In response to increasing COVID-19 cases, Panama imposed rigorous restrictions to contain the disease. People were limited to six hours outside the home each week, with men and women allowed out on alternate days. The measures had some success, leading to a gradual easing of restrictions, but concerns regarding the impact of lockdowns on marginalized groups, particularly those most at risk of HIV, have been mounting.
Isolated in their homes for six months, sex workers, men who have sex with men, and transgender people — faced a frightening new reality. With many health facilities closed or re-purposed to fight COVID-19, people struggled to access life-saving HIV services. Transgender people faced the threat of increased discrimination when leaving their homes on particular days, and sex workers faced the dilemma of either being pushed further into poverty or continuing to work at increased risk to themselves and their clients.
Quick to adapt
“Before we went to public places — parks, bus stops, nightclubs — where the young men would gather. We would meet, give talks and deliver condoms. With the pandemic we had to change,” explained Fredy, a community outreach worker with the Asociación de Hombres y Mujeres Nuevos de Panamá, or New Men and Women Association of Panama (AHMNP).
As one of UNDP’s local partner organizations, AHMNP provides preventive health and education services to lesbian, gay, bisexual and transgender (LGBT) people in Panama, with an emphasis on respecting and defending human rights. With long-standing relationships with marginalized groups, community-based organizations were well placed to listen to and support people in accessing healthcare. The result of these conversations was a digital approach, utilizing social media platforms and various popular apps.
“We identified ourselves, explaining who we were,” continued Fredy.
“Many agreed to receive information, others simply said they were not interested. We told them if they ever wanted information, they could look for us on the networks and we would be there to talk.”
Working from home, Fredy contacts approximately 60 people a month online. The power of social media networks, which are used by 2.4 million people in Panama, or just over half of the population, lies in the fact that community outreach workers can interact with people safely in their homes. Having established a relationship, clients are directed to safe spots for HIV services, underscoring the vital importance of ensuring online interactions lead to more people getting tested, knowing their status or practicing safe sex.
‘Many young men reject the HIV test in the first conversation, so it is important to keep in touch’, Fredy continued.
Crucial to this was an agreement secured with the Ministry of Health during the early weeks of lockdown, allowing HIV services to be provided in local civil society organizations’ offices. Establishing a safe space was fundamental, as it is estimated that the fear of discrimination caused three out of 10 people living with HIV in Latin America to refrain from accessing services in the midst of the COVID-19 pandemic.
In total, AHMNP carried out 489 HIV tests between 14 May and 10 September 2020, of which 78 were confirmed positive. 95% of these positive cases have now begun antiretroviral treatment.
Anthony lives in Panama City and met Fredy through a popular app.
“Fredy chatted to me, explaining the difference between HIV and AIDS and other sexually transmitted diseases I didn’t know much about. We also talked about the possibility of doing a HIV test,” he explained.
“I’ve not had sex for a year, so I was confident the result was going to be negative, and it was. If the test had been positive, I would have collapsed,” he continued.
Anthony has kept in touch with Fredy and has found the support provided helpful.
“He left it open for any questions and assured me of confidentiality. He also said the work they do is endorsed by the Ministry of Health”, Anthony continued.
Confidentiality is of particular importance when utilizing social media platforms and community outreach workers are careful to fully introduce themselves at the start of all interactions and to explain their role. The commitment to privacy and confidentiality shown by the organizations is also in line with national law.
“I started with 30 contacts, then it snowballed. We share information on condom use, HIV testing and other diseases.”
For Fulvia Saldaña, a community outreach worker with the organization Viviendo Positivamente, building contacts with sex workers had usually meant meeting people in the places where they worked. COVID-19 lockdowns changed all of this and the organization transitioned to using a popular app, having identified it as the way sex workers contacted clients and advertised their services.
“I worked in a bar, which is where I first met people from Viviendo Positivamente. Before I had no control over my health. Now I have regular check-ups. With the closure of the bar, I manage my clients through a popular app. The volume of business has dropped but we continue working,” said Cindy, a sex worker.
One important aspect of Fulvia’s work is to recommend friendly clinics, where sex workers can access free services including psychological care and medical tests. Edith attends a friendly clinic in the province of Panama Oeste, 20 minutes from the city of Panama.
“Viviendo Positivamente taught me how to take care of myself. You think you know how to do this, but they talk about it more in-depth. The clinics gave me condoms and lubricants. The fact this is all for free made me doubt it at first, but when they contacted me through the video call I could see that it all checked out. The services they provide help me save money and the care is really good,” she explained.
Despite not currently working because she has two small children at home, Edith still keeps in touch with the Fulvia, the community outreach worker who contacted her.
“I found the community outreach worker trustworthy, which was important to me,” she continued.
A forgotten population
“They authorized our organization to re-open on 1 June because the number of people testing positive for HIV was rising” said Venus Tejada, president of the Asociación Panameña de Personas Trans.
“The problem was how to get to the office, how we are viewed when out in public. It is not easy; we are a forgotten population.”
With the public health system fully dedicated to COVID-19, the Ministry of Health granted permission for the Viviendo Positivamente to provide HIV tests and health services at their offices. Venus estimates there are approximately 2,000 transgender people registered with the organization, about 90% of whom are sex workers. Without economic support, many decided to risk working on the streets from the early hours of the day, exposing them not only to COVID-19 but also to discrimination and the possibility of being detained by the authorities.
“The women were afraid, but they went out to continue with sex work because it is their only way to generate income. With the changes in times we are allowed out, the work hours changed. Many were forced to practice sex work during the day, with the increased risk of discrimination this brings,” continued Venus.
With limited support available and no other means of generating an income, the women faced a stark choice.
“We would rather die of COVID than starve,” she explained.
For the community outreach workers, visual contact is crucial.
“Our goal has been to make sure we can be around them during this period. I used my cell phone for calls and in three months I reached 45 people. I use video calls to show my face and build trust,” explained Leanis Zuñiga, community outreach worker at Viviendo Positivamente.
By building relationships online, Leanis has successfully encouraged more women to come into the organization to access the health services on offer.
“I was interested because of what I could learn. They taught me about using condoms and generally how to protect myself. I already knew Leanis and when we started chatting on a popular app, she explained the services offered by the organization and that’s why I ended up coming,” said Mónica, a transgender woman.
Protecting HIV responses
Digital approaches have established a trusted and regular channel for communication during the pandemic, but organizations have also seen a significant increase in the needs. AHMNP recently reported the highest number of positive HIV tests among men who have sex with men in the last three years of their operations. Yet limited resources mean that of the 14 community outreach workers currently employed, only five will remain in the coming months.
UNDP, with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), has been supporting the HIV response in Panama since 2015. Working closely with the government and local partner organizations, efforts have focused on supporting communities at higher risk to access HIV prevention, treatment and care services. This has resulted in over 12,800 people now accessing anti-retroviral treatment and 18,800 people receiving counselling and testing.
The knock-on effects of the COVID-19 pandemic are threatening to derail progress in the fight against HIV. Global Fund surveys in more than 100 countries show up to 75 percent of HIV, TB and malaria service delivery has been disrupted as a result of the COVID-19 pandemic and it is estimated AIDS-related deaths could double in the next year — eliminating over 10 years of hard-won gains. The world must urgently invest to defend progress in HIV, TB and malaria, fight COVID-19, and save lives from all four diseases.
In line with UNDP’s Strategic Plan 2018–2021 and its HIV, Health and Development Strategy 2016–2021: Connecting the Dots, UNDP partners with the Global Fund, governments and civil society to support and strengthen multi-sectoral national responses to HIV, TB and malaria, by providing integrated policy, programme and capacity development support. To date, this has resulted in 51 million people receiving HIV testing.
Photos: UNDP/Grey Díaz