Aid Organization for Refugees and Asylum Seekers in Israel (ASSAF)

ASSAF promotes the welfare and rights of RAS by providing advocacy services and psychosocial support for asylum seekers at the individual and community levels while engaging in macro-level advocacy to change public discourse and official Israeli policy.¹⁶ Since 2007, ASSAF has been the central Israeli organization offering psychosocial support and programs for the most vulnerable RAS, including:

• • survivors of torture and human trafficking,
• • women who suffer from domestic violence,
• • individuals with physical and mental disabilities,
• • HIV carriers and AIDS patients, and
• • youths aged 9-19

Israel AIDS Task Force (IATF¹⁷)

IATF was founded in 1985, at the start of the AIDS epidemic, with the mission to stop the spread of the AIDS epidemic in Israel and to protect and promote the rights, interests, quality of life, and life expectancy of people living with HIV.

Brief year by year description of IATF/ASSAF activities and accomplishments for the four years of the initiative

In year I

Working with RAS community workers, the IATF/ASSAF community health workers (CHW) became increasingly known in the RAS community as HIV knowledge experts and go-to people to obtain needed services. RAS call the CHWs to ask HIV-related questions. For example, some have asked if they can get infected after performing oral sex. Twenty workshops, including those for women, were conducted in the first year, with 403 people attending. The evaluation report was based on IATF’s work, using evaluation questionnaires that were fielded before and after educational workshops providing information about, and tools to deal with HIV/AIDS, stigma, and safe sex. Unfortunately, only 36 of the 403 returned questionnaires. For example, in the IATF visit to Holot, where 158 participated in IATF workshops, no one filled out the questionnaire, as IATF staff were not allowed to bring them into the facility. In other workshops, participants were reluctant to fill them out. Thus, this chapter does not include any summary of the questionnaire results.

IATF also successfully lobbied the Israeli government for the inception of appropriate medication treatment for HIV-positive RAS who were held in Holot detention center. The IATF managed to persuade the Israeli Ministry of Health to continue their treatment once they were released from Holot. ASSAF provided counseling to 28 HIV-positive RAS. Since the coordinators are exposed to disturbing content that can take an emotional toll on them and the two community consultants, ASSAF and IATF’s coordinator and the two community consultants receive outside support provided by two certified psychologists. IATF Israeli volunteers living with HIV consisted mainly of gay men who do not speak Tigrinya, a language spoken in Eritrea and Ethiopia. The RAS community found it difficult to open themselves to a person so different from their culture.

In year 2

Activities

ASSAF and IATF spent a considerable amount of time at the beginning of year 2 refining the questionnaires and adopting new strategies to obtain maximum reliability and validity for questionnaire completion. IATF conducted 12 workshops with 450 participants. Of these, 191 were tested (at IATF’s testing center/mobile clinic). IATF staff accompanied more than 20 HIV-positive people for treatment during this time. A week’s activities typically included:

• • Meeting with HIV-positive RAS who are not fully aware of their needs and treatment options.
• • Case management and support for beneficiaries on an as-needed basis, which includes accompanying people to appointments (for example, to hospitals and outpatient medical centers and AIDS centers, the Center for Tuberculosis, UNHCR, Physicians for Human Rights-Israel, or PHRI), speaking with beneficiaries on the phone, conducting meetings in the community, doing intakes and periodic psychosocial evaluations with the ASSAF psychosocial counselor, or helping with translations for communication with the beneficiaries.
• • Promoting the interests of HIV-positive RAS within the Israeli Ministry of Health (MoH).
• • Conducting workshops, both preplanned and spontaneous, in main gathering areas and recreational places of the RAS community.

Joint efforts between ASSAF and IATF

• Together, these organizations produced a short YouTube video about HIV, with RAS community-related topics. Within twenty-four hours it received 35,000 views and 179 likes. A week later, it reported more than 69,300 views, 320 likes, and 485 shares.

• IATF and ASSAF conducted three educational workshops for mothers and the staff teaching kindergarten. Some of the women even took condoms and asked them to give more workshops.

IATF

• • Tel Hashomer Hospital, a major hospital in Tel Aviv, began offering medical tests for pregnant HIV-positive RAS.
• • Reached out to Holot detention center and conducted four educational workshops with 343 participants. IATF also conducted a testing day, with 56 people coming to the IATF mobile unit.
• • An HIV-positive asylum seeker reached out to IATF with a CD4 count of 0, meaning that the AIDS was completely uncontrolled. In less than a week IATF was able to refer her to the community program, and she began to receive appropriate medication.

ASSAF

• Psychosocial support was given to 45 RAS throughout the year; 28 RAS are currently in the project. A total of 68 evaluations with 36 clients (each of whom completed between one to four evaluations) were carried out in the project, with more than 16 evaluations done in the second year.

Results of year 2 evaluation of workshops

In the second year, after a complete restructuring of the questionnaires, IATF distributed questionnaires in eight workshops. In total, 184 participants answered the questionnaires. Of these, 22 were women in two groups. IATF also obtained data from four of the groups (one group of women) for post-workshop questionnaires with 33 respondents. All of the participants were of Eritrean descent.

Overall well-being

Participants reported an overall small increase in well-being from the time of their first evaluation to the time of their last. Of note, women and victims of torture experienced greater increases in well-being than their counterparts.

Blame

Across subgroups, the participants experienced a slight decrease in the amount of blame they felt. Women and victims of torture reported the greatest negative change, indicating that their feelings of blame had been alleviated somewhat over the course of this project.

Stigma

On average, participants reported a slight decrease over time in the degree of stigma they experienced in their daily lives within the community. At the start of the project, all participants stated that they faced a high level of stigma in the community. Over time, women and victims of torture reported the greatest change in the level of stigma they felt, with results indicating that they feel less stigmatized now than they did when they began participating in the project.

Perceptions of social support

Sense of support was measured in order to understand if the participants felt they could be supported by ASSAF or from within their own community. Across all subgroups of participants, there was a significant increase in the sense of support, with women and victims of torture reporting the greatest increase in perceptions of social support. Participants reported "ASSAF,” “social worker,” “doctor,” “church,” and “friend” as people they could count on for social support.

Interpretation of year 2 results

By the end of year 2, women experienced an increase in physical and emotional well-being, and a significant decrease in both self-blame about the infection and feeling of stigma. Women also showed a sizable increase in perceptions of social support. Although men did not demonstrate improvement in well-being, they did not experience a deterioration in emotional well-being. Like the women, they reported a decrease in self-blame and stigma, as well as a considerable increase in perception of social support. At the beginning of the program, when naming their sources of social support, many participants named no one. By the end, many named ASSAF’s social worker as a source of social support. This was especially true of men, who are often without families, unlike women, many of whom benefited from familial relationships. Having social support proved extremely valuable.

Previous research shows the detrimental effects of torture: depression, anxiety, self-helplessness, impaired memory and concentration, fear of intimacy, and somatic symptoms.¹⁸ It is therefore not surprising that the victims of torture ( VOT) reported lower cognitive, emotional, and overall well-being. Comparisons with participants who were not victims of torture indicate that the project is especially helpful to clients who are coping with traumas and hardships as a result of torture. Many VOT contracted HIV as a result of sexual violence perpetrated against them, and they bear heavy burdens of subsequent self-blame and stigma. Over time in the program, VOT showed a slight decrease in self-blame and a sizable decrease in stigma, as well as a substantial increase in perceptions of social support. These were important, positive results in the most vulnerable clients. The psychosocial work targeting and countering self-blame and stigma about HIV also addressed the stigma surrounding torture and violence.

Not receiving medication can, not surprisingly, have a significant physical and psychological impact on an individual. However, the medication of asylum seekers who receive it is often second-generation medication, meaning that it may be less effective. The government program provides only this type of medication, as it is cheaper than first-line medication. As a result, some participants reported feeling poorly and having bad side effects shortly after taking medications. The results of the analysis concerning medication varied wildly and were, not surprisingly, very inconsistent.

As was true throughout this initiative, ASSAF and IATF faced several challenges in obtaining data. Some of the asylum seekers cannot read or write and thus sometimes show reluctance to fill out the questionnaire, in order not to expose themselves to their peers. Moreover, some of them simply did not wish to fill out the questionnaires, regardless of their literacy status. This is partly because they felt uncomfortable answering questions relating to sex and their sexual habits (e.g., condom use). Those who filled out the questionnaire were mostly the more educated participants in workshops, who come from a stronger socioeconomic background in their home country. Trying to learn from year 1, IATF conducted a verbal questionnaire for post-workshop evaluation. Even so, IATF still found it difficult to get in contact with many of the participants to obtain answers to this verbal, over the phone, questionnaire.

In year 3

ASSAF continued its counseling and community work in the last year of the program. As mentioned above, for a twenty-four-hour period in 2018, the Israeli government negotiated an agreement with the UNHCR to give refugee status to many RAS in return for the UNHCR resettling the remainder in third countries. After intense right-wing push-back, the conservative government of Benjamin Netanyahu pressed to have the entire RAS community deported to different African countries (with payment to these countries of a substantial sum per RAS). In the third year, the IATF focused on the political and legal fight against this deportation program. HATD raised additional funds via a crowd funding campaign to support the fight.

Examples of this struggle

An HIV patient received a pre-deportation hearing but refused to reveal the fact that he was HIV-positive to the Ministry of Interior (he feared that Mol would not keep the medical information confidential, and IATF was unsuccessful in its efforts to convince him otherwise). Nevertheless, with the assistance of the Refugee Rights Clinic, his deportation was canceled without revealing his status, as his wife had just given birth, and fathers of children are excluded from deportation at this stage.

Another HIV patient failed to renew his visa for a long time due to severe physical and emotional problems (he had been diagnosed several months before with a low CD4 count, meaning that the disease was not well controlled). The IATF provided him with a letter explaining the situation and he managed to renew his visa without being summoned to a pre-deportation hearing.

With the active involvement of IATF and additional fund-raising support from HATD, the High Court of Justice issued a temporary order freezing the deportation process to Rwanda until the state responded to the petitions filed against deportation. The government eventually gave up on the deportation, but it has made life increasingly difficult for the remaining RAS community.

In year 4, the last year of the program

In 2018-19, the project was not operated in conjunction with IATF. The final evaluation report was based on individual psychosocial evaluations of participants in the program. These consisted of questionnaires administered verbally by the social worker managing the client’s case or by a community health worker in the program acting as a linguistic and cultural interpreter (in Tigrinya, Arabic, Amharic, English, and Hebrew) to facilitate communication. Psychosocial evaluations were administered every few months. For a more detailed description of the revisions, please see the section “Measures.”

Sample

At the end of the last year of the project, 48 asylum seekers living with HIV/AIDS in Israel, 25 males and 23 females (from ages 25 to 58 years, though for various reasons, such as lack of documentation, the exact age of many asylum seekers is not known), completed psychosocial evaluations. Most of the participants were from Eritrea and Sudan, the rest from other African countries. Whereas 108 psychosocial evaluations were completed in total by 48 individuals, 34 individuals completed more than one evaluation (either two, three, or four evaluations). In order to evaluate change over time, for the purpose of this chapter, the data analyzed includes only those participants who completed more than one evaluation. The data compares the changes in their results over time, from the first psychosocial evaluation, the second, the third, and, for whom it is relevant, the fourth psychosocial evaluation.

Measures

The evaluation consisted of a two-part survey, covering well-being and stigma, based on a Likert scale (questionnaire available on request). Each participant was asked to fill out the survey during their intake and then ideally every three to four months. In reality, this was not realistic for every participant, for several reasons: 1) some clients are so vulnerable (emotionally or physically) that answering the evaluation questionnaire would have triggered their post-traumatic stress disorder (PTSD), doing more harm than good; 2) while some clients had completed the first evaluation questionnaire, their treatment did not continue on a regular basis, foreclosing the opportunity to fill out a second evaluation; 3) other clients were not interested in completing the evaluation questionnaire, and ASSAF staff respected their request. Additionally, the use of the Likert scale presented obstacles; many participants found it difficult to use numbers to assess their feelings and preferred to answer the questions verbally. This created a further challenge, as assigning a number depending on a verbal response left room for interpretation and inconsistencies between administrators of the evaluation. ASSAF staff added an open-ended question to learn more about whom participants turned to when they needed support.

The evaluation provided more than measures of assessment. It also enabled the clients to bring up critical issues they confronted that would not always come up otherwise in treatment. The evaluation was always done by the social worker, sometimes with the help of a community health worker. The questions addressed four different areas of well-being (physical, emotional, cognitive, and overall), as well as self-blame, stigma, and perception of social support.

Well-being was measured through four different areas: physical, emotional, cognitive, and overall well-being. Questions were taken from Medical Outcomes Study (MOS)-HIV, World Health Organization Quality of Life (WHO QOL)-HIV, and the Coping Self-Efficacy Scale.¹⁹ Questions were chosen based on relevance and cultural appropriateness. In order to measure social support and community and internal stigma, questions were taken from HIV Related Stigma Measure and HIV Stigma Scale. Again, questions were chosen for their relevance and cultural appropriateness. Community and internal stigma were measured.

Results

The results of the analysis of the sample are summarized below. It is important to note that the results are only for the sample of participants who filled two evaluations or more (29 participants).

Physical well-being

Questions focused on physical well-being were designed to measure the amount of physical pain that a person performed on a daily basis. Most reported increased well-being and decreased pain.

Emotional well-being

Participants who received HIV medication reported an increase in their emotional well-being, whereas participants who did not receive HIV medication reported minimal change in their emotional well-being. Men showed an increase in emotional well-being between the first and second psychosocial evaluation. Women, on the other hand, showed an increase in emotional well-being between the second and third psychosocial evaluation. Participants who were not survivors of torture in Sinai reported an increase in emotional well-being, while those who were survivors of torture in Sinai did not show strong changes over time. The participants did not report a significant change in cognitive well-being over the evaluations. Most participants experienced a decrease in self-blame and stigma. Finally, the participants reported a marginally increased sense of support over time, specifically, from friends and the community.