will hopefully be able to visit the center again during its working hours and get to sit in on some of the counseling sessions if the patients allow it.

For next week, Monday and Tuesday are holidays here (Independence Days) so there is no work. Thus, I am spending the four day weekend in Zabljak, a small town up in the mountains in which my family has a house. The nature there is beautiful with lots of open fields, beautiful lakes, and mountains and the weather is much cooler than here. Hopefully, with the cooler weather and the peaceful isolation I will be able to get a lot of work done on medical school secondary essays which have been piling up and which I have not been able to work on adequately yet. For the end of the week, I will be doing outreach work each day and will be in charge of recording the data. I am not yet sure what I will be doing in the office during the day but the director said she would email me with things to do over this weekend. Overall, I am learning more and more each week here and am really excited about my involvement in the outreach work.