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HIV and AIDS in Germany
Sabine Sauer, Aids-Hilfe Bielefeld

Introduction
My name is Sabine Sauer. I've been working for the AIDS advice centre Bielefeld for.
My focus is health promotion for female drug addicts, involved in prostitution for the procurement of drugs.

I owe this invitation to give a lecture at this conference to a client coming from Eastern Europe as victim of human trafficking, who was taken care of by the advice centre in Nadeshda Herford. This client was also infected with HIV. She needed information and came to our Bielefeld AIDS advice centre.
The counselling seemed to have been satisfactory, for actually I was invited to speak to you today about the issue of HIV and AIDS in Germany. We already heard a lot about the increase in HIV infections in Eastern Europe, particularly Ukraine has alarming figures.

I’ll talk about the German situation. First of all I’ll go back to the early days of the occurrence of AIDS. Then I point out the basics of AIDS policy and prevention in Germany. Finally, I ‘ll have a closer look onto infection risks following the drug related prostitution.

HIV and AIDS in Germany

How it started: a mysterious new disease takes its course
In 1981 sporadic young homosexual men in the United States and Western Europe suffered from severe lung diseases, skin cancer and lengthy herpes-ulcers. 
These diseases worried the experts, because they were previously known only from patients in end-stage conditions.

First doctors thought that these symptoms come from an immune deficiency somehow related to the homosexuality. The term "GRID" emerged as a generic term for the unusual clinical picture mentioned before. GRID was a shortcut and stood for "Gay related immunodeficiency.

As a precaution the doctors reported these diagnoses on a voluntary basis to the national health authorities. In Germany this was the Federal Department for public Health in Berlin.

In 1982, only a year later, the above mentioned severe lung, skin cancer and herpes diseases were no longer found only with homosexual men, but now also diagnosed with patients who had received blood products. A little later the circle widened around people whose common characteristic was that they consumed drugs intravenously.

Since autumn 1982, there is therefore the term "AIDS". This abbreviation stands for "Acquired Immune Deficiency Syndrome.“ In 1983/1984, the virus causing AIDS was discovered. It was named HIV. This abbreviation stands for “Human Immunodefciency virus”. HIV infects and destroys blood cells, which are necessary for a functioning human immune system.

The introduction of antiretroviral therapy (ART) in 1996, caused a paradigm shift in the western industrialized countries,. AIDS changed more and more from a deadly threat to a chronic disease in the public awareness. Despite huge advances in medical treatment a cure for AIDS is still not possible.

In the following, I’ll talk about how the disease AIDS is encountered in Germany. What is the situation of the people concerned, how they are dealt with? How was it at the beginning and how it looks today?

Foundation of AIDS assistance in Germany
With the appearance of the first unknown syndrome - 1982 a gay man in Frankfurt was diagnosed with the first AIDS disease in Germany - gay men gathered in order to respond to something that they heard about from the U.S., but whose dimensions they could not at all estimate.

At the beginning fear, chaos and apocalypse ruled. At the beginning was the helplessness. However, this state of being paralyzed didn’t last long, then they had to deal with consultation, support, care of the sick and terminal care. The exchanges on the latest conclusions to protect against infection were a key engine of these first initiatives.

On 23 September 1983, 25 years ago, German AIDS-Help (DAH) started in Berlin out of such a context, self-help. On 16 January 1984 was the inaugural meeting of the Munich AIDS-Help. This was the first regional group in Germany. In the same year a number of AIDS advice centres were founded all over Germany. The Bielefeld AIDS advice centre was established in 1985. Meanwhile, Deutsche AIDS-Hilfe (DAH) has 130 member organizations.

The DAH is the umbrella organization and professional association for the member organizations, but still also representing the interests of those struck by HIV and AIDS.

Positioning and finding a good way of handling
In the early stages there were bitter struggles for the proper handling of the disease AIDS. There were strong supporters of law enforcement measures against HIV-infected and AIDS patients, for example, forced testing and enforced quarantine.

The media did their lot of stirring the general hysteria. They did the preliminary work for those politicians who vehemently pleaded for repression and the dismantling of civil rights. However, the liberal voices took hold in Germany. They repeatedly pointed out that the further spread of HIV can be curbed only through prevention and counselling without discrimination and exclusion. Finally, the Government of the Federal Republic of Germany in February 1987 passed the “emergency programme to combat AIDS”.

The emergency programme had the following priorities:
1. Protection of the population against HIV infection
2. optimum advice and care of HIV-infected persons and AIDS patients
3. Prevention of exclusion and discrimination

By implementing these objectives, the federal government followed the principle that education and advice should have priority before repressive measures.

Selected epidemiological data:
Germany has a concentrated HIV epidemic. Currently around 60,000 people in Germany are HIV infected. The general population is only marginally affected. The prevalence here is at approximately 0.1%.

The prevalence is the ratio, that states, how many people of a certain group of defined size, usually 10,000 or one million, suffer from a particular disease. In Germany, about three-quarters of those infected are men, approximately one quarter women. 90% of HIV infections are sexually transmitted. Over two-thirds of all infections in Germany are due to unprotected sex between men.

Germany has the second lowest rate of new infections among western European countries. Andorra shows the lowest rate. Every year there are about 3,000 new HIV diagnoses in Germany.

The number of new cases is called incidence.
The incidence is an epidemiological index. It indicates the number of new cases
- of a certain disease
- among a population of defined size, (often per 100,000 inhabitants)
- during a certain time, usually in a year
.
In 2006 Germany had 33 new cases in 1 million inhabitants, in Switzerland, there were 104, in the United States 188, in Portugal even 205 new cases per 1 million inhabitants. These figures confirm the effectiveness of German prevention strategies.

Nevertheless, we can’t rest on our laurels of low numbers in Germany. Since 2001 the number of new HIV diagnoses is on the rise again. While not dramatically but steadily. The increase is mainly among the group of men who have sex with men (MSM).
The increase in HIV cases in recent years shows that prevention meets new challenges.

Prevention is a "painful, ongoing business". It is "never finished".
Prevention must be constantly adapted to changing conditions of a dynamic HIV epidemic. It must check its messages and flexiblly adapt its priorities to the epidemiological trends. Only then Germany can continue to successfully fighting HIV in the future.

Now I’d like to show how HIV prevention is organized in Germany and how we manage to keep low HIV new cases in Germany:

HIV prevention in Germany

Organization of HIV and AIDS prevention
The Government established the following major players in its emergency programme to fight AIDS:

• the Federal Ministry of Health has the overall responsibility for HIV and AIDS
• the Federal Centre for Health Education (BZgA) is responsible for the AIDS education of the so-called general population,
• the aim of the German AIDS-Advice Association (DAH) with their local Member organizations is to reach groups, who are affected by AIDS or are exposed to high risk of infection, e.g. gay men, drug addicts, prostitutes and prisoners.

The education by the BZgA (see chart 5) is colourful and generally accepted.
The DAH (see chart 6), however, addresses to the main stakeholders with direct and specific campaigns.

The DAH works on three levels of prevention:

The model of combining primary, secondary and tertiary prevention

• the primary prevention is to avoid HIV infection and other sexually transmitted infections (STI). Primary Preventive measures have purely prophylactic character.
• The secondary preventions aims at diagnosing infections and diseases in an early stage in order to hinder progression of the disease through early treatment.
• In the tertiary prevention is about assistance for AIDS sufferers, namely nursing, terminal care, bereavement counselling
  The tertiary prevention tries to mitigate the effects of a disease.

The model of combining primary, secondary and tertiary prevention and involving the HIV affected and threatened persons is still internationally recognised as groundbreaking and as decisive for the relatively low HIV infection-rates in Germany. Many AIDS advice centre staff themselves belong to the main stakeholders, they speak their language, they know the fear of AIDS and the difficulties associated with prevention of infection from personal experience.

Principles of AIDS prevention
The AIDS advice centres apply the principle of structural prevention (see chart 8). Basis is the Ottawa Charta of 1986 for health promotion. Unfortunately, I can only briefly outline structural prevention at this point:

Structural prevention is characterized by the fact that it is not exclusively focused on individual behaviour (behavioural prevention), but also tries to influence the political, social and cultural factors that affect the individual's behaviour (ratio prevention).
At least as important is the approach that the target groups are included in the prevention, one of the main principles of DAH is "no prevention without participation".
Health promotion in terms of structural prevention notes that there are different ways of life.
 
Advice and assistance seekers are respected in their strengths, weaknesses and special features. AIDS advice centres encourage the clients identity, decision making and responsibility. (Empowerment). The difference between ways of life must be respected and may be actively used for a differentiated approach specific to social surroundings.

The primary prevention based on target groups is a good example in this context. It is tailored to its respective addressee by setting priorities, means of prevention (like: personal appeal, using print media, internet-appeal), its choice of words, its image design and the establishment of distribution channels. And its tailored according to their viewing patterns, their thinking and acting habits.

Accepting different ways of life also puts an end to the idea that infection prevention everything and everything else is nothing.
In this sense, the idea is also to acknowledge the profound human desires for delimitation, disinhibition, lust and frenzy ... All of this is difficult to implement in the "no-risk" area. The task is thereby to develop pragmatic, creative ideas and projects, not moralising and to reduce risk and harm.

Successful examples are the syringe exchange and methadone programs for intravenous drug users. These certainly contributed to the reduction of HIV prevalence among intravenous drug users.

Before I conclude my lecture, I would like to have a closer look on the target group, I’m working with, being a street worker with drug addicted prostitutes.
I would also connect to the largest HIV-most affected group in Eastern Europe, the heterosexual drug users aged 20 to 29 years. Many women prostitute themselves in order to be able to buy expansive drugs. Often they have no other source of income.

Risks
Addicted women working as prostitutes face diverse risks, including infection with HIV or other sexually transmitted infections (STI).

Risk intravenous drug use
Beyond prostitution women are more vulnerable only because of their sex in regard of infectious diseases such as HIV and hepatitis.
Women can be found at the lower end of the hierarchy in the male-dominated drug scene. When there are no sterile syringes available and thus one syringe is used by several people, women get the injection equipment last.
If there is a rest of blood infected with HIV or hepatitis by a previous user, it is a high risk of infection.

Risk violence
Drug withdrawal and the conditions of street prostitution carry a higher risk to be victim of abuse and sexual violence. Some punters misuse the bad situation of a woman trying to obtain drugs: they try to cut prices, demand intercourse without condom or pay supplement for intercourse without condom. Some punters humiliate the women or expect unusual sexual practices. Work is dangerous for prostitutes in deserted areas.

Repressive acts by the police add to this situation. Prostitutes continually suffer from stress and anxiety, being in constant danger to be hunted and taken into police custody. All these are possible unfavourable conditions for the enforcement of safer sex.

Risk private sexual contacts
A risk of infection lies also in sexual contacts in the private sector. Since addicted women often have relationships within the drug scene, they face a high risk to be infected with HIV and other viruses by their partners. Female drug addicts often don’t protect themselves in their private relationships. The use of condoms reminds the women of sexual contacts with punters and therefore is incompatible with private love relations. Often they lack of strategies to enforce protective behaviour within the relationship, especially if the partner is violent.

Risk prisons
Women who consume illegal drugs and the work as prostitutes illegally violate several laws. Again and again, they are put in jail. If the intravenous drug use continues in the prison, this is under disastrous hygienic conditions. Also the HIV prevalence in prisons is higher than outside the prison walls.

Outlook
Finally, I would like to refer to the title of this conference very briefly "United against human trafficking. Human trafficking and HIV / STD ".

HIV and AIDS is especially spread in countries,

• Where poverty rates are particularly high
• Where women are denied sexual self-determination
• Where there is much violence and oppression

All these factors do preliminary work for the traffickers. They find their victims precisely where the social need is greatest, where the lack of prospects makes people vulnerable to fatal promises. The fight against HIV and AIDS and thus for the protection of health is always a fight for a socially fair world and for the preservation of human rights.
This is actually only possible through openness, dialogue, exchange and transfer of knowledge, possible through nourishing a new consciousness of the problems and raising awareness. Learning from each other is an important keyword.

Transfers of concepts and experiences are of course never 1:1, but that one idea or the other can certainly be taken in account in even a different cultural background.

Only together can we search for solutions.