By Jirair Ratevosian and Amy Hagopian
Earlier this year, we visited Armenia en route to a meeting of the 12th World Congress of Public Health Associations. We stopped in Yerevan to help celebrate with local organizations their recent success in persuading the government to repeal unwarranted requirements for foreign travelers to be tested for HIV.
In crafting the change in the law, Armenia's president and parliamentarians realized that longstanding regulations "did not meet the present-day requirements in the fight against HIV/AIDS," and acknowledged the lack of public health justification for barring immigrants with HIV. The parliament said the new rules were passed with the aim of "strengthening legal reforms and sustaining large-scale HIV/AIDS awareness raising activities" and "safeguarding human freedoms, dignity, and rights." This was a huge victory for public health and a proud moment for all Armenians.
There is added success to report in the global battle against HIV and AIDS. Several nations have demonstrated considerable progress in slowing national epidemics. In the last six years, rates of infection and death have slowed as the number of people receiving antiretroviral treatment has increased immensely. Many actors share credit in this achievement, most notably the United States, which mobilized billions of dollars in many low- and middle-income countries.
Despite progress in reducing HIV infections, the past years have also been marked by missed opportunities. There is a real danger in some countries, including Armenia, that the epidemic could surge in vulnerable populations, including women, injecting drug users, and men who have sex with men. These socially marginalized groups face considerable barriers to HIV prevention and treatment access, often as a result of institutionalized discrimination, stigma, and lack of awareness.
In fact, the United Nations estimates 7,400 people become infected with HIV every day. Globally, an estimated 33 million people were living with HIV in 2007. The number of people living with HIV in the countries of Eastern Europe and Central Asia, including countries of the former Soviet Union, has reached 1.5 million. Of that group, 2,300 are living in Armenia, according to the National Centre for AIDS Prevention, though the World Health Organization estimates the total to be higher. Silence, shame, and fear of ostracism enable HIV stigma and discrimination to flourish, resulting in fewer being tested and, ultimately, decreasing numbers of HIV/AIDS cases being reported.
Without appropriate health messages and support structures, vulnerable populations unknowingly engage in behavior that increases their risk of infection. A survey by Armenia's We For Civil Equality revealed young Armenian men who have sex with men are so poorly informed about HIV transmission that only half of the youngest men (18-30 years old) understood that "unprotected sexual intercourse" was a mode of HIV transmission. Half of those youngest men also believed, falsely, that one may get HIV through shaking hands.
Even more serious is the prejudice exhibited by members of the medical profession itself. Doctors, nurses, and staff responsible for the care and treatment of people living with HIV can sometimes turn out to be the most hurtful agents of HIV-related stigma and discrimination.
Scientific advancement and public health education have turned AIDS from a death sentence into a chronic disease. Armenia has an opportunity to ensure that HIV infection rates remain low and that people living with HIV and AIDS receive proper care. Investing in needs-based prevention programming, public awareness campaigns, expansion of access to antiretroviral drugs, and accurate and comprehensive sexual health education are critical components of an effective national response. Further, legal reforms are needed to create an environment conducive to eliminating discrimination, stigma, and violence against sexual minorities.
The lesson to learn from the countries where HIV infection rates have fallen sharply is that active participation of civil society is critical for success, including participation from organizations representing sexual minorities and people living with HIV/AIDS. Armenia has courageous groups working to provide life-saving services to vulnerable populations, such as Real World/Real People, Public Information and Need of Knowledge (PINK Armenia), and the Women's Resource Centre. With sufficient funding and political support, these and other organizations can transform community attitudes, drive policy, and mobilize the necessary resources to reverse the alarming spread of HIV among vulnerable populations.
The government, civil society groups, the private sector, the church, and the media all have a critical role to play in keeping Armenians healthy. Leaders in all sectors must model a willingness to discuss these issues openly and affirmatively enact policies to protect all citizens against discrimination and social exclusion. In turn, government must foster increased collaboration by supporting efforts to share information, address new challenges, and work collectively to design and deliver innovative and effective HIV/AIDS services.
Armenia has come a long way in a short time and the response to HIV will signal how it wants to advance on the global development agenda. While it was the last country in the south Caucasus to decriminalize sex between two males (2002), it demonstrated a progressive attitude by becoming the first country in the region to sign on to a UN statement against discrimination related to sexual orientation and gender identity.
Ultimately, countries are judged by how they treat their poor, marginalized, and stigmatized people. Armenia can flourish as a regional leader by ensuring its people are healthy and cared for in a compassionate way.
Jirair Ratevosian, MPH, based in Washington D.C., chairs the International Health Advocacy and Policy Committee of the American Public Health Association. He was recently named deputy director of public policy for amfAR, the Foundation for AIDS Research.
Amy Hagopian, Ph.D. teaches at the University of Washington School of Public Health in Seattle, Washington. She is also a senior health workforce policy advisor for Health Alliance International.