Peru

"My name is Jonathan. Today I'm not going to tell you how I got monkeypox, but how complicated it is to carry this disease", says the activist and crossdresser Jonathan Albinagorta. He is also known as Samantha Braxton, one of the influencers supporting the Ministry of Health in its video campaigning on monkeypox prevention in Peru.

With more than 2300 confirmed cases of Monkeypox by the end of September, Peru had the world's highest infection rate per million people, according to Our World in Data, a collaborative online platform led by researchers at the University of Oxford.

The response to the outbreak in Peru was set up under the leadership of the national HIV strategy team, which developed a plan to raise awareness of the disease. Its public real-time data dashboard, inspired by the COVID-19 response, provided concrete evidence for the rapid of an awareness campaign. However, the same data, mainly from HIV-specialized centres, also had the unwelcome side-effect of increasing stigma and discrimination for some groups of people.

"The data created a biased sample at the beginning. Evidence showed that people living with HIV and some key populations, such as gay men, were among the most affected in Peru", recalls Andrea Boccardi, UNAIDS director for Peru, Bolivia, Ecuador and Colombia. "But these are the very people who have the culture of going to the HIV-friendly services for consultations, for periodical examinations and HIV treatment."

Referral Centers for Sexually Transmitted Infections, known as Cerits, and Periodic Health Care Units provide HIV services for Peru's most vulnerable and key populations. "These groups of people do not go to hospitals where they tend to suffer discrimination. They go to these centres, where the greatest number of monkeypox diagnoses came from at first", explains Boccardi.

Experience in dealing with the HIV pandemic shows that data must be accompanied by adequate information-sharing to the public and impacted groups in a non-stigmatizing way. An inclusive approach and the correct use of language are key to engage with communities so that they become an integral part of the response instead of being driven away.

UNAIDS supported the country in quickly setting up a strategy that included meetings between health officials and civil society representatives. Community leaders also contributed by reviewing messages coming out of the ministry of health.  People also received training to act as spokespeople in media interviews.  

“Often, the communication from the ministry of health ends up being very institutional or quite distant. Something that the community cannot fully digest”, says Mauricio Guitierrez, a GayLatino network activist. “We elaborated friendly visual materials for dissemination. It is important to translate and personalize the information for people and that was what we tried to do by supporting the ministry in these campaigns.”

”As well as informing and clinically diagnosing the most at-risk populations in saunas, hotels, and other sites, monkeypox working group convinced mayors to keep these establishments open and to use them as critical platforms for the dissemination of relevant information on monkeypox directing people to the information and services made available.”

In Peru, LGBTIQ+ people and people living with HIV are the most discriminated against, with 71% and 70% of them, respectively, reporting to have suffered discrimination at some level, according to the National Human Rights Survey released in 2021 by the Ministry of Justice and Ipsos Peru.

“Out of fear of stigma and of what people will say, a lot of us don’t ask and fall into the same trap of ignorance”, says Albinagorta. “It was great that the Ministry placed QR codes in LGBT establishments, for example.”

Alliances with telecom companies and social networking apps, such as Grindr, created opportunities to inform the most vulnerable populations through an estimated 40 million messages focused on monkeypox prevention and treatment. Former COVID-19 spaces were also used for the 21-day isolation period for people not able to comply with thisrequirement, including migrants and refugees.

Despite some early signs of stabilization, the Pan American Health Organization (PAHO) said recently that it is too early to proclaim victory. It called on countries "to intensify the response actions, prioritizing detection, surveillance and community engagement to reduce new cases and put an end to the outbreak in the region." The United States still accounts for more than half of cases, but rapid increases have been witnessed in Brazil, Peru, Colombia, Mexico and Chile in the past month.

The Ministry of Health of Peru is purchasing vaccines through the PAHO Strategic Fund, but the total number of vaccines available for the entire region is 100 000.  The main challenges are the criteria for prioritization as the expected number of vaccines per country will be no more of 5000.

"Many people contacted me after my first video for the ministry of health in Peru. For those who are suspicious, it inspires more confidence to approach someone like me, who has had monkeypox and talks freely about it, than to go to a hospital, an institution or the ministry itself, " says Samantha. "Of course, there are also haters. Some people believe that when a gay man shares that he has had monkeypox, he is stigmatizing himself. But that's not it.”

When Lima celebrated this year’s World AIDS Day, the Mayor, Jorge Muñoz, decided to go beyond the traditional lighting of buildings and participation in official events to mark the day. By signing the Paris Declaration to end the AIDS epidemic in cities, he joined the Fast-Track cities initiative, a network of more than 300 municipalities around the world, 70 of which are in Latin America and the Caribbean, and committed to ending the AIDS epidemic as a public health threat by 2030.

Lima has a population of more than 10 million people and accounts for around one third of the national population. Lima and the two other Peruvian municipalities that have already signed the Paris Declaration, Callao and La Victoria, accounted for around 50% of all new HIV infections in the country in 2019.

“Through this public commitment, the city of Lima pledges to carry out the necessary actions to accelerate the response to AIDS, including education, awareness-raising and non-discrimination campaigns,” said Mr Muñoz during the signing ceremony. “We will also implement a work plan to train health personnel and promote access to information and sex education.”

“With the signature of the Paris Declaration, the city has committed to eliminate stigma and discrimination against people living with HIV and key populations, scale up HIV prevention services and contribute to achieving national targets to end AIDS as a public health threat by 2030 as part of the Sustainable Development Goals,” said Andrea Boccardi, the UNAIDS Country Director and Representative for Peru, Ecuador and the Plurinational State of Bolivia.

This is not the first time that Mr Muñoz has taken action against discrimination. In May 2019, when he was the Mayor of the city of Miraflores, he established an ordinance that prohibited discrimination in all its forms in the public and private spheres of the district. Now, as the Mayor of Lima, he has extended that policy to the entire province.

On 1 December 2014, mayors from around the world met in Paris to launch the Fast-Track cities initiative and pledged to adopt a series of commitments to accelerate their response to HIV, with the aim of ending the AIDS epidemic by 2030. Besides committing to ending the AIDS epidemic at the municipal level and uniting as leaders, the signatories also commit to putting people at the centre, addressing the causes of risk, vulnerability and transmission of HIV, using the AIDS response for positive social transformation, building and accelerating appropriate responses reflecting local needs, and mobilizing resources for integrated public health and sustainable development. 

Transgender women face significant barriers that limit their access to health services and/or increase their vulnerability to HIV: stigma and discrimination, gender-based violence and gender inequities. As a result, the percentage of transgender women reached with HIV prevention and treatment services is very low.

To address the HIV prevention gap for transgender people, the Peruvian Ministry of Health organized a national consultation on combination HIV prevention in 2014 in partnership with Cayetano Heredia University and UNAIDS. This consultation opened a dialogue between stakeholders and community leaders on the future of HIV prevention in Peru. During the consultation, the Ministry of Health expressed its commitment to improve HIV combination prevention programming for transgender women. In 2015, it launched a targeted strategic plan for prevention and comprehensive care for HIV and other sexually transmitted infections (STIs) for transgender women .

The plan addresses the leading causes of the HIV epidemic among transgender women in Peru, including their poor socioeconomic conditions, their difficult living and working environments and the low accessibility of health services. In the plan, consideration is given to identifying effective strategies to respond to specific legal and human rights challenges, stigma and violence. The development of the plan was the result of a decade-long process of evidence generation, policy dialogue and capacity-building with the transgender community.

The plan is being translated into practice. Activities already implemented include special trainings of health personnel at STI treatment centres and community peer educators in how to address the HIV needs of transgender people, the provision of prevention services, including condoms and lubricants, HIV testing and linkage to health services for antiretroviral therapy and awareness-raising of local law enforcement personnel on the respect of human rights and prevention of gender-based violence for the transgender community.

Mao, a transgender women activist and peer educator of the Ministry of Health, said, “The focused plan is bringing services closer to the community. Some transgender women who could not go to the sexually transmitted infection treatment centres are now asking for condoms and testing, for information and for comprehensive health services. We are proud of being part of this initiative.”

The next phase of the transgender health plan will include an increase in the number of decentralized prevention and treatment service sites and a demonstration study on pre-exposure prophylaxis. The plan will be incorporated into and aligned with the national HIV programme.

Transgender people often face violence, unemployment and poverty, owing to ignorance and prejudice. Such stigma and discrimination places transgender women at a higher risk of HIV infection.

All people are equal and no one should be discriminated for any reason. “In our country it will take a lot to make this affirmation a reality,” the Peru’s Ombudsman Eduardo Vega Luna said in response to the situation. However, he called for “more awareness campaigns that encourage citizens to look at the future with hope and without violence and discrimination.”

One such activity was recently organized by United Nations organizations in Peru, including UNAIDS, UNDP, OHCHR and United Nations Information Centre, and civil society organizations, like PROMSEX, IESSDEH, Center for Interdisciplinary Studies in Sexuality, AIDS and Society of the Cayetano Heredia University, transgender people, the Magnum Foundation and the European Union. An exhibition, “Yo tengo derechos”, meaning “I have rights”, presented photographs taken by Danielle Villasana, an award-winning photojournalist whose work focuses on gender, identity, health and social politics. A recent graduate of the University of Texas, Austin, she has worked with transgender communities since 2012.

The photographs in the exhibition—part of the United Nations Free and Equal campaign, which advocates for lesbian, gay, bisexual and transgender equality—showed transgender people with their colleagues and family members in their daily lives as students, artists, professionals and activists. In their testimonies for the exhibition, transgender people spoke about happiness, love and how they cope with daily struggles.

María del Carmen Sacasa, United Nations Resident Coordinator in Peru, said, “For us, the main human rights theme is non-discrimination. It’s not a minor issue, particularly when it comes to transgender people, who are rejected in many fields.”

The exhibition reminded people of one of the main human rights principles: discrimination is unacceptable. 

Under the revised penal code young people between the age of 14 and 18 years old will be able to exercise their sexual and reproductive rights.
Credit: UNAIDS

The Constitutional Tribunal of Peru is amending an article in its penal code which for many years had criminalized consensual sexual activity among young people. Sentencing was particularly severe with adolescents facing up to 30 years in prison. Article 173 of the penal code was also preventing young people from accessing essential health and reproductive services for fear of prosecution.

Under the revised penal code young people between the age of 14 and 18 years old will be able to exercise their sexual and reproductive rights providing the two parties are consenting. Non-consensual sexual relations will still constitute a crime in Peru with lengthy sentencing for people found guilty.

"The Constitutional Tribunal ruling generates a protective effect in relation to adolescents, because it provides them with greater access to sexual and reproductive health services as well as guidance and information to avoid sexually transmitted infections, including HIV," said Mima Barnechea from the United Nations Population Fund (UNFPA).

In 2012, UNFPA and UNAIDS presented a formal request before the Constitutional Tribunal advocating for the declaration of unconstitutionality of Article 173.  This process was part of a wider effort particularly from the Office of Peru’s Ombudsman, Eduardo Vega Luna as well as legal demands presented before the Tribunal by more than 10 000 Peruvian citizens.

"UNAIDS welcomes the Constitutional Tribunal’s decision and congratulates the magistrates for their determination to protect adolescents’ human rights,” said UNAIDS Coordinator for Peru and Bolivia, Regina Castillo. “The Tribunal’s decision reinforces young people’s right to make decisions regarding their health and sexuality and the need to construct policies and programmes that recognize young people as active actors of change.”

According to a National Demography and Health Survey of 2011 a large percentage of Peruvians initiate sexual relations before the age of 18.  More than 12% of female adolescents (ages between 15 and 19) have been pregnant at least once.

"This decision is a milestone that sets the basis for plans and programs at national level to prevent teen pregnancy and reduce sexually transmitted infections including HIV and maternal mortality," said Carlos Tacuri Calderon, youth activist in Peru and member of INPPARES.

UNAIDS estimates that around 74 000 people are living with HIV in Peru of which approximately half became infected before the age of 20. This situation stresses the need to raise awareness on HIV and its modes of transmission among teenagers. In December 2012, the Ministry of Health in collaboration with UNAIDS and other partners launched the campaign “take an HIV test––it’s better to know” which aimed to reach young men with key HIV prevention messages and provided free HIV tests.

Vice-Minister of Health José del Carmen Sara launching the campaign “It is better to know: Get an HIV test.”

In the lead up to this year’s World AIDS Day, the Ministry of Health of Peru in collaboration with Asociación Dignidad, UNAIDS and the Pan American Health Organization (PAHO), launched the campaign “It is better to know: Get an HIV test.” The initiative aims to increase HIV testing coverage in the country, particularly among men, by providing free HIV tests.

Men aged 18 to 25 years are the main focus of the campaign, which aims to test 10 000 people by 1^st December (World AIDS Day). The testing will take place in 16 different venues set up by the Ministry, including in various universities, in order to reach as many young men as possible.

“This is an effort by the Ministry of Health to make HIV testing more accessible for men,” said Vice-Minister of Health José del Carmen Sara during the event.

There are 74 000 people living with HIV in Peru, 77% of whom are men. 56% of new infections occur in men who have sex with men and 9 out of 10 women acquire HIV from their stable partners, who may engage in high-risk behavior such as buying sex or having sex with other men. It is estimated that half of the people living with HIV in Peru were infected before the age of 21.

Although men are at higher risk of HIV infection than women, their access to health services has traditionally been poorer. Despite the fact that 3 of 4 people living with HIV are men, only 7% of men reported having been tested for HIV in 2008. Increased testing would provide greater opportunities for HIV prevention and early treatment.

Peru introduced rapid HIV testing and counseling for pregnant women in 2006, and in 2008 a large scale HIV testing and counseling campaign was organized focusing on women of reproductive age. In the same year the Ministry of Health also increased access to HIV testing and counseling for men who have sex with men, transsexuals and sex workers, but so far HIV tests have only been free for women.

“Half of the people living with HIV in Peru do not know their HIV status. It is important to save lives by increasing access to both HIV diagnosis and treatment,” said Regina Castillo, UNAIDS Country Coordinator for Peru and Bolivia.

The launch on November 21^st brought together people living with HIV, UN representatives, government officials, journalists, international organizations, and renowned artists, including entertainer and HIV activist Ernesto Pimentel and singer Eva Ayllon.

Luis Agois President of the Peruvian Press Council, Renate Ehmer, UNAIDS Coordinator for Peru, Ecuador and Bolivia and Jorge Chediek, Resident Representative of the UN system at the launch of the new campaign.
Credit: UNAIDS/UNDP/CPP

In Peru, 76 000 people are living with HIV. While HIV prevalence in the general population is relatively low at 0.5%, the men who have sex with men and the transgender communities have been hard hit by the epidemic with an estimated prevalence of 10.8% and 32% respectively.

A range of complex social prejudices result in people living with the HIV being frequently subject to discrimination in the workplace and in wider society.

To counter stigma towards people living with HIV in Peru a new campaign was launched in November 2009; a joint initiative by UNAIDS, UNDP and the Peruvian Press Council.

The purpose of the multimedia campaign, entitled “An image against stigma and discrimination caused by HIV and AIDS”, is to create a supportive environment for people living with HIV, free of discrimination and fear.

Speaking at the launch, the President of the Peruvian Press Council Luis Agois noted the role media can play. “Our contribution is the broadcasting of this campaign, an initiative which has been enthusiastically joined by the press in general in Peru.”

Fear of social repercussions and the discrimination that might result from a positive HIV test, many Peruvians avoid leaning their HIV status according to Jorge Chediek, Resident Representative of the UN system, further jeopardizing their health. “As a consequence, they can’t access treatment; and HIV treatment in Peru is free.”

Renate Ehmer, UNAIDS Coordinator for Peru, Ecuador and Bolivia highlighted the extreme expressions of stigma and discriminations that result in violence, “hate crimes; when men and women are killed because of their sexual orientation or gender identity.”

“Estimates by civil society organizations reveal that an increasing number of hate crimes are taking place every year, most of which go unpunished,” Ms Ehmer continued.

The campaign brings together Peruvian celebrities and people living with HIV who appear on posters and brochures and distributed nation-wide.

The high profile participants include Javier Velasquez Quesquen, Head of the Cabinet of Ministers; Javier Villa Stein, President of the Judiciary; Oscar Ugarte, Minister of Health; Jose Antonio Garcia Belaunde, Minister of Foreign Affairs; Antonio Brack, Minister of Environment; Monsignor Bambaren, Nolberto Solano, football players, members of the music group Grupo 5 and comedian Carlos Alvarez as well as Economist Hernando de Soto.

Two short films have also been produced as part of the campaign and can be watched here:
An image against stigma and discrimination caused by HIV and AIDS vol 1
An image against stigma and discrimination caused by HIV and AIDS vol 2