Transcript Document

The Impact of HIV among East
Africans Living in the United States
Meti Duressa, MSW
African Americans Reach & Teach Health Ministry
Northwest AIDS Education & Training Center
(206) 850-2070 ~ www.aarth.org
Learning Objectives
 Explore cultural differences among East
African immigrants and refugees
 Discuss the impact of HIV and stigma among
East African immigrants and refugees
 Identify barriers to care for East African
immigrants and refugees
 Identify strategies to improve access to health
care
East African Countries
Sudan is the largest country in Africa
Language & Religion

The official languages of Sudan are Arabic and
English
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There are 400 languages (dialects) in Sudan, which
causes barriers in communication. For example, some
members of the Sudanese community in Washington State
face challenges in communicating with each other

English, Swahili and Arabic are well spoken within
certain tribes, but others speak only their own dialect
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The two main religions are Christianity expressed in
southern Sudan and Islam in most of regions
Diversity

Ethnicity in Sudan is an important marker of regional
identity and heritage

Around 40% of Sudanese claim lineal Arab heritage
or an Arab cultural identity
Ethnicities/People Groups
% of Sudan Population
Dinka (or Muonyjieng)
Nilotic people Group
89%
Nuba
Approx 6%
Nuer
Approx 4%
Etiquette
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Women hug each other and on occasion men, but this
implies more to the younger generation
Older women and men are greeted with full respect and
no eye contact
Looking at an elder directly in the eye is a sign of
disrespect
Handshakes is a sign of acknowledgement and paying
attention
In some tribes and religion, handshakes might not be
appropriate across gender
When asked “How are you?” the cultural reply is “Thank
God all is well”
Hospitality
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Sudanese love sharing especially when someone
comes to their house
Foods: Chai, teas, cookies and desserts
Accepting food from a Sudanese is a way of
acknowledging ones’ friendship and courtesy
From a young age, most Sudanese (particularly in
the southern region) are taught to live by Biblical
principals, including prayer before eating
Reconciliation and Death
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Reconciliation: is a major practice in the Southern
Sudanese culture and even takes place during
funerals
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When there is news of death or serious sickness, an
elder person is supposed to tell/break the news

Doctors can tell the family about the news but also
depends on what kind of news/sickness
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If there is no elder of that specific community, a
close elderly friend takes that responsibility of
eldership
Cont. Reconciliation and Death
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Death: In most Sudanese traditions, burial takes
place within 1-3 days
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In Sudan dead bodies are kept at home and are
buried in family graveyards
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In the US, dead bodies are kept in the hospital, then
in the funeral homes. Sudanese gather in the house
of the family of the deceased to mourn and pray

Sudanese cultural prohibits cremation, so it is very
disrespectful to suggest burning a dead body for a
Sudanese as a mean to saving money
Sudanese Emigration/Immigration

Most Sudanese came to the United States as
refugees, some are asylees
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Sudanese started migrating to the United States in
late and early 1990’s
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Many refugees and immigrants who fled Sudan have
suffered various traumas
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Many of the Southern Sudanese resettled in the
United States without family members because of
the war
Somalia
Religion
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More than 99% of Somalis are Sunni Moslem.
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Allah’s will determines life, death, health and illness
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Prayer is done 5 times a day, wherever you are,
preceded by ablutions
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Fasting during Ramadan is a tenet of the faith. This
alteration of eating schedule needs to be factored into
assessment and treatment
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Many Somali women in Seattle wear hijab and almost
all Somali women in Seattle cover their heads. Health
care workers need to support Somalis who wish to
maintain modesty
Family
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Islam allows up to four wives, if a man is able to
provide well and justly for four families
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Divorce is common in Somalia and the U.S.
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The U. S. government only allows one wife to
immigrate with one husband
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Children who emigrated with their father may be
living in a family where the woman is not their
mother
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Family is defined as extended family
Patient Identification
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Somali names have 3 parts: the first name is the given
name, the middle is the father’s surname, and the last is
the grandfather’s surname
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In Somalia it’s rare to use the last name, but common in
the U.S. and a potential source of confusion
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Women do not change their last names when they
marry
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Birthdates are not important in Somalia. Many Somalis
were assigned January 1st birthdates when they
entered the U.S.
Etiquette
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The right hand is the correct and polite hand to use in
daily life (eating, greeting, etc.)
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Greeting is with a handshake and Salam Alechem, but
traditionally hand shakes do not occur across gender
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Women hug and kiss (on both sides or on the hand)
when they meet each other
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It is considered impolite to not ask, “how are you and
how is your family?”
Dying
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It is considered uncaring for a physician to tell a
patient or their family that they are dying
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It is acceptable to describe the extreme seriousness
of an illness
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A special portion of the Qur’an, Yasin, is read at
bedside when a patient is dying
Relationship Building and
Communications
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Time spent establishing a relationship will pay off for
the patient and the provider
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Somalis are traditionally oral historians and are not
prone to brevity
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The evil eye and “Mashallah”
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A loud and serious tone of voice is not unusual for a
Somali speaker and doesn’t necessarily imply anger
ETHIOPIA
Language & Religion
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There are 80 languages and 200 dialects among
Ethiopians
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The predominant language among Ethiopians in
Seattle is predominantly Amharic, Tigrigna, Oromiffa
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The predominant religions are Ethiopian Orthodox,
Moslem, Pentecostalism, and Catholicism
Etiquette
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Women, and women & men who know each other,
hug and kiss on the cheeks three or four times
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Handshakes are exchanged between people who do
not know each other
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Those of the Moslems faith do not touch across
genders
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Modesty is highly valued
Death and Dying
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Death is a community responsibility:
 In Ethiopia burial societies support when there is a death
in a neighborhood
 The society is responsible for making the announcement
and for taking care of all the organizational details of the
funeral including preparing the food
 Members of a burial society pitch in money every month
for membership
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In Ethiopia the family will wash the body. In the U.S.,
the funeral home prepares the body and the family
brings the clothing
Cont. Death and Dying
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Delivery of news about death:
 In Ethiopia the immediate family usually isn't told
right away
 An elder is called upon to deliver the news
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In the United States, a close friend or family relation,
other than an immediate family member, is still told
first. Often, this person is an elder
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For three days after a death, a family doesn't have to
do anything except mourn
Relationship Building and
Communications
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Relationships will be established by accepting the
offer to drink tea or coffee
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Time spent establishing a relationship will pay off
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The answer to “ How are you?” will likely be “Thank
God, I am fine.”
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This may not be an accurate statement
concerning the patients state of being
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A numeric assessment of pain is not usually
helpful
Common Cultural Practice
Healthcare Services Preference
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Most East Africans prefer to be seen by female
healthcare providers especially if it involves
examination of private parts
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In some cases it is okay for health providers of
different gender to examine Sudanese patients;
however, some might not be open to express
themselves fully.
Self-Care
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Men and women do not often complain about
experiencing pain
Pain is not supposed to be expressed unless in
death, where people tend to cry out loud, scream or
throw themselves on the floor
Sickness is not taken seriously until one is very
seriously ill
Over the counter medications such as Pain
medications are used for serious illness
Children are not supposed to know what parents
are suffering from unless the parents decide to tell them
HIV/AIDS Stigma as a Barrier to
Care and Services
Activity 1: What Does Stigma Feel
Like?
Part 1:

Recall a time when you felt rejected for seeming
different from others
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Time = 2 minutes
Part 2:
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Recall a time when YOU rejected another person
because they were different
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Time = 2 minutes
Stigma
 Stigma perpetuates denial and silence
 Stigma prevents acknowledgment of problem and
care-seeking
 Stigma is associated with shame
 Stigma prevents dissemination of accurate
information
Self-Stigmatization
What is it?
 The shame that PLWH/A experience when they
internalize negative reactions of others
What impact does/can it have?
 It may lead to:
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Mental health issues, depression, withdrawal, and feelings of
worthlessness, suicidal tendencies
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Isolation of the person
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Negatively impact his/her ability to access critical services
HIV/AIDS related stigma
impacts:
1. Testing and counseling seeking
behavior
2. Disclosure of seropositive status
3. Access to care
1. Impact on Testing & Counseling
The decision to test is impacted by:
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Stigma (concerns that others may think less of us)
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The manner in which HIV/AIDS testing and
counseling is perceived by others
2. Impact on Disclosure of
Serostatus
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Disclosure of HIV positive status is associated with
level of comfort within one’s environment
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Disclosure tied to perceptions of the risks associated
with the disclosure
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The more accepting, caring, and nonjudgmental a
social network is towards HIV, the more likely it is for
individuals to disclose their status
Common Reasons for Not
Disclosing HIV-Positive Status
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Fear of rejection
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Fear of being ostracized by family/friends
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Fear of loss of employment
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Fear of physical violence
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Fear of deportation
3. Impact on Access to Care
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Once diagnosed, individuals who are concerned
about being stigmatized are more likely to delay care
and/or not to adhere to care
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As the disease progresses, individuals tend to
retreat and isolate themselves
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Denial of serostatus can also cause delayed care
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Health care providers may exacerbate avoidance of
care
Lack of HIV/AIDS Information
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Prevention vs. treatment
Ignorance
Some cannot read
Lack of trust
It cannot happen to me
Women are a strong support
System for those exposed
to HIV/AIDS
Responsibility of raising
grandchildren for those lost
their parents to AIDS
Activity 2: What are the Outcomes
of HIV/AIDS Stigma?
Individual Response:

Consider the three areas that HIV/AIDS stigma
impacts:
 Testing and counseling seeking behavior
 Disclosure of seropositive status
 Access to care

Discussion the results of each of the above
situations?”
Time = 2 minutes
Psychosocial Factors
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Psychosocial factors play a major role in delay in
care
Denial/secrecy of status and significance of one’s
infection
 Fear and anxiety about the illness
 HIV as a “death sentence…”
o Who view HIV as a death sentence
experience feelings of hopelessness, despair,
and fears of dying
Harmful traditions
Female genital
circumcision
Abduction
Forced marriage
Underage marriage
Exposes to HIV/AIDS
HIV/AIDS and Women’s rights
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Fear of domestic violence/ Divorce
She is not faithful
Cultural practice that expose woman to infection
Women’s Rights Issues
 Rapes occur without legal attention
 Witches/ traditional doctors plays role on hurting
young girls and children
Respecting women’s
rights would
prevent HIV/AIDS
Immigration Issues
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Concern that as part of the application they would be
required to take an HIV test
FALSE for citizenship status
 True for asylum and refugee process
 Fear of deportation
 Especially for those who are in the asylum
process
Sample case
50 y/o African born heterosexual male tested HIV+ as a
part of INS screening for asylum purpose. Patient (Pt).
referred to clinic to establish HIV care. Pt. came to clinic
with his girlfriend. Repeat blood rest done in the clinic for
him and checked his girlfriend. Lab result shows that he
has low CD4 count. His girlfriend tested HIV negative.
Medical provider suggested pt. to start on HIV meds. Pt.
resisted starting on HIV meds; he does not believe he is
HIV+.
1. Explore possible barriers for this Pt?
Traditions & Beliefs
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I am under a spell-witchcraft Voodoo Sun-Power
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My girlfriend/boyfriend, wife/husband is negative so
that means it is a bad spirit or witchcraft- People
wanting to make money and they put
spell/witchcraft on me
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Looking for “traditional” medicine; meaning
traditional religious cure to exercise or cure the bad
spirit
Western vs. Traditional Medicine
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It differs from culture to culture
It has to be visible to the patient:
• Must have symptoms
• Weakness
• Losing weight
• Unable to work or move
• To be bed ridden
To Take Meds or Not
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Once past the original denial they are now ready
and eager to take medications as soon as possible
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Confusion
 If I have it then give me the medications-do not want to wait,
cannot understand the “wait” until the CD4 drops and the
Viral Load increases…
 Undetectable Viral Load vs. Detectable-what does this
mean? Either I have it or I do not have it…
 Important to stress that Undetectable does not mean Cured!
Financial Constraints
 Financial constraints have been found to be
a barrier to care for African born trying to
access care:
 Costs associated with treatment, not
reimbursable by medical insurance
 Lack of private medical insurance
 Cost associated with child care services
 Access to reliable means of transportation
Cont. Financial Constraints
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Burden of helping family back home
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Sending money back home is a priority and will
cause refugees and immigrants to neglect their own
health needs.
Confidentiality
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Given the size of the community people are VERY
concerned regarding confidentiality
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Avoid as much as possible to be seen at the clinic,
especially if they see someone from the same country
or their same origin
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They suffer due to lack of cultural and or emotional
support
Four Types of Stigma Reduction
Intervention Methods
1.
Information-based Approaches
2.
Coping Skills Approaches
3.
Counseling Approaches
4.
Contact with Affected People
Source: Brown, L., Trujillo, L., & Macintyre, K. (August 2001)
Interventions to Reduce HIV/AIDS Stigma: What Have We
Learned?
1. Information-Based Approaches
 Information-based approaches focus on
disseminating information:
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At multiple levels
Using various mediums of communication
To reach a variety of audiences
Appropriate languages
Ethnic, gender, age appropriate
Examples:
flyers, ads, information packets, and/or
presentations to community based
organizations (e.g., schools)
2. Coping Skill Acquisition
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Designed to reduce negative attitudes directed at
PLWH/A
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Provide techniques and tools for coping
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Exercises such as role-playing to act out various
confrontational situations, group discussions have
been found to reduce negative perceptions directed
at PLWH/A
Coping with Illness & Living Well
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Denial
 For some people this may take for a year or more
before they accept the diagnosis.
 Once they get past the denial process and
established HIV care they engage in medical care.
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Patients gain hope (and weight) and think of family
and of having children once they start feeling well
Strengths Perspective
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Family
Children
Future plan
Hope
Coping skills
Religious belief
3. Counseling Approaches
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Counseling approaches have been utilized with:
 The target of HIV/AIDS stigma (PLWH/A )
 The perpetrators of stigma
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In counseling PLWH/A, the focus is on building coping
and conflict resolution skills

In counseling perpetrators of stigma the focus is to:
 Provide information
 Defuse potential volatile situations
4. Contact with Affected People

Infected individuals disclose their seropositive status
to members of a community and interact in a way
that provides information and allows the audience to
interact with the individual
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By giving a “face and voice” to PLWH/A, contact
interventions often are an effective tool for reducing
stigma
Summary

HIV in African Immigrants differs from other groups
in the United States.
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Cultural considerations are important for building
rapport.
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There are several barriers that prevent African
Immigrants from receiving the care that they need.
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The impact of HIV/AIDS stigma on accessing care.
Resources
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AARTH Ministry Seattle, WA; www.aarth.org
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Ethnomed www.ethomed.org
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Hearts of Angels for Health-Sudan Initiative (HAH-S), Seattle WA;
www.hah-s.org
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lliuliuk Family Health Services, Dutch Harbor Unalaska 907-5811201
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Northwest AIDS Education and Training Center, University of
Washington Seattle, WA; http://depts.washington.edu/nwaetc/

National Minority AIDS Council: HIV/AIDS Stigma Program;
www.nmac.gov
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Harborview Medical Center: Community House calls program Bria
Chakofsky-Lewy 206-744-9256; [email protected]