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North Macedonia

Articles by North Macedonia

Youth Voices, Youth Choices youth group
01 June 2023

Youth Voices, Youth Choices

Young people and groups with vulnerabilities in the Western Balkans face a great many barriers to accessing sexual and reproductive healthcare. Throughout the COVID-19 pandemic, they bore the brunt of additional obstacles to accessing information, support and care. COVID-19 demonstrated how fragile national health systems are and highlighted countries’ unpreparedness to deal with health emergencies. But it also stimulated creativity by civil society and other actors to counter these barriers, with digital outreach and support playing an expanding, crucial role. Youth Voices, Youth Choices is a project dedicated to learning from the COVID-19 experience in the Western Balkans to ensure sexual and reproductive health services, information and education become more accessible and youth-friendly in the long term, especially for marginalised groups. Running from 2020 until 2023, it brings together IPPF members and partners in Albania, Bosnia and Herzegovina, Bulgaria, North Macedonia and Kosovo, supported by IPPF EN’s Regional Office. Project partners have conducted research into the impact of the pandemic on young people’s SRH needs and access to services and information, and the role of integrated digital services, with a focus on communities living in remote areas and unfavourable social conditions. They are sharing good practices and empowering young people as campaigners and advocates using digital and offline education tools. And working in multi-stakeholder partnerships, they are developing policy recommendations to support advocacy and youth-led campaigns for stronger health systems and increased access to care, in and beyond emergency situations. In October 2022, IPPF EN launched a set of regional policy recommendations based on our research into how the pandemic affected young people. All partners also created national recommendations. Collectively, we built upon these through regional and national advocacy campaigns and actions. Check out our YVYC resources page! Take a look at our series of interviews carried out by young people with their peers on how COVID affected their access to SRHR information, education and care, and their vision for the future. RESEARCH REPORT  As a basis for this work, in 2021 and early 2022, we conducted a study to provide us with a clearer picture of the impact of the pandemic on young people’s SRHR. The data was published in a series of reports presenting the findings of the study, carried out by and among youth in five Balkan countries. The reports, available for download below, document young people’s SRH needs and experiences and the perspectives of healthcare providers and other relevant stakeholders on these needs. They also capture the latter’s needs as they deliver services, information and education to young people, building on their experience of COVID-19. POLICY RECOMMENDATIONS In October 2022, IPPF EN launched a set of regional policy recommendations that call on decision-makers to listen to young people and uphold their SRHR as they build back health and social systems in the wake of the pandemic. Presented at the European Parliament on 26 October by youth advocates and experts, with the support of MEP Fred Matić, the recommendations were developed by a group of specialists who came together to develop a blueprint for designing systems that prioritise access to youth-friendly SRH care, and better support of young people’s health and well-being. The policy recommendations are available for download below. The policy recommendations were used to set advocacy priorities for further actions and campaigning. YOUTH VOICES Young people are at the heart of this work: as researchers, as members of the expert groups that developed policy recommendations, and as advocates and campaigners for change. They were also in the lead at the 'Healthy Youth – Healthy Future' multi-stakeholder meeting in Tirana in spring 2023, where youth representatives and staff from our partner organisations came together with decision-makers and experts from the field - see Tirana joint declaration on protecting the health and social wellbeing of young people. The young participants presented advocacy campaigns carried out at regional and national levels, and shared their needs and experiences at an event held in the Albanian parliament. For more information about this work, please contact us at: [email protected]           This work is funded by MSD for Mothers.

YVYC illustration of young people
25 October 2022

"COVID measures curtailed the freedom of movement of people who needed sexual and reproductive healthcare the most."

We spoke to young people from the Western Balkans about how their access to sexual and reproductive health and rights was affected by the COVID pandemic, and asked them about their vision for re-designing a more youth-friendly future in which young people can flourish.  Yellow is a 22-year-old student from Skopje, North Macedonia.   Yellow, describe your experience of access to SRHR* education, information and care before and during COVID.    During the beginning of the pandemic, my access (as a student) to health services was limited due to bureaucratic obstacles to enjoying the right to free health care. Sexual and reproductive health, as well as non-COVID services, were deprioritized, hence access to them was difficult. Since COVID, things are slowly starting to return to normal, but due to the global economic situation, some of the services offered by the NGO sector are being cut and we are working strictly with certain groups of individuals who are being targeted at the moment. I have witnessed young people being turned away from accessing SRHR-related services because they do not belong to a certain group.   Did anything change for the better for you during the pandemic in terms of access to SRHR? Has this continued since COVID is no longer an urgent crisis? What has improved is access to SHRH education, due to the expansion of availability with new digital tools. But many of these alternatives, which were of great importance in the time of COVID, have been cut off by the easing of restrictions.   What was the biggest obstacle to your SRHR during the pandemic? How could decision-makers/medical professionals have removed this obstacle?   The main obstacle during the pandemic was the complete deprioritization of all health care at the expense of COVID. Due to the novelty of dealing with a pandemic, the government and institutions had difficulties in managing things. Additionally, I believe that gender blindness in making these decisions was shown by curtailing the freedom and movement of people who were most in need of SRH services. This could have been prevented by including the perspective of different marginalised groups in the creation of recommendations and protocols to deal with the pandemic.     What lessons do you think governments and professionals working with young people should learn from the COVID experience about how to look after young people’s health and well-being in a crisis?  I don't think any new lessons were learned, unfortunately. I hope that the experience of this pandemic will help in creating programs and protocols that will prevent similar situations like this. In a number of states, states of emergency have been misused to push political agendas. Additionally young people were again placed at the bottom of the list for maintaining their well-being, reinforcing the stereotype that health care should not be a priority for young people because of their 'youth/age'.     What is your number 1 recommendation on what is needed to make services more youth-friendly? What difference would this make in the life of a young person like you or your friends? Very easy: ask and listen to young people. High quality, youth-friendly services should be available and accessible to young people in appropriate locations. Employees need to be motivated and ready to adapt to work with young people. Perhaps an additional piece of advice would be to invest in young people who can be professionally involved in these institutions.   * SRHR = sexual and reproductive health and rights Interview conducted by Anamarija Danevska, a member of the regional youth group of the IPPF EN project Youth Voices, Youth Choices, funded by MSD for Mothers  

Youth Voices, Youth Choices research report front cover
30 March 2022

Youth access to SRH information, education and care in the Balkans in COVID times

COVID-19 created the largest health and socio-economic crisis of our generation. Many health systems were pushed to the brink by restrictive measures rushed in to respond to the pandemic, resulting in the deprioritisation of some existing healthcare services. In almost all European countries, COVID-19 had a negative impact on the delivery of vital sexual and reproductive healthcare, including maternal health and family planning, for women and groups that face barriers to accessing care, including young people. The pandemic also uncovered weaknesses within our systems and exposed the fact that countries are not adequately prepared to deal with health emergencies. To help bring about positive change for young people, IPPF European Network is working to strengthen healthcare systems through the project Youth Voices, Youth Choices, and to remove all kinds of barriers preventing youth from accessing essential care in five Balkan countries: Albania; Bosnia & Herzegovina; Bulgaria, Kosovo and North Macedonia. We are focusing particularly on the needs of those living in remote areas, as well as those from communities that face challenging social conditions, such as the Roma. POLICY RECOMMENDATIONS In October 2022, IPPF EN launched a set of regional policy recommendations that call on decision-makers to listen to young people and uphold their SRHR as they build back health and social systems in the wake of the pandemic. Presented at the European Parliament on 26 October by youth advocates and experts, with the support of MEP Fred Matić, the recommendations were developed by a group of specialists who came together to develop a blueprint for designing systems that prioritise access to youth-friendly SRH care, and better support of young people’s health and well-being. The policy recommendations are available for download below. RESEARCH REPORT  As a basis for this work, in 2021 and early 2022, we conducted a study to provide us with a clearer picture of the impact of the pandemic on young people’s SRHR. The data was published in a series of reports presenting the findings of the study, carried out by and among youth in five Balkan countries. The reports, available for download below, document young people’s SRH needs and experiences and the perspectives of healthcare providers and other relevant stakeholders on these needs. They also capture the latter’s needs as they deliver services, information and education to young people, building on their experience of COVID-19. YOUTH VOICES Young people are at the heart of this work. They were part of the teams that carried out the research presented in the reports below. They participated in the expert groups that developed our regional recommendations for policy change (below) at national and regional level, and they are being supported and empowered to advocate for these changes. Youth were also in the lead at our 'Healthy Youth – Healthy Future' multi-stakeholder meeting in Tirana in spring 2023, where together with staff from our partner organisations they held discussions with decision-makers and experts from the field, concluding with the signing of a joint declaration on protecting the health and social wellbeing of young people during and beyond moments of crisis - available for download below.     Young people also carried out a series of interviews among their peers to share stories of how the pandemic affected their access to SRHR, and what their vision is for a more youth-friendly future that listens to the younger generations and upholds their SRHR.

young people
14 January 2022

Sharing Innovations

YSAFE, IPPF EN’s youth network, created the project “Sharing Innovations” as a response to the Covid-19 lockdowns and the impact they had on the delivery of relationship and sexuality education (RSE). It is an Erasmus+ project aiming to improve access to sexuality education online. We are collaborating with seven national sexual and reproductive health and rights organizations (IPPF EN members in Portugal, Cyprus, Estonia, Spain, North Macedonia, Latvia, Serbia) and the End FGM EU network to create a new set of guidelines on delivering safe and effective digital sexuality education. It will incorporate everything that we have learned during the first year of the pandemic about pivoting quickly to online RSE delivery into a user-friendly tool. Young sexuality educators will be testing the tool out in 6-month programmes of activities they will design themselves, focused on different national priorities around sexual and gender-based violence (SGBV) prevention. We expect the results to be published in the summer of 2022.

North Macedonia’s abortion care law signals new dawn for reproductive freedom
04 April 2019

North Macedonia’s abortion care law signals new dawn for reproductive freedom

The North Macedonian Parliament adopted a law on March 14, 2019, that makes dignified, women-focused abortion care a reality. The new law puts women’s needs at the heart of the system, dismantling many of the obstacles that until now undermined their reproductive autonomy and made it difficult to access basic health care. HERA (IPPF’s member in North Macedonia) has worked tirelessly in a coalition of civil society organisations to make abortion care safe, accessible and dignified for all Macedonian women. “We wholeheartedly welcome this vote for change which makes abortion care safe, legal and accessible. Our legislation now puts women’s well-being and safety on top and makes it possible for health providers to care for their patients when they are at their most vulnerable.” said Bojan Jovanovski, Executive Director of HERA. The previous retrograde law, imposed by the former conservative government, forced women to undergo biased counselling aimed at persuading them to continue through a pregnancy, and then made them wait for 3 days, with no medical justification, before they could access care. Forcing women to jump through these hoops undermines their decision-making abilities. “I did not like the attitude, especially the heartbeat thing and when they tried to persuade me not to have an abortion, that is subtle persuasion.” (Woman from Macedonia, 33 years old) But with the new law in place, these obstacles will be swept away. From now on any information about abortion care will have to be evidenced-based, in line with World Health Organisation standards. A number of other changes in the new law will remove barriers that previously made it difficult to access care. The Parliament shifted the legal gestation limit for having an abortion from 10 to 12 weeks. Women will be able to access abortion care up to 22 weeks of gestation in case of rape, incest, foetal malformation, for socio-economic reasons or in case of crisis pregnancies. They will no longer have to endure an approval process in front of a hospital commission, nor will they have to bring proof from the Public Prosecutor’s office in case of sexual assault. From now on, women and their families will be protected from strangers meddling in their reproductive lives. Increasing access to safe abortion care is at the heart of the new law. Medical abortion pills – recognised by the WHO as being the safest method in early stages of pregnancy - will be introduced for the first time. Medical abortion care will be available at the primary level of health care as well as in hospitals, making it available in more cities and towns. The changes eliminate many of the barriers which put additional financial burden on women, creating more expenses and increasing the time spent away from work and family. The new law also unties doctors’ hands by significantly reducing the penalties and fines they once faced for refusing to make women endure the 3 days waiting period or for providing compassionate counselling rather than biased. These fines were higher for practitioners in this field than for other health care providers in an effort to bully them into delaying abortion care. Doctors can now provide quality and compassionate care to their patients. In a Europe where we are fighting against reproductive coercive movements, North Macedonia now stands out as a defender of reproductive freedom. In a sea of conservatism, the country has managed to become an example of compassion for its neighbours and for Europe as a whole. Bojan added “HERA and our partners are carefully following the timely implementation of this law. We are also fighting to improve language on request for parental/guardian consent for minors above 16 and for people with intellectual disabilities.”  

Silvana Naumova, HOPS programme manager, outside drug support clinic
20 July 2018

Battling to ensure stigma-free care for young drug users and sex workers

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s government has committed to providing long-term funding for all HIV programmes for marginalised people. Just off a highway in downtown Skopje, halfway down a long concrete track, a middle-aged man stamps his feet before a door. He is here to pick up clean needles from a drop-in centre run by HOPS – Healthy Options Project Skopje – an NGO that provides drug users and sex workers with clean needles, contraception, information and advice. Inside, four women are busy packaging up needles, typing on computers and talking to clients. One of them is Silvana Naumova, a social worker and programme manager who has been working at HOPS since 2003. “Immediately after completing my studies of social work and policy, I started my work with sex workers,” Silvana says. “I was motivated because it was a group of people who had been marginalised and find themselves at the edge of society.” HOPS started life in the mid-nineties as a needle exchange programme for drug users, with the aim of preventing the spread of HIV. Spurred by the desperate needs of these people, it quickly evolved into a centre providing social welfare, medical services, legal aid, human rights campaigning, and educational workshops and services to support people’s basic needs of clothing and food. In 2000, it launched a programme for sex workers – both those working on the street, those employed in brothels and massage parlours, and those living in the Roma community of Šuto Orizari (Šutka) in the Skopje suburbs. The focus is on sexual health education, services and rights, but spans a broad gamut of social welfare and education services as well. There is a lot of crossover between these two groups: around a third of sex workers use drugs – usually heroin or methadone if they work on the streets, or cocaine, ecstasy, amphetamines and marijuana if they work “behind closed doors”. Some are forced to do drugs by clients. “We deal with the most marginalised groups of sex workers and drug users,” says Silvana. “They’re most marginalised in terms of lack of education in the first place – some of them have incomplete primary education; some of them do not attend school at all.” Through its close partnership with IPPF member HERA, too, HOPS builds links with young, marginalised people: young people using HERA services are referred on to HOPS if they are using drugs or are involved in sex work.  Many people have no idea how to exercise their rights to healthcare and social welfare, particularly if they are Roma, for whom language barriers and a lack of ID are major problems, she says. Violence and discrimination is a fact of life for many sex workers and drug users. “Sex workers working on the street are most exposed to violence … from their clients, the police passers by … domestic violence.” Drug users are often harassed or discriminated against because they are so easy to spot. Risky behaviour like having unprotected sex with long-term partners or sharing needles is widespread among drug users, Silvana says. The sex workers they support tend to look after themselves better. “As far as sex workers that we are in touch with are concerned, I can say that their knowledge about sexual and reproductive health and rights and how to protect themselves from HIV and STIs is at a very low level,” she says. Since HOPS began running sex worker support services, “the level has risen a lot”. Last year, HOPS supported around 230 sex workers, both through its drop-centres, mobile testing vans, and through outreach workers who offer support, contraception and advice to women working on the streets. “I think that if it weren’t for HOPS, the sex workers would not know that much about how to protect their health,” Silvana adds. She is currently working hard to ensure the organisation is sustainable and well-funded in the coming years, a goal made more difficult after the Global Fund phased out support for Macedonian HIV programmes in late 2016. Although HIV levels are not high in Macedonia, the fact that so many vulnerable groups rely on NGOs like HOPS – whose futures look more uncertain since the Global Fund withdrawal – make their safety and protection precarious. “If those services stopped, we are afraid there would be a pandemic.” Photo: Silvana Naumova outside the drug support clinic run by HOPS, credit: Jon Spaull / IPPF EN

Zoran Joranov, founder of EGAL, talks to HERA's Vojo Ivanof
20 July 2018

Reaching young men whose health and well-being are at risk

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s government has committed to providing long-term funding for all HIV programmes for marginalised people. Back in 2004, Zoran Jordanov decided that someone needed to take action to support Macedonia’s LGBTI community and open up access to sexual health services. A close friend, a doctor at Macedonia’s Centre for Infectious Diseases, encouraged him to take a look into issues of HIV prevalence in the LGBTI community and the importance of prevention. This encouraged him to set up EGAL, Equality for Gays and Lesbians – Macedonia’s only community organisation focused exclusively on LGBTI sexual health and rights. The level of ignorance about sexual health and rights in Macedonia in general was astonishing, he says. “Not just in the gay community but among Macedonians in general, it’s very rare to talk about sexuality – no one broaches that topic.” HIV, too, “is a topic that is very hidden – no one speaks about it”. The staunchly patriarchal culture and ‘traditional values’ of Macedonian society mean that many gay people live under the radar. “There are a couple of challenges when you work in this totally hidden group in Macedonia,” Zoran explains. “And there are reasons why they are hidden – a lot of problems of stigma and discrimination, which are closely connecting to the traditions … in this part of the world, especially in Balkan countries.” One challenge is encouraging men, be they gay or straight, to open up about sexual health. “When we speak generally about sexual health with men, not just men who have sex with men, it’s much lower than the sexual health of women. Women … sometimes go to the gynaecologist when they’re pregnant or hit puberty or whatever, but men don’t use those kind of services at all. … they just go to the pharmacy and try to solve the problem directly. … they are embarrassed.” For gay or bisexual men, things become even more challenging. “They have the same behaviour as all other men but at the same time ... because they are hidden, they are at even bigger risk.” Attitudes to condoms are also a problem, he adds, with many perceiving them as a way of preventing pregnancy rather than as protection against sexual transmitted diseases. “When there are two men, they feel they don't need to use condoms.” Research in 2013/14 by IPPF member HERA, a leading sexual health organisation that focuses on young people's needs, revealed that just 47 per cent of men interviewed used a condom when they last had sex. Some men are even harder to reach because they might not identify as gay, but frequently have sex with men. Sex between men is particularly widespread within Macedonia’s Roma community, where around 70-80 per cent of men have their first sexual experience with another man, due to strict cultural norms about girls being virgins when they marry making them off-limits. “I’m very afraid that if HIV entered into this community, it would spread very quickly,” Zoran says.  Opening up links with the Roma can be a struggle: “Sometimes the Roma community can be very closed and actually a little bit difficult to enter the community as someone who is not Roma.” One strategy EGAL uses is to employ ‘gatekeepers’ – people from within a certain community who are trained up to act as links between a community and sexual health services. Other strategies include running drop-in centres, distributing information and running events, festivals and ‘movie nights’, where clients, social workers and psychologists come together to watch films and then discuss the issues they throw up. EGAL also works in close partnership with HERA. “We had a lot of help from them,” Zoran says. “We collaborate with them, we use their youth-friendly services and we refer our clients to their services.” EGAL also runs workshops for medical staff and HIV experts to make them more comfortable talking about homosexuality and better able to support young LGBTI people. This is vital work, not least because government training for sexual health care workers does not cover the specific needs of young people. The internet has made EGAL’s work more complicated, he adds. Until about five years ago, the best way to meet and support LGBTI people would be to head down to Skopje’s cruising areas. With the arrival of the internet, people began meeting online instead, which makes reaching people more difficult. “It’s much easier when you have face to face contact in the field – you have more opportunity to reach the people, to attract the people and to give them materials, as well as condoms and lubricants.” Another problem EGAL has is that young people are not legally allowed to access sexual health services until they are aged 18, unless they have permission from their parents. “It’s a boundary for us and it’s very difficult for us to cross,” Zoran says. “We know that sexual activities among people begin much earlier, and if you don't start with them from the beginning, working on how they can prevent themselves and protect themselves, then sometimes 18 years is too late.” Research shows that one third of sexually active men who have sex with men are under the age of 15, and almost three quarters are sexually active under 17. Shifting behaviour later on is much more difficult. This kind of work demands investments of time and money. Fundamentally, Zoran says, it requires conversation. “Changing behaviour – it’s not just with free access to condoms and lubricants and contraceptives. It needs more focus on talking with the client, and explaining a lot of other things, and showing them the way they can take care about their sexual health.” The organisation stands at a crossroads. In 2016, the Global Fund to Fight AIDS, Tuberculosis and Malaria, one of EGAL’s main backers, began phasing out funding for Macedonia.  This has left the organisation’s finances in crisis. Zoran hopes that the new government will step into at least some of the breach left by the Global Fund. “We really hope we will have a good agreement with the government and they will take care of some of our services – maybe not 100 per cent but some of them.” - This article was written in September 2017. Since then, thanks to the work of NGOs including HERA, Macedonia’s government has committed to providing long-term funding for all HIV programmes for marginalised people. - Photo: Zoran Joranov talks to HERA's Vojo Ivanof. Credit: Jon Spaull/IPPF EN

Sex worker Mihaela (not her real name) in Roma neighbourhood of Shuto Orizari.
20 July 2018

Sexual and reproductive health care a lifeline for mistreated communities - Mihaela's story

When Mihaela (not her real name) was six years old, her father sent her onto the streets to scavenge for food for the family and beg for money to fund his alcoholism treatment. “We were very poor,” she says. “I started going through containers, through dustbins. Then I started begging.” At nine, Mihaela dropped out of school. By the age of 16, she was selling sex. Mihaela grew up in Šuto Orizari – or Šutka – a sprawling, run-down neighbourhood on the edge of Macedonia’s capital, Skopje. Of the roughly 50,000 people living here, over three quarters are Roma. Šutka is a lively place, abuzz with the patter of market traders. But it also faces huge social problems, from poverty, unemployment and illiteracy to gender-based violence and poor health. The community is ill-served by state social services and healthcare, and Roma people are often denied access to state services due to stigma and discrimination. Mihaela married at 16 – a common age for girls in Šutka to marry. Roma tradition dictates that girls should be virgins upon marriage: Mihaela’s bedsheets were displayed outside the house after the wedding night for inspection by the community. She left her husband shortly after marrying and began selling sex. She would arrange to meet clients – non-Roma Macedonians – by telephone, and meet them “downtown” in central Skopje, about half an hour away. At 17, she married a Roma man from Kosovo and began a family: they now have six children, aged between two and ten. Life was tough. “My husband was unemployed. I continued my work because I had to make money. I started doing everything, and he was just being lazy. I supported the whole family –  I was working all day long, seeing two or three clients a day. In this community, women are the breadwinners.” Four months ago, Mihaela’s husband left for Serbia, ostensibly to get hold of ID documents. “I don’t know if he’s going to come back or not and I can hardly stand the situation,” she says. “I am alone with the six children and it’s really difficult for me. My children are starving. There’s no one to look after them.” Both Mihaela’s parents are now dead, and her only sibling, a brother, is blind and unable to help the family. “I don’t have any means of support,” she says. “Sometimes I want to hang myself.” Roma families are often large and contraception rarely used within marriage. Mihaela’s husband insisted sex should be “natural”, while misinformation also played a role: “my husband wouldn't allow me to use condoms during sex because he told me that I would catch an infection.” Abortion is frowned upon within the Roma community, while high fees and a controversial abortion law from 2013 make the procedure inaccessible for most.  “I had the first two children out of love,” Mihaela says. “But when I became pregnant for the third time, I wanted to have an abortion but my father-in-law wouldn’t let me because they come from Kosovo and abortion isn’t allowed in their culture.” Poverty forces her to work throughout each pregnancy, up until delivery. Mihaela’s eldest child, aged ten, now looks after the children in the evenings so she can go to work. Like many sex workers in Skopje, she meets clients on ‘Television Street’, on the north bank of the Vardar River, a short stroll from the city’s main square and tourist hotspots. Life for street sex workers in Skopje is perilous. “Sometimes when you refuse to do something the clients want, you get beaten up,” Mihaela describes. The police also harass the women. Mihaela earns between 500 and 1000 Macedonian denars a day – around US$ 9-19. “It’s not enough to feed six kids,” she says. She insists on using condoms with clients, and gets them free at the Šutka branch of I Want to Know, a sexual health centre run by IPPF member HERA, a leading Macedonian sexual health organisation. Like many sex workers, particularly those from the Roma community, Mihaela is almost entirely reliant on NGOs for her sexual health and contraception needs. She says she would be lost with the support of Nicolina Nikolovska, a social worker at the Šutka centre. “She organised IUDs [contraceptive coil] for me, provides condoms, advises me. If it weren’t for her, I would have been completely destroyed.” “I have had HIV tests done here with Nicolina and I swear by this organisation for everything – literally everything – smear tests, STI testing, HIV testing, guidance and advice.” Mihaela herself now acts as a “focal point”, encouraging other women to get HIV and STI tests at the centre or its mobile van. They are given brochures, contraception and lubricants as well as workshops on sexual health and rights. She hopes to stop sex work one day. “If there was something else, I would gladly leave this job,” she says.  “This is why I now teach my kids and make them understand that I am in a bad situation – so they can learn from my mistakes and not make the same mistakes.” “I wouldn’t want my children to do what I do, I wouldn’t want them to live how I live. That’s why I encourage them to go to school and get an education, move away from my life and learn from my mistakes, because I wouldn’t wish this on anyone, especially my kids.” Photo: Mihaela looks out over the Roma neighbourhood of Shuto Orizari, credit: Jon Spaull/IPPF EN This article was written in September 2017.   

Rumena Gjerdovska, Macedonia’s only social worker focused exclusively on supporting people with HIV, and one of the first HIV specialists people meet on diagnosis. 
01 December 2017

On the Frontline: Macedonia’s Only Social Worker Supporting People Living with HIV

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s incoming socialist government has committed to providing long-term funding for all HIV programmes for marginalised people. Tucked away behind a line of trees in the grounds of Skopje’s University Hospital, lies a modest concrete building. This is the Clinic for Infectious Diseases, where people newly diagnosed with HIV come to access treatment and support. Deep in the basement of this building is the office of Rumena Gjerdovska, Macedonia’s only social worker focused exclusively on supporting people with HIV, and one of the first HIV specialists people meet on diagnosis.  Rumena’s interest in HIV was triggered as a young student. “It was an especially interesting topic for me because while I was studying social work had very little to do with HIV/AIDS and health issues,” she says.  “We were mainly dealing with child protection, divorce cases, children who were threatened socially.” The link between HIV/AIDS and social work was a new area. “Even nowadays people do not recognise how social work is connected with HIV/AIDS and health aspects,” she adds. She began volunteering for sexual health organisation and IPPF member HERA (Health and Research Association), mainly running the SOS hotline for people concerned about HIV. In the era before the internet was widely accessible and when government HIV services were skeletal, this hotline was often the first port of call for those with concerns. “Mainly I received calls from concerned parents, because parents were frightened of their children’s sexual behaviour and drug use,” she explains. In 2007, she joined the clinic. Ten years later, she remains a unique figure in the world of Macedonian sexual health and rights. “I’m the only one who has direct contact with these people and that is my main challenge,” she says. “That’s why I decided to get so deep into the matter.” When people test positive for HIV at a mobile van or clinic, they are then sent to the clinic in Skopje to confirm the diagnosis and, if confirmed, get support and begin treatment. The clinic remains the only place in Macedonia where people living with HIV can pick up medication. The first part of Rumena’s role is to break the news of positive diagnoses and explain how the Macedonian health system for people living with HIV works. When delivering a positive diagnosis, it’s important to remain calm, she says. “The manner in which you give the news is very, very important – it’s critical. If you know how to do it then you will calm them down and they will be willing to accept the situation.” She often finds herself up against a barrage of misinformation about HIV – stemming, she says, from Macedonia’s failure to teach children about sexual health. The silence and stigma surrounding HIV is another barrier. Many people in Macedonia “associate HIV with highly stigmatised behaviours such as sex work, drug use and being gay,” she says. “This is the reason people cannot get rid of the stigma that is related to HIV in society.” New clients are often familiar with how HIV is contracted. “However they have very little information about the availability of treatment. ... they may think that HIV is a death sentence and it is fatal and there is no cure for it. “But once we explain to them that treatment can be administered at home and it’s only pills that they should take regularly just like any chronic disease, the story changes and there is hope for them.” Their clients are mainly young and around 80 per cent are men – mostly gay men or men who who have sex with men (MSM). In 2014, of the 42 new people diagnosed with HIV, 30 were men. Rumena talks through any concerns people have, describes the services they will receive – from medication to counselling – refers them on to other services, and offers them psychosocial care. She also advises people on how to tell their families and friends about their diagnosis – a complicated issue in a country where stigma towards HIV remains extreme. “Experience has shown that they should not rush into disclosing their HIV status immediately to everyone they know but sleep on it, because sometimes they are betrayed by the closest ones and the gossip starts and their HIV status is disclosed very quickly. Then stigma and discrimination start.” Fundamental to Rumena’s work is ensuring a “continuum of care” – making sure that services and support are in place every step of the way, from diagnosis onwards. She also puts people in touch with organisations like Stronger Together, a network for people living with HIV to meet, chat and support each other. This ongoing support is crucial. “Everything looks nice at the beginning when we say to them that there is no need to be afraid, … they will be offered health services,” she says. “And all of a sudden they encounter an obstacle – for example they need to have an operation in a health facility and they will need to provide an HIV negative test.” Discrimination amongst Macedonia’s medical staff is a major problem. GPs are often reluctant to register patients with HIV: “they give excuses like ‘no, don’t send us HIV positive patients because we have small kids here... or ‘we cannot admit such a patient, the boss will be angry and won’t allow it’.” Surgeons frequently refuse to operate on HIV positive patients: “Once [patients] disclose their HIV positive status they are immediately denied the surgical intervention … and all of a sudden it appears that there are problems.” This is illegal, but still happens frequently. Cases of legal action against hospital staff are few and far between. “I’m afraid these people do not file any applications because they don’t believe in the judicial system. … they don’t believe their cases will be won in the end so they give up” she says. The fact that legal action will involve disclosing their status to lawyers, court clerks and the entire system is also a major deterrent. It is vital to keep up pressure on the government and authorities to ensure people living with HIV are not denied treatment, she says. She also calls for laws protecting the rights and privacy of people living with HIV, in part by penalising those who violate their right to privacy. More resources for HIV services are also vital, she adds. “I think the primary need here is to strengthen the team that is working in the hospital since the number of HIV positive people is rising on a daily basis and the team is too small to be able to meet all the needs.” Photo credit: John Spaull/ IPPF EN

"Mirror,mirror on the wall who's the most affected of them all?" Bojan holds up a mirror as part of a HIV campaign, photographed at the Clinic for Infectious Diseases, Skopje.
01 December 2017

Living with HIV in a Society of Rampant Homophobia and Stigma

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s incoming socialist government has committed to providing long-term funding for all HIV programmes for marginalised people. “I remember when I was little, there was one very stigmatising ad on Macedonian TV about how to protect yourself from HIV,” recalls philosophy student Bojan. “It was really scary. It was like: ‘Do you know that in every discotheque you go to, there is at least one HIV positive person? In every school, in every university .... HIV means a really short life, HIV is a monster.’  “This was also my first picture of HIV. I was about 11 years old.” Today, Bojan is a tall, confident 23-year-old. Two years ago, he was diagnosed with HIV. After his partner told him that he had tested positive, Bojan spent a month preparing himself to get tested. “I was 99.9 percent sure that I was already HIV positive, so I had a little time to prepare myself for what to expect, I had time to cope.” Bojan went to the Clinic for Infectious Diseases, Macedonia’s main centre for HIV testing and services, where he was diagnosed and met Rumena Gjerdovska, a former volunteer with IPPF member HERA (Health Education and Research Association), and Macedonia’s only social worker focused exclusively on HIV. Like all people registered as living with HIV in Macedonia, Bojan picks up his medication and has regular check-ups at the Clinic for Infectious Diseases. He also remains in regular contact with social worker Rumena. “If Macedonia awards a Nobel Prize for a social worker, the award must be in her name,” he says. Taboos and stigma around HIV mean that Bojan still feels unable to tell his family about his diagnosis. But, as a young, well-educated student, he says he harbours few fears about the disease. “These days HIV is much more well-managed. The scientists are searching for a cure …  western society is working very hard to destigmatise the disease.” Things are very different in Macedonia. Myths and misinformation about HIV are rife, Bojan says – a problem stemming from the chronic lack of public information and education on HIV and AIDS. “Older people still think that if you get HIV you will die the same week that you acquire it,” he says. “They immediately assume that you are gay, like this goes together with [HIV]. “There are also a very high number of older people who think that if you get HIV, this is your punishment for bad things that you did, for low morals,” Bojan says. Growing up, he says, there was an no sexuality education in school at all, which has fed into the myths and misinformation surrounding HIV. The media doesn’t help to dispel these myths. Newspapers, radio and TV rarely report on it, he says: “It’s total silence.” What media coverage there is has largely been negative, backed up by the anti-LGBTI campaigns from Macedonia’s former government, in power until June 2017. The internet and NGOs are the only real source of reliable information on living with HIV, he adds. Discrimination is also pervasive in the health services. Bojan mentions one friend who was turned down for an operation because of their HIV status. HIV services exist but are poorly resourced and understaffed, partly due to some medical staff avoiding coming face to face with HIV positive patients. There is only one doctor in Macedonia specialising in HIV, Milena Stefanovic, Boyan explains. “She really tries hard. She is like our mother. She [does] everything, everything.” “I see my GP as well but I can’t speak to her in the same way that I can speak with Milena. She is the one who really knows what this means, what my problem is when I say this hurts me.” Another problem encountered at the GP’s surgery is patient confidentiality – or the lack of. Patient files are stored manually, and doctors often leave patients’ files lying around so that anyone could catch sight of them, Bojan says. Given the taboo and stigma around the disease, this lack of privacy discourages people living with HIV from using public healthcare. Most people living with HIV rely on NGOs to top up their care, particularly when it comes to support services and counselling. When he was first diagnosed, Bojan used a service called Stronger Together, a support network for people living with HIV that grew out of HERA. “[Through Stronger Together] I was speaking with another HIV positive person. And this really helped me a lot, because you know you read things on the internet [about how] you can manage this, it’s not terrible, you will be ok, you will live a nearly normal life with these therapies,” he says. “But I needed someone to tell me in my own language, a personal touch.” “My key message would be: test yourself today because every day of life gives you more time for living, if you start with treatment early. If you are HIV positive, don’t be afraid of it and find people you can speak with yourself. “It did change my life for sure, but I learned to love my life more and to take care of myself now.” Photo: John Spaull/ IPPF EN

Youth Voices, Youth Choices youth group
01 June 2023

Youth Voices, Youth Choices

Young people and groups with vulnerabilities in the Western Balkans face a great many barriers to accessing sexual and reproductive healthcare. Throughout the COVID-19 pandemic, they bore the brunt of additional obstacles to accessing information, support and care. COVID-19 demonstrated how fragile national health systems are and highlighted countries’ unpreparedness to deal with health emergencies. But it also stimulated creativity by civil society and other actors to counter these barriers, with digital outreach and support playing an expanding, crucial role. Youth Voices, Youth Choices is a project dedicated to learning from the COVID-19 experience in the Western Balkans to ensure sexual and reproductive health services, information and education become more accessible and youth-friendly in the long term, especially for marginalised groups. Running from 2020 until 2023, it brings together IPPF members and partners in Albania, Bosnia and Herzegovina, Bulgaria, North Macedonia and Kosovo, supported by IPPF EN’s Regional Office. Project partners have conducted research into the impact of the pandemic on young people’s SRH needs and access to services and information, and the role of integrated digital services, with a focus on communities living in remote areas and unfavourable social conditions. They are sharing good practices and empowering young people as campaigners and advocates using digital and offline education tools. And working in multi-stakeholder partnerships, they are developing policy recommendations to support advocacy and youth-led campaigns for stronger health systems and increased access to care, in and beyond emergency situations. In October 2022, IPPF EN launched a set of regional policy recommendations based on our research into how the pandemic affected young people. All partners also created national recommendations. Collectively, we built upon these through regional and national advocacy campaigns and actions. Check out our YVYC resources page! Take a look at our series of interviews carried out by young people with their peers on how COVID affected their access to SRHR information, education and care, and their vision for the future. RESEARCH REPORT  As a basis for this work, in 2021 and early 2022, we conducted a study to provide us with a clearer picture of the impact of the pandemic on young people’s SRHR. The data was published in a series of reports presenting the findings of the study, carried out by and among youth in five Balkan countries. The reports, available for download below, document young people’s SRH needs and experiences and the perspectives of healthcare providers and other relevant stakeholders on these needs. They also capture the latter’s needs as they deliver services, information and education to young people, building on their experience of COVID-19. POLICY RECOMMENDATIONS In October 2022, IPPF EN launched a set of regional policy recommendations that call on decision-makers to listen to young people and uphold their SRHR as they build back health and social systems in the wake of the pandemic. Presented at the European Parliament on 26 October by youth advocates and experts, with the support of MEP Fred Matić, the recommendations were developed by a group of specialists who came together to develop a blueprint for designing systems that prioritise access to youth-friendly SRH care, and better support of young people’s health and well-being. The policy recommendations are available for download below. The policy recommendations were used to set advocacy priorities for further actions and campaigning. YOUTH VOICES Young people are at the heart of this work: as researchers, as members of the expert groups that developed policy recommendations, and as advocates and campaigners for change. They were also in the lead at the 'Healthy Youth – Healthy Future' multi-stakeholder meeting in Tirana in spring 2023, where youth representatives and staff from our partner organisations came together with decision-makers and experts from the field - see Tirana joint declaration on protecting the health and social wellbeing of young people. The young participants presented advocacy campaigns carried out at regional and national levels, and shared their needs and experiences at an event held in the Albanian parliament. For more information about this work, please contact us at: [email protected]           This work is funded by MSD for Mothers.

YVYC illustration of young people
25 October 2022

"COVID measures curtailed the freedom of movement of people who needed sexual and reproductive healthcare the most."

We spoke to young people from the Western Balkans about how their access to sexual and reproductive health and rights was affected by the COVID pandemic, and asked them about their vision for re-designing a more youth-friendly future in which young people can flourish.  Yellow is a 22-year-old student from Skopje, North Macedonia.   Yellow, describe your experience of access to SRHR* education, information and care before and during COVID.    During the beginning of the pandemic, my access (as a student) to health services was limited due to bureaucratic obstacles to enjoying the right to free health care. Sexual and reproductive health, as well as non-COVID services, were deprioritized, hence access to them was difficult. Since COVID, things are slowly starting to return to normal, but due to the global economic situation, some of the services offered by the NGO sector are being cut and we are working strictly with certain groups of individuals who are being targeted at the moment. I have witnessed young people being turned away from accessing SRHR-related services because they do not belong to a certain group.   Did anything change for the better for you during the pandemic in terms of access to SRHR? Has this continued since COVID is no longer an urgent crisis? What has improved is access to SHRH education, due to the expansion of availability with new digital tools. But many of these alternatives, which were of great importance in the time of COVID, have been cut off by the easing of restrictions.   What was the biggest obstacle to your SRHR during the pandemic? How could decision-makers/medical professionals have removed this obstacle?   The main obstacle during the pandemic was the complete deprioritization of all health care at the expense of COVID. Due to the novelty of dealing with a pandemic, the government and institutions had difficulties in managing things. Additionally, I believe that gender blindness in making these decisions was shown by curtailing the freedom and movement of people who were most in need of SRH services. This could have been prevented by including the perspective of different marginalised groups in the creation of recommendations and protocols to deal with the pandemic.     What lessons do you think governments and professionals working with young people should learn from the COVID experience about how to look after young people’s health and well-being in a crisis?  I don't think any new lessons were learned, unfortunately. I hope that the experience of this pandemic will help in creating programs and protocols that will prevent similar situations like this. In a number of states, states of emergency have been misused to push political agendas. Additionally young people were again placed at the bottom of the list for maintaining their well-being, reinforcing the stereotype that health care should not be a priority for young people because of their 'youth/age'.     What is your number 1 recommendation on what is needed to make services more youth-friendly? What difference would this make in the life of a young person like you or your friends? Very easy: ask and listen to young people. High quality, youth-friendly services should be available and accessible to young people in appropriate locations. Employees need to be motivated and ready to adapt to work with young people. Perhaps an additional piece of advice would be to invest in young people who can be professionally involved in these institutions.   * SRHR = sexual and reproductive health and rights Interview conducted by Anamarija Danevska, a member of the regional youth group of the IPPF EN project Youth Voices, Youth Choices, funded by MSD for Mothers  

Youth Voices, Youth Choices research report front cover
30 March 2022

Youth access to SRH information, education and care in the Balkans in COVID times

COVID-19 created the largest health and socio-economic crisis of our generation. Many health systems were pushed to the brink by restrictive measures rushed in to respond to the pandemic, resulting in the deprioritisation of some existing healthcare services. In almost all European countries, COVID-19 had a negative impact on the delivery of vital sexual and reproductive healthcare, including maternal health and family planning, for women and groups that face barriers to accessing care, including young people. The pandemic also uncovered weaknesses within our systems and exposed the fact that countries are not adequately prepared to deal with health emergencies. To help bring about positive change for young people, IPPF European Network is working to strengthen healthcare systems through the project Youth Voices, Youth Choices, and to remove all kinds of barriers preventing youth from accessing essential care in five Balkan countries: Albania; Bosnia & Herzegovina; Bulgaria, Kosovo and North Macedonia. We are focusing particularly on the needs of those living in remote areas, as well as those from communities that face challenging social conditions, such as the Roma. POLICY RECOMMENDATIONS In October 2022, IPPF EN launched a set of regional policy recommendations that call on decision-makers to listen to young people and uphold their SRHR as they build back health and social systems in the wake of the pandemic. Presented at the European Parliament on 26 October by youth advocates and experts, with the support of MEP Fred Matić, the recommendations were developed by a group of specialists who came together to develop a blueprint for designing systems that prioritise access to youth-friendly SRH care, and better support of young people’s health and well-being. The policy recommendations are available for download below. RESEARCH REPORT  As a basis for this work, in 2021 and early 2022, we conducted a study to provide us with a clearer picture of the impact of the pandemic on young people’s SRHR. The data was published in a series of reports presenting the findings of the study, carried out by and among youth in five Balkan countries. The reports, available for download below, document young people’s SRH needs and experiences and the perspectives of healthcare providers and other relevant stakeholders on these needs. They also capture the latter’s needs as they deliver services, information and education to young people, building on their experience of COVID-19. YOUTH VOICES Young people are at the heart of this work. They were part of the teams that carried out the research presented in the reports below. They participated in the expert groups that developed our regional recommendations for policy change (below) at national and regional level, and they are being supported and empowered to advocate for these changes. Youth were also in the lead at our 'Healthy Youth – Healthy Future' multi-stakeholder meeting in Tirana in spring 2023, where together with staff from our partner organisations they held discussions with decision-makers and experts from the field, concluding with the signing of a joint declaration on protecting the health and social wellbeing of young people during and beyond moments of crisis - available for download below.     Young people also carried out a series of interviews among their peers to share stories of how the pandemic affected their access to SRHR, and what their vision is for a more youth-friendly future that listens to the younger generations and upholds their SRHR.

young people
14 January 2022

Sharing Innovations

YSAFE, IPPF EN’s youth network, created the project “Sharing Innovations” as a response to the Covid-19 lockdowns and the impact they had on the delivery of relationship and sexuality education (RSE). It is an Erasmus+ project aiming to improve access to sexuality education online. We are collaborating with seven national sexual and reproductive health and rights organizations (IPPF EN members in Portugal, Cyprus, Estonia, Spain, North Macedonia, Latvia, Serbia) and the End FGM EU network to create a new set of guidelines on delivering safe and effective digital sexuality education. It will incorporate everything that we have learned during the first year of the pandemic about pivoting quickly to online RSE delivery into a user-friendly tool. Young sexuality educators will be testing the tool out in 6-month programmes of activities they will design themselves, focused on different national priorities around sexual and gender-based violence (SGBV) prevention. We expect the results to be published in the summer of 2022.

North Macedonia’s abortion care law signals new dawn for reproductive freedom
04 April 2019

North Macedonia’s abortion care law signals new dawn for reproductive freedom

The North Macedonian Parliament adopted a law on March 14, 2019, that makes dignified, women-focused abortion care a reality. The new law puts women’s needs at the heart of the system, dismantling many of the obstacles that until now undermined their reproductive autonomy and made it difficult to access basic health care. HERA (IPPF’s member in North Macedonia) has worked tirelessly in a coalition of civil society organisations to make abortion care safe, accessible and dignified for all Macedonian women. “We wholeheartedly welcome this vote for change which makes abortion care safe, legal and accessible. Our legislation now puts women’s well-being and safety on top and makes it possible for health providers to care for their patients when they are at their most vulnerable.” said Bojan Jovanovski, Executive Director of HERA. The previous retrograde law, imposed by the former conservative government, forced women to undergo biased counselling aimed at persuading them to continue through a pregnancy, and then made them wait for 3 days, with no medical justification, before they could access care. Forcing women to jump through these hoops undermines their decision-making abilities. “I did not like the attitude, especially the heartbeat thing and when they tried to persuade me not to have an abortion, that is subtle persuasion.” (Woman from Macedonia, 33 years old) But with the new law in place, these obstacles will be swept away. From now on any information about abortion care will have to be evidenced-based, in line with World Health Organisation standards. A number of other changes in the new law will remove barriers that previously made it difficult to access care. The Parliament shifted the legal gestation limit for having an abortion from 10 to 12 weeks. Women will be able to access abortion care up to 22 weeks of gestation in case of rape, incest, foetal malformation, for socio-economic reasons or in case of crisis pregnancies. They will no longer have to endure an approval process in front of a hospital commission, nor will they have to bring proof from the Public Prosecutor’s office in case of sexual assault. From now on, women and their families will be protected from strangers meddling in their reproductive lives. Increasing access to safe abortion care is at the heart of the new law. Medical abortion pills – recognised by the WHO as being the safest method in early stages of pregnancy - will be introduced for the first time. Medical abortion care will be available at the primary level of health care as well as in hospitals, making it available in more cities and towns. The changes eliminate many of the barriers which put additional financial burden on women, creating more expenses and increasing the time spent away from work and family. The new law also unties doctors’ hands by significantly reducing the penalties and fines they once faced for refusing to make women endure the 3 days waiting period or for providing compassionate counselling rather than biased. These fines were higher for practitioners in this field than for other health care providers in an effort to bully them into delaying abortion care. Doctors can now provide quality and compassionate care to their patients. In a Europe where we are fighting against reproductive coercive movements, North Macedonia now stands out as a defender of reproductive freedom. In a sea of conservatism, the country has managed to become an example of compassion for its neighbours and for Europe as a whole. Bojan added “HERA and our partners are carefully following the timely implementation of this law. We are also fighting to improve language on request for parental/guardian consent for minors above 16 and for people with intellectual disabilities.”  

Silvana Naumova, HOPS programme manager, outside drug support clinic
20 July 2018

Battling to ensure stigma-free care for young drug users and sex workers

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s government has committed to providing long-term funding for all HIV programmes for marginalised people. Just off a highway in downtown Skopje, halfway down a long concrete track, a middle-aged man stamps his feet before a door. He is here to pick up clean needles from a drop-in centre run by HOPS – Healthy Options Project Skopje – an NGO that provides drug users and sex workers with clean needles, contraception, information and advice. Inside, four women are busy packaging up needles, typing on computers and talking to clients. One of them is Silvana Naumova, a social worker and programme manager who has been working at HOPS since 2003. “Immediately after completing my studies of social work and policy, I started my work with sex workers,” Silvana says. “I was motivated because it was a group of people who had been marginalised and find themselves at the edge of society.” HOPS started life in the mid-nineties as a needle exchange programme for drug users, with the aim of preventing the spread of HIV. Spurred by the desperate needs of these people, it quickly evolved into a centre providing social welfare, medical services, legal aid, human rights campaigning, and educational workshops and services to support people’s basic needs of clothing and food. In 2000, it launched a programme for sex workers – both those working on the street, those employed in brothels and massage parlours, and those living in the Roma community of Šuto Orizari (Šutka) in the Skopje suburbs. The focus is on sexual health education, services and rights, but spans a broad gamut of social welfare and education services as well. There is a lot of crossover between these two groups: around a third of sex workers use drugs – usually heroin or methadone if they work on the streets, or cocaine, ecstasy, amphetamines and marijuana if they work “behind closed doors”. Some are forced to do drugs by clients. “We deal with the most marginalised groups of sex workers and drug users,” says Silvana. “They’re most marginalised in terms of lack of education in the first place – some of them have incomplete primary education; some of them do not attend school at all.” Through its close partnership with IPPF member HERA, too, HOPS builds links with young, marginalised people: young people using HERA services are referred on to HOPS if they are using drugs or are involved in sex work.  Many people have no idea how to exercise their rights to healthcare and social welfare, particularly if they are Roma, for whom language barriers and a lack of ID are major problems, she says. Violence and discrimination is a fact of life for many sex workers and drug users. “Sex workers working on the street are most exposed to violence … from their clients, the police passers by … domestic violence.” Drug users are often harassed or discriminated against because they are so easy to spot. Risky behaviour like having unprotected sex with long-term partners or sharing needles is widespread among drug users, Silvana says. The sex workers they support tend to look after themselves better. “As far as sex workers that we are in touch with are concerned, I can say that their knowledge about sexual and reproductive health and rights and how to protect themselves from HIV and STIs is at a very low level,” she says. Since HOPS began running sex worker support services, “the level has risen a lot”. Last year, HOPS supported around 230 sex workers, both through its drop-centres, mobile testing vans, and through outreach workers who offer support, contraception and advice to women working on the streets. “I think that if it weren’t for HOPS, the sex workers would not know that much about how to protect their health,” Silvana adds. She is currently working hard to ensure the organisation is sustainable and well-funded in the coming years, a goal made more difficult after the Global Fund phased out support for Macedonian HIV programmes in late 2016. Although HIV levels are not high in Macedonia, the fact that so many vulnerable groups rely on NGOs like HOPS – whose futures look more uncertain since the Global Fund withdrawal – make their safety and protection precarious. “If those services stopped, we are afraid there would be a pandemic.” Photo: Silvana Naumova outside the drug support clinic run by HOPS, credit: Jon Spaull / IPPF EN

Zoran Joranov, founder of EGAL, talks to HERA's Vojo Ivanof
20 July 2018

Reaching young men whose health and well-being are at risk

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s government has committed to providing long-term funding for all HIV programmes for marginalised people. Back in 2004, Zoran Jordanov decided that someone needed to take action to support Macedonia’s LGBTI community and open up access to sexual health services. A close friend, a doctor at Macedonia’s Centre for Infectious Diseases, encouraged him to take a look into issues of HIV prevalence in the LGBTI community and the importance of prevention. This encouraged him to set up EGAL, Equality for Gays and Lesbians – Macedonia’s only community organisation focused exclusively on LGBTI sexual health and rights. The level of ignorance about sexual health and rights in Macedonia in general was astonishing, he says. “Not just in the gay community but among Macedonians in general, it’s very rare to talk about sexuality – no one broaches that topic.” HIV, too, “is a topic that is very hidden – no one speaks about it”. The staunchly patriarchal culture and ‘traditional values’ of Macedonian society mean that many gay people live under the radar. “There are a couple of challenges when you work in this totally hidden group in Macedonia,” Zoran explains. “And there are reasons why they are hidden – a lot of problems of stigma and discrimination, which are closely connecting to the traditions … in this part of the world, especially in Balkan countries.” One challenge is encouraging men, be they gay or straight, to open up about sexual health. “When we speak generally about sexual health with men, not just men who have sex with men, it’s much lower than the sexual health of women. Women … sometimes go to the gynaecologist when they’re pregnant or hit puberty or whatever, but men don’t use those kind of services at all. … they just go to the pharmacy and try to solve the problem directly. … they are embarrassed.” For gay or bisexual men, things become even more challenging. “They have the same behaviour as all other men but at the same time ... because they are hidden, they are at even bigger risk.” Attitudes to condoms are also a problem, he adds, with many perceiving them as a way of preventing pregnancy rather than as protection against sexual transmitted diseases. “When there are two men, they feel they don't need to use condoms.” Research in 2013/14 by IPPF member HERA, a leading sexual health organisation that focuses on young people's needs, revealed that just 47 per cent of men interviewed used a condom when they last had sex. Some men are even harder to reach because they might not identify as gay, but frequently have sex with men. Sex between men is particularly widespread within Macedonia’s Roma community, where around 70-80 per cent of men have their first sexual experience with another man, due to strict cultural norms about girls being virgins when they marry making them off-limits. “I’m very afraid that if HIV entered into this community, it would spread very quickly,” Zoran says.  Opening up links with the Roma can be a struggle: “Sometimes the Roma community can be very closed and actually a little bit difficult to enter the community as someone who is not Roma.” One strategy EGAL uses is to employ ‘gatekeepers’ – people from within a certain community who are trained up to act as links between a community and sexual health services. Other strategies include running drop-in centres, distributing information and running events, festivals and ‘movie nights’, where clients, social workers and psychologists come together to watch films and then discuss the issues they throw up. EGAL also works in close partnership with HERA. “We had a lot of help from them,” Zoran says. “We collaborate with them, we use their youth-friendly services and we refer our clients to their services.” EGAL also runs workshops for medical staff and HIV experts to make them more comfortable talking about homosexuality and better able to support young LGBTI people. This is vital work, not least because government training for sexual health care workers does not cover the specific needs of young people. The internet has made EGAL’s work more complicated, he adds. Until about five years ago, the best way to meet and support LGBTI people would be to head down to Skopje’s cruising areas. With the arrival of the internet, people began meeting online instead, which makes reaching people more difficult. “It’s much easier when you have face to face contact in the field – you have more opportunity to reach the people, to attract the people and to give them materials, as well as condoms and lubricants.” Another problem EGAL has is that young people are not legally allowed to access sexual health services until they are aged 18, unless they have permission from their parents. “It’s a boundary for us and it’s very difficult for us to cross,” Zoran says. “We know that sexual activities among people begin much earlier, and if you don't start with them from the beginning, working on how they can prevent themselves and protect themselves, then sometimes 18 years is too late.” Research shows that one third of sexually active men who have sex with men are under the age of 15, and almost three quarters are sexually active under 17. Shifting behaviour later on is much more difficult. This kind of work demands investments of time and money. Fundamentally, Zoran says, it requires conversation. “Changing behaviour – it’s not just with free access to condoms and lubricants and contraceptives. It needs more focus on talking with the client, and explaining a lot of other things, and showing them the way they can take care about their sexual health.” The organisation stands at a crossroads. In 2016, the Global Fund to Fight AIDS, Tuberculosis and Malaria, one of EGAL’s main backers, began phasing out funding for Macedonia.  This has left the organisation’s finances in crisis. Zoran hopes that the new government will step into at least some of the breach left by the Global Fund. “We really hope we will have a good agreement with the government and they will take care of some of our services – maybe not 100 per cent but some of them.” - This article was written in September 2017. Since then, thanks to the work of NGOs including HERA, Macedonia’s government has committed to providing long-term funding for all HIV programmes for marginalised people. - Photo: Zoran Joranov talks to HERA's Vojo Ivanof. Credit: Jon Spaull/IPPF EN

Sex worker Mihaela (not her real name) in Roma neighbourhood of Shuto Orizari.
20 July 2018

Sexual and reproductive health care a lifeline for mistreated communities - Mihaela's story

When Mihaela (not her real name) was six years old, her father sent her onto the streets to scavenge for food for the family and beg for money to fund his alcoholism treatment. “We were very poor,” she says. “I started going through containers, through dustbins. Then I started begging.” At nine, Mihaela dropped out of school. By the age of 16, she was selling sex. Mihaela grew up in Šuto Orizari – or Šutka – a sprawling, run-down neighbourhood on the edge of Macedonia’s capital, Skopje. Of the roughly 50,000 people living here, over three quarters are Roma. Šutka is a lively place, abuzz with the patter of market traders. But it also faces huge social problems, from poverty, unemployment and illiteracy to gender-based violence and poor health. The community is ill-served by state social services and healthcare, and Roma people are often denied access to state services due to stigma and discrimination. Mihaela married at 16 – a common age for girls in Šutka to marry. Roma tradition dictates that girls should be virgins upon marriage: Mihaela’s bedsheets were displayed outside the house after the wedding night for inspection by the community. She left her husband shortly after marrying and began selling sex. She would arrange to meet clients – non-Roma Macedonians – by telephone, and meet them “downtown” in central Skopje, about half an hour away. At 17, she married a Roma man from Kosovo and began a family: they now have six children, aged between two and ten. Life was tough. “My husband was unemployed. I continued my work because I had to make money. I started doing everything, and he was just being lazy. I supported the whole family –  I was working all day long, seeing two or three clients a day. In this community, women are the breadwinners.” Four months ago, Mihaela’s husband left for Serbia, ostensibly to get hold of ID documents. “I don’t know if he’s going to come back or not and I can hardly stand the situation,” she says. “I am alone with the six children and it’s really difficult for me. My children are starving. There’s no one to look after them.” Both Mihaela’s parents are now dead, and her only sibling, a brother, is blind and unable to help the family. “I don’t have any means of support,” she says. “Sometimes I want to hang myself.” Roma families are often large and contraception rarely used within marriage. Mihaela’s husband insisted sex should be “natural”, while misinformation also played a role: “my husband wouldn't allow me to use condoms during sex because he told me that I would catch an infection.” Abortion is frowned upon within the Roma community, while high fees and a controversial abortion law from 2013 make the procedure inaccessible for most.  “I had the first two children out of love,” Mihaela says. “But when I became pregnant for the third time, I wanted to have an abortion but my father-in-law wouldn’t let me because they come from Kosovo and abortion isn’t allowed in their culture.” Poverty forces her to work throughout each pregnancy, up until delivery. Mihaela’s eldest child, aged ten, now looks after the children in the evenings so she can go to work. Like many sex workers in Skopje, she meets clients on ‘Television Street’, on the north bank of the Vardar River, a short stroll from the city’s main square and tourist hotspots. Life for street sex workers in Skopje is perilous. “Sometimes when you refuse to do something the clients want, you get beaten up,” Mihaela describes. The police also harass the women. Mihaela earns between 500 and 1000 Macedonian denars a day – around US$ 9-19. “It’s not enough to feed six kids,” she says. She insists on using condoms with clients, and gets them free at the Šutka branch of I Want to Know, a sexual health centre run by IPPF member HERA, a leading Macedonian sexual health organisation. Like many sex workers, particularly those from the Roma community, Mihaela is almost entirely reliant on NGOs for her sexual health and contraception needs. She says she would be lost with the support of Nicolina Nikolovska, a social worker at the Šutka centre. “She organised IUDs [contraceptive coil] for me, provides condoms, advises me. If it weren’t for her, I would have been completely destroyed.” “I have had HIV tests done here with Nicolina and I swear by this organisation for everything – literally everything – smear tests, STI testing, HIV testing, guidance and advice.” Mihaela herself now acts as a “focal point”, encouraging other women to get HIV and STI tests at the centre or its mobile van. They are given brochures, contraception and lubricants as well as workshops on sexual health and rights. She hopes to stop sex work one day. “If there was something else, I would gladly leave this job,” she says.  “This is why I now teach my kids and make them understand that I am in a bad situation – so they can learn from my mistakes and not make the same mistakes.” “I wouldn’t want my children to do what I do, I wouldn’t want them to live how I live. That’s why I encourage them to go to school and get an education, move away from my life and learn from my mistakes, because I wouldn’t wish this on anyone, especially my kids.” Photo: Mihaela looks out over the Roma neighbourhood of Shuto Orizari, credit: Jon Spaull/IPPF EN This article was written in September 2017.   

Rumena Gjerdovska, Macedonia’s only social worker focused exclusively on supporting people with HIV, and one of the first HIV specialists people meet on diagnosis. 
01 December 2017

On the Frontline: Macedonia’s Only Social Worker Supporting People Living with HIV

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s incoming socialist government has committed to providing long-term funding for all HIV programmes for marginalised people. Tucked away behind a line of trees in the grounds of Skopje’s University Hospital, lies a modest concrete building. This is the Clinic for Infectious Diseases, where people newly diagnosed with HIV come to access treatment and support. Deep in the basement of this building is the office of Rumena Gjerdovska, Macedonia’s only social worker focused exclusively on supporting people with HIV, and one of the first HIV specialists people meet on diagnosis.  Rumena’s interest in HIV was triggered as a young student. “It was an especially interesting topic for me because while I was studying social work had very little to do with HIV/AIDS and health issues,” she says.  “We were mainly dealing with child protection, divorce cases, children who were threatened socially.” The link between HIV/AIDS and social work was a new area. “Even nowadays people do not recognise how social work is connected with HIV/AIDS and health aspects,” she adds. She began volunteering for sexual health organisation and IPPF member HERA (Health and Research Association), mainly running the SOS hotline for people concerned about HIV. In the era before the internet was widely accessible and when government HIV services were skeletal, this hotline was often the first port of call for those with concerns. “Mainly I received calls from concerned parents, because parents were frightened of their children’s sexual behaviour and drug use,” she explains. In 2007, she joined the clinic. Ten years later, she remains a unique figure in the world of Macedonian sexual health and rights. “I’m the only one who has direct contact with these people and that is my main challenge,” she says. “That’s why I decided to get so deep into the matter.” When people test positive for HIV at a mobile van or clinic, they are then sent to the clinic in Skopje to confirm the diagnosis and, if confirmed, get support and begin treatment. The clinic remains the only place in Macedonia where people living with HIV can pick up medication. The first part of Rumena’s role is to break the news of positive diagnoses and explain how the Macedonian health system for people living with HIV works. When delivering a positive diagnosis, it’s important to remain calm, she says. “The manner in which you give the news is very, very important – it’s critical. If you know how to do it then you will calm them down and they will be willing to accept the situation.” She often finds herself up against a barrage of misinformation about HIV – stemming, she says, from Macedonia’s failure to teach children about sexual health. The silence and stigma surrounding HIV is another barrier. Many people in Macedonia “associate HIV with highly stigmatised behaviours such as sex work, drug use and being gay,” she says. “This is the reason people cannot get rid of the stigma that is related to HIV in society.” New clients are often familiar with how HIV is contracted. “However they have very little information about the availability of treatment. ... they may think that HIV is a death sentence and it is fatal and there is no cure for it. “But once we explain to them that treatment can be administered at home and it’s only pills that they should take regularly just like any chronic disease, the story changes and there is hope for them.” Their clients are mainly young and around 80 per cent are men – mostly gay men or men who who have sex with men (MSM). In 2014, of the 42 new people diagnosed with HIV, 30 were men. Rumena talks through any concerns people have, describes the services they will receive – from medication to counselling – refers them on to other services, and offers them psychosocial care. She also advises people on how to tell their families and friends about their diagnosis – a complicated issue in a country where stigma towards HIV remains extreme. “Experience has shown that they should not rush into disclosing their HIV status immediately to everyone they know but sleep on it, because sometimes they are betrayed by the closest ones and the gossip starts and their HIV status is disclosed very quickly. Then stigma and discrimination start.” Fundamental to Rumena’s work is ensuring a “continuum of care” – making sure that services and support are in place every step of the way, from diagnosis onwards. She also puts people in touch with organisations like Stronger Together, a network for people living with HIV to meet, chat and support each other. This ongoing support is crucial. “Everything looks nice at the beginning when we say to them that there is no need to be afraid, … they will be offered health services,” she says. “And all of a sudden they encounter an obstacle – for example they need to have an operation in a health facility and they will need to provide an HIV negative test.” Discrimination amongst Macedonia’s medical staff is a major problem. GPs are often reluctant to register patients with HIV: “they give excuses like ‘no, don’t send us HIV positive patients because we have small kids here... or ‘we cannot admit such a patient, the boss will be angry and won’t allow it’.” Surgeons frequently refuse to operate on HIV positive patients: “Once [patients] disclose their HIV positive status they are immediately denied the surgical intervention … and all of a sudden it appears that there are problems.” This is illegal, but still happens frequently. Cases of legal action against hospital staff are few and far between. “I’m afraid these people do not file any applications because they don’t believe in the judicial system. … they don’t believe their cases will be won in the end so they give up” she says. The fact that legal action will involve disclosing their status to lawyers, court clerks and the entire system is also a major deterrent. It is vital to keep up pressure on the government and authorities to ensure people living with HIV are not denied treatment, she says. She also calls for laws protecting the rights and privacy of people living with HIV, in part by penalising those who violate their right to privacy. More resources for HIV services are also vital, she adds. “I think the primary need here is to strengthen the team that is working in the hospital since the number of HIV positive people is rising on a daily basis and the team is too small to be able to meet all the needs.” Photo credit: John Spaull/ IPPF EN

"Mirror,mirror on the wall who's the most affected of them all?" Bojan holds up a mirror as part of a HIV campaign, photographed at the Clinic for Infectious Diseases, Skopje.
01 December 2017

Living with HIV in a Society of Rampant Homophobia and Stigma

This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s incoming socialist government has committed to providing long-term funding for all HIV programmes for marginalised people. “I remember when I was little, there was one very stigmatising ad on Macedonian TV about how to protect yourself from HIV,” recalls philosophy student Bojan. “It was really scary. It was like: ‘Do you know that in every discotheque you go to, there is at least one HIV positive person? In every school, in every university .... HIV means a really short life, HIV is a monster.’  “This was also my first picture of HIV. I was about 11 years old.” Today, Bojan is a tall, confident 23-year-old. Two years ago, he was diagnosed with HIV. After his partner told him that he had tested positive, Bojan spent a month preparing himself to get tested. “I was 99.9 percent sure that I was already HIV positive, so I had a little time to prepare myself for what to expect, I had time to cope.” Bojan went to the Clinic for Infectious Diseases, Macedonia’s main centre for HIV testing and services, where he was diagnosed and met Rumena Gjerdovska, a former volunteer with IPPF member HERA (Health Education and Research Association), and Macedonia’s only social worker focused exclusively on HIV. Like all people registered as living with HIV in Macedonia, Bojan picks up his medication and has regular check-ups at the Clinic for Infectious Diseases. He also remains in regular contact with social worker Rumena. “If Macedonia awards a Nobel Prize for a social worker, the award must be in her name,” he says. Taboos and stigma around HIV mean that Bojan still feels unable to tell his family about his diagnosis. But, as a young, well-educated student, he says he harbours few fears about the disease. “These days HIV is much more well-managed. The scientists are searching for a cure …  western society is working very hard to destigmatise the disease.” Things are very different in Macedonia. Myths and misinformation about HIV are rife, Bojan says – a problem stemming from the chronic lack of public information and education on HIV and AIDS. “Older people still think that if you get HIV you will die the same week that you acquire it,” he says. “They immediately assume that you are gay, like this goes together with [HIV]. “There are also a very high number of older people who think that if you get HIV, this is your punishment for bad things that you did, for low morals,” Bojan says. Growing up, he says, there was an no sexuality education in school at all, which has fed into the myths and misinformation surrounding HIV. The media doesn’t help to dispel these myths. Newspapers, radio and TV rarely report on it, he says: “It’s total silence.” What media coverage there is has largely been negative, backed up by the anti-LGBTI campaigns from Macedonia’s former government, in power until June 2017. The internet and NGOs are the only real source of reliable information on living with HIV, he adds. Discrimination is also pervasive in the health services. Bojan mentions one friend who was turned down for an operation because of their HIV status. HIV services exist but are poorly resourced and understaffed, partly due to some medical staff avoiding coming face to face with HIV positive patients. There is only one doctor in Macedonia specialising in HIV, Milena Stefanovic, Boyan explains. “She really tries hard. She is like our mother. She [does] everything, everything.” “I see my GP as well but I can’t speak to her in the same way that I can speak with Milena. She is the one who really knows what this means, what my problem is when I say this hurts me.” Another problem encountered at the GP’s surgery is patient confidentiality – or the lack of. Patient files are stored manually, and doctors often leave patients’ files lying around so that anyone could catch sight of them, Bojan says. Given the taboo and stigma around the disease, this lack of privacy discourages people living with HIV from using public healthcare. Most people living with HIV rely on NGOs to top up their care, particularly when it comes to support services and counselling. When he was first diagnosed, Bojan used a service called Stronger Together, a support network for people living with HIV that grew out of HERA. “[Through Stronger Together] I was speaking with another HIV positive person. And this really helped me a lot, because you know you read things on the internet [about how] you can manage this, it’s not terrible, you will be ok, you will live a nearly normal life with these therapies,” he says. “But I needed someone to tell me in my own language, a personal touch.” “My key message would be: test yourself today because every day of life gives you more time for living, if you start with treatment early. If you are HIV positive, don’t be afraid of it and find people you can speak with yourself. “It did change my life for sure, but I learned to love my life more and to take care of myself now.” Photo: John Spaull/ IPPF EN