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