Activism, NGOs, and HIV Prevention in Postsocialist Poland: The Role of “Anti-Politics”

Abstract

With the collapse of socialism, the number of nongovernmental organizations in Eastern Europe increased dramatically, as part of democracy and capitalism building. In the West, NGOs have served as key players in shaping the response of the HIV epidemic, reflecting both the withdrawal of the state from service provision in line with neoliberal reforms and the activist roots from which many of these organizations originated. As a result, AIDS NGOs and the people who work in them are often characterized as engaging in an activist endeavor in order to affect social and political change that will enable better prevention and care. This article explores the extent to which a similar framework applies to AIDS NGOs in Poland and Eastern Europe, more generally, where the notion of “anti-politics” and disengagement from political activism remains strong. As they developed in Poland, AIDS NGOs have focused on caring for clients, cultivating a professional identity, and abstaining from politics, to the eschewal of advocacy activities on behalf of their clients. This orientation has implications for the types of HIV prevention programs these organizations offer, as well as the possibilities for collaborating with researchers and service providers from the West.

Introduction

In the immediate aftermath of socialism’s demise in Eastern Europe, questions emerged about the role of the state and the emerging civil society sector—particularly in the form of nongovernmental organizations (Sampson 1996)—in the provision of goods and services in the new political landscape.¹ Fostering civil society through the formation of NGOs served two goals of the postsocialist transition: creating democracy and instituting capitalism by providing services where the role of the state was diminished (Kennedy 2002; Mandel 2002). Agencies such as the World Bank, the Soros Foundation, USAID, and the European Union’s PHARE held conferences, seminars, and other educational forums to teach Eastern Europeans organizational capacity building, fundraising, and project development (Sampson 1996). The push to build civil society in Eastern Europe reflected a model of the state with a limited role in public sector service provision, in line with neoliberal notions of government. Globally, the advent of HIV and the ensuing epidemic coincided with the declining role of the state, and nongovernmental organizations have been key actors in shaping responses to the HIV epidemic. As Robins and Backstrom (1999) argue, the highly controversial nature of risk and prevention has meant that public health officials often rely on NGOs to deliver prevention and care services to target communities. NGOs pressured governments to develop more compassionate attitudes towards and comprehensive care for those infected with the virus, provide direct services to People Living with HIV/AIDS (PLWHA), and create and disseminate HIV prevention programs to the most marginalized and vulnerable populations (Petchey et al. 1998; Poindexter 2002). When HIV/AIDS emerged in the early 1980s, governments throughout the world were slow to respond and failed to develop formal policies to combat the growing health threat, reflecting the perception that this disease was a health concern unique to stigmatized and marginalized groups (e.g., gay men and injection drug users). At the same time, the association between AIDS and an already-constituted social group based on identity (gay man), allowed well-organized NGOs—with fundraising capacity and access to political power—to mount a response (Epstein 1995; Treichler 1999).

The AIDS organizations that emerged, and which have since become paradigmatic of nongovernmental AIDS organizations, combined social and political activism with identity politics (Altman 1994). AIDS NGOs, such as Gay Men’s Health Crisis (GMHC) in New York City, have both allied themselves with the state, through collaboration with agencies such as the Centers for Disease Control, and directly challenged the state, such as in the provision of clean needles in places where needle exchange was illegal. With the emergence of ACT UP—the AIDS Coalition to Unleash Power—from GMHC in 1989—the links between activism, AIDS treatment and prevention, and NGOs became explicit (Lune and Oberstein 2001). Same sex displays of physical affection in heteronormative public spaces (“kiss-ins”) confronted growing homophobia in the context of AIDS and protestors at a “die-in” during mass at St. Patrick’s Cathedral in New York City challenged the Church’s anti-gay principles and stance against condoms (DeLuca 1999). They took homophobia as contributing to the continued high rates of HIV among and lack of treatment options for gay men. They also demonstrated against drug pricing and mandatory testing and in favor of access to clinical trials; boycotted drug companies; and staged protests at both the FDA and NIH headquarters (Epstein 1995).

Over time, as these and similar organizations became more successful in influencing AIDS policies and the scope of both the epidemic and the services they provided grew, they have undergone significant changes in the nature of their work, diversity of populations served, and organizational structure. Specifically, through the process of “professionalization,” they have shifted from a reliance on non-paid volunteers to full-time paid staff (Altman 1994). In addition, as the epidemic expanded beyond the initial so-called “risk groups,” women, heterosexuals, and racial and sexual minorities became both volunteers and targets of outreach and services (Cassel and Ouellette 1995). Furthermore, as in other sectors (Fisher 1997), these organizations developed more complex relationships with each other, funding agencies, and public health institutions, blurring the lines between “governmental” and “nongovernmental” by providing services through contracts with the government and foregoing political and social advocacy in favor of service provision through federal financial support (Altman 1994; Fisher 1997; Lune and Oberstein 2001; Robins and Backstrom 1999).

Despite these changes and a general decrease in activism as access to treatment and prevention for even the most marginalized populations has improved, AIDS NGOs are still frequently characterized as inherently political or activist organizations. For example, Poindexter (2002:54) describes ASOs as “social change organizations addressing inequity of access and civil rights and characterized by charismatic leadership, committed volunteers, collaboration and consensus building, participatory planning, innovative programs, and marginal financial status.” Similarly, AIDS NGOs are frequently distinguished for their “relative absence of bureaucracy and flexibility to quickly develop innovative new programs, low cost of operation, autonomy from restrictive and conservative government policies, the potential for high levels of community participation in program development, and the ability to reach and advocate on behalf of population segments in greatest needs of services” (Kelly et al. 2006:12). Volunteers and employees of these organizations are often evaluated within this same framework. Studies of United States-based AIDS organizations draw attention to personal and political motivations for joining these organizations, such as using work within such an organization as an expression of personal values and giving something back to their communities (Snyder, Omoto, and Crain 1999); volunteerism as an altruistic act or “constructive backlash to a lack of social and governmental support for persons with AIDS” (Liou and Cruise 1994:278, citing Gabard 1991); a desire to be involved in the “AIDS fight” (Cassel and Ouellette 1995; Omoto and Snyder 2002; Ouellette et al. 1995); a desire to ease the suffering of others (Demmer 2002); and helping the “gay family” or other afflicted groups (Cassel and Ouellette 1995; Ouellette et al. 1995). As Altman (1994) describes, many of the early AIDS volunteers were more politically aware than typical volunteers in the health sector, and incorporated activism and lobbying into their work.

In each of these examples, discussion of the work of AIDS NGOs and the motivation and attitudes of both volunteers and paid employees are based on notions of identity politics, antagonistic relations between NGO/service providers and public health institutions, and an understanding that time spent within an AIDS NGO can have broader social and/or political consequences. The question remains, however, to what extent such generalizations hold for non-United States contexts, given very different relationships between state public health institutions, politics, NGOs, and activism (Rau 2006). As a result of the efforts to build civil society in Eastern Europe, the number of NGOs grew dramatically in Eastern Europe throughout the 1990s. In Poland in 2007, there were 63,000 registered NGOs (USAID 2008), representing extremely diverse interests, institutional structure and size, and funding. As in the United States and Western Europe, NGOs in Poland play a large role in HIV prevention activities and providing support services for people living with HIV/AIDS. At the same time, the Polish government treats NGOs skeptically, seeing their activities as undermining the development of a strong state (USAID 2008). Furthermore, HIV/AIDS remains highly stigmatized: approximately one quarter of Poles believe that HIV can be transmitted through public toilets, and around half of those surveyed believe that those infected with HIV are “guilty” (CBOS 2001).

As Omoto and Synder (2002) argue, motivations to work in an AIDS NGO and satisfaction with this work are shaped by individual motivations, relationships between volunteers and clients, the structures of the organization itself, and the broader social and political context of volunteerism and nongovernmental organizations. The challenges of working or volunteering in the nongovernmental sector are magnified when dedicating one’s time and energy to a problem or social group that is stigmatized or marginalized, as in the case of HIV/AIDS or sexual minorities (Demmer 2002; Ramirez-Valles and Brown 2003; Snyder, Omoto, and Crain 1999). In this paper, I examine the role of NGOs in HIV prevention in Poland, particularly the position of the organizations within the broader sociopolitical context of negative attitudes towards HIV and NGOs, and how staff and volunteers view their work. By comparing the Polish context to that in the United States and other Western countries, I focus in particular on the ways in which work in AIDS NGOs in Poland compares with paradigmatic AIDS organizations in the United States and Western Europe that are often viewed as having social and political activism at their roots. I explore how the origins of these organizations reflects their current engagement with the public health bureaucracy, what motivates people to begin working for these organizations, and the extent to which volunteers and paid staff of Eastern European AIDS NGOs view their work as political.

Materials and Methods

Settings and Participants

Data collection was carried out over a 15-month period from September 2004 through November 2005 in Warsaw, Poland’s political and financial capital and largest city with over 1.7 million residents. Warsaw is home to numerous organizations with HIV prevention programs, and until recently, it has been the epicenter of the Polish HIV epidemic. Officially, there are approximately 11,000 people infected with HIV in Poland, but estimates put the actual number around 30,000 (NAC 2007). For this study, organizations with active HIV prevention-related programs in Warsaw were sought, and interview participants were recruited from primarily three organizations; clients of the HIV prevention programs were not interviewed. Organizations included TADA, which works with female and male prostitutes and has branches in several Polish cities; Młodzieżowy Ruch na Rzecz Przeciwdziałania Narkomanii (MONAR), which is a national organization with local branches throughout Poland that targets injection drug users; and Lambda-Warszawa, which works with sexual minorities. Each nongovernmental organization has a client base ranging from 5 to 15 participants on any given day, and the number of staff and volunteers ranged from 3 to 10. Clients of these organizations often overlapped, and some volunteers and staff worked at multiple organizations as well.

All staff and volunteers who worked in the HIV prevention programs of these organizations were invited to participate in the interviews; key informant interviews were also conducted with organization directors. Interview participants were also purposively recruited from other organizations that had HIV prevention programs in the past. Thirty-six people in total were interviewed. Data were also collected at four overnight HIV prevention workshops held by different organizations, including Lambda-Warszawa, a medical students association, the Social Education Foundation, and the National AIDS Center. Data concerning health, gay rights, and HIV from the 1960s through the present were also collected through archival research at three libraries (Warsaw University library, the National Library in Warsaw, and Lambda-Warszawa’s library), as well as the archives of the television station Telewizja Polska (TVP).

Data Collection and Analysis

Data were collected using systematic ethnographic methods, including unobtrusive observation; participant observation; and semi-structured, key informant, and informal interviews. Ethnographic observation during weekly meetings of HIV prevention programs at Lambda-Warszawa, TADA, and MONAR allowed for observation of day-to-day processes, interaction between NGO staff and clients, and the NGOs’ prevention messages in practice (Hong et al. 2005). Detailed fieldnotes were recorded daily, focusing on the range of activities at each intervention session and client/staff interactions. Closed-door counseling sessions between clients and staff were not recorded. Participant observation at the four overnight, two-three day HIV prevention workshops yielded information on the variety of prevention messages and strategies available to different organizations, as well as the resources available to these organizations. Participants gave consent to have observation conducted and recorded during the course of the workshops. Detailed notes were taken during the workshops and then recorded into a computer at the conclusion of each day’s activities.

Interviews ranged from 40 minutes to three hours. Interviews were conducted by the author in English or Polish, depending on the preference of the interviewee. The interviews consisted of open-ended questions about individuals’ own histories of involvement with HIV prevention, perceptions of successes and failures of HIV prevention in Poland, and understanding of the role of various institutions (e.g., the Catholic Church, schools, nongovernmental organizations) in HIV prevention. When interviewees permitted, the interview was digitally recorded. In the cases where the interviewee did not want to be recorded, permission was given to take detailed notes throughout the interview. These notes were then entered into a word processing program. Polish interviews were transcribed into Polish by a native Polish speaker, and English interviews were transcribed by the author. All interviews were analyzed together, not based on individual organization or role as staff or volunteer (due to the small sample size). Transcripts were coded and analyzed to explore organizational scope and purpose; individuals’ motivations for working in HIV prevention; how individuals came to be affiliated with their particular organization; perspectives on work in civil society; challenges, frustrations, and successes working in this field; families’ and friends’ attitudes towards their work; and perspectives on effective HIV prevention.

The Role of NGOs in the Eastern European HIV Epidemic

In contrast with AIDS organizations in the United States, their Eastern European counterparts are relatively young, having only developed in the 1990s with the demise of socialism and concomitant ability of such organizations to officially form. These organizations face significant barriers to carryout their programs, particularly political, social, or religious opposition to their work; lack of funding or high taxation of budgets; governmental indifference; stigma against both AIDS and those at risk for infection; and lack of awareness by the wider community that HIV is a health threat (Amirkhanian et al. 2004). They receive funding from diverse sources, including international charitable organizations, international aid organizations, home-country governments, and foreign governments. Their institutional philosophies, organizational structure, and agency goals stem from the region’s socialist past.

HIV Prevention Efforts in Poland from Socialism through the Transition

As the HIV epidemic exploded in sub-Saharan Africa, Western Europe, and the United States, many socialist governments in Eastern Europe denied that HIV could become a problem in their region (Feshbach 2006; Field 2000; Hamers and Downs 2003). In Poland, after the first AIDS case was registered in 1985, however, government experts, health service workers, and advocates for injection drug users recognized the potential danger of HIV (Ołowski 1985). The threat of an epidemic prompted the government and the few nongovernmental organizations that existed to begin prevention efforts. The Polish Red Cross, for example, distributed a mass-circulated brochure by mail in 1988 (Strękowski 1990). The Polish government unsuccessfully attempted to increase condom production, a scarce commodity in an economy of shortages (Służba Zdrowia 1988), and despite limited funds and resources within the health services sector more generally, purchased large numbers of the expensive test for detecting HIV antibodies just months after it was developed and registered in the United States (Ołowski 1985). Although HIV testing was never mandatory in Poland, the government obligated all wojewódzkie (provincial) STD clinics to identify all “gay patients” and persuade them to undergo testing at the National Institute of Hygiene. The government sponsored education workshops for doctors as early as 1986, but health service workers in general felt that the lack of adequate supplies (needles, syringes, protective clothing such as rubber gloves, analytical and testing equipment, and sterilization and disinfectant materials) prevented them from following sanitary guidelines and feeling safe in the workplace. Other “prevention” efforts were more oppressive, such as the interrogation and surveillance of men suspected of homosexual activity (Kopka 1986; Świeczyński 1988). In general, due to the dearth of nongovernmental organizations, the Polish response to HIV, as in other socialist countries, was guided by government initiatives with little input from outside agencies or instituti Individuals and organizations, aware of the inadequacy of these prevention efforts, took advantage of new political and social freedoms and the influx of international money that came with the demise of socialism, to engage in HIV prevention activities of their own. International donor agencies such as the Open Society Institute, USAID, and the European Union spurred the development of NGOs dedicated to HIV and its prevention, while simultaneously pushing governments to develop national agencies dedicated to HIV. The attention to HIV prevention stemmed from the belief that preventing HIV and curbing other public health crises will strengthen democratization efforts (Saldanha 2006; Stachowiak and Peryshkina 2006). Saldanha (2006) suggests that the funneling of money to NGOs in Eastern Europe also partly reflected a desire by international donor agencies to cultivate a grassroots response to the epidemic similar to that in Western countries. NGOs concerned with HIV prevention soon emerged, and existing NGOs modified their mandates to incorporate HIV prevention and education, as the three organizations in this study illustrate.² The drug abuse prevention organization MONAR, for example, had existed as a legal nongovernmental organization to combat drug addiction among youth in Poland since the early 1980s. In response to violent protests against hospice centers for people living with HIV/AIDS, MONAR expanded its activities in 1990 to advocate for the care of PLWHA and later developed a prevention program around needle exchange and harm reduction. Lambda formed in the 1990s with HIV prevention integrated into its mandate. Two of its four main goals were dedicated to HIV: the first to promote behavioral guidelines to prevent HIV and the second to cooperate with social and governmental organizations in the field of HIV prevention and fighting AIDS in general (Adamska 1998). The other two goals of Lambda’s efforts focus on building a positive gay identity among its members and increasing social acceptance of sexual minorities. TADA formed in the 1990s with HIV/STD prevention among commercial sex workers as a central mission; it also has a public education component to address issues of stigma, as well as access to social services for clients, such as violence/crisis intervention, social reintegration, and health promotion.³

At the national level, the National AIDS Center (NAC) coordinates and funds many of the HIV programs of NGOs. In 1987, the Global Programme for the Prevention of AIDS was established as part of the World Health Organization, and member countries were called to establish their own programs. Although the outline for a national program was developed in socialist Poland, it never received funding and failed to materialize (Daniluk-Kula and Ciastoń-Przecławska 2002). After the collapse of socialism, the Polish parliament established the National Office of AIDS Prevention in 1993, which was transformed into the National AIDS Center in 1999. Today, the national program addresses both HIV prevention and care for people living with HIV/AIDS, and today coordinates the cooperation of a broad array of governmental and nongovernmental agencies on matters of HIV prevention. It distributes HIV prevention funds and materials to regional and local programs, sponsors HIV prevention workshops, and develops yearly national prevention campaigns to counter epidemiological trends. To distribute HIV prevention funds, the NAC holds annual competitions to which organizations submit program proposals in various categories, including nationwide actions, education programs directed to various segments of society (e.g., students, educators, and health service workers), prevention interventions for specific risk groups, and programs for people living with HIV/AIDS. In Warsaw, both TADA and Lambda receive funds and supplies from the NAC for their programs, but they also receive money from regional and municipal governments. MONAR, however, cooperates more closely with the National Bureau for Drug Prevention.

The Politics and Anti-Politics of NGOs

As described above, paradigmatic AIDS NGOs in the United States such as Gay Men’s Health Crisis trace their origins to a social advocacy model of politicized engagement with public health institutions, based on notions of a shared gay identity or solidarity in the face of the AIDS epidemic. These origins have led many observers to suggest that AIDS NGOS, and the people who work in them, are inherently politicized and activist-oriented, and that they have complex yet antagonistic relationships with government agencies, despite processes of professionalization and increased reliance on funding from government sources over the past decades. With the advent of AIDS in Poland, no institutions based on shared gay identity existed in Poland to take up the fight against AIDS. Although a small, underground gay rights movement existed in the 1980s, the associated organizations were unable to officially register with the government, based on the argument that such organizations would inflict “moral damage to society” (Szczygiel 1989). Combined with more generalized and intensive homophobia, the inability to publicly organize quelled the formation of a gay rights movement in Poland through the 1980s and early 1990s (see Essig 1999 for the Russian case). Rather than using pre-existing networks organized around gay identity to coalesce in order to combat HIV/AIDS, fledgling gay rights organizations used HIV/AIDS as a way to lend legitimacy to their organizations. Lambda’s founders viewed a commitment to HIV/AIDS prevention partially as a means through which the need for a gay rights and support organization could be justified in the highly homophobic context of postsocialist Poland.

As a result, in Poland, creating links between gay rights activism, identity politics, and HIV prevention was fraught with tension from the outset. The initial opposition Lambda faced, particularly in efforts to obtain funding, illustrate the problem. Without a strong tradition of people donating money to charitable organizations not affiliated with the Church (CBOS 2006), and funds from international organizations available to only three percent of the most well-organized NGOs, 75 percent of Polish NGOs lack any financial reserves (USAID 2008). Instead, most rely on local governments, which can voluntarily reserve money for HIV prevention and care, to award them contracts to carry out services (USAID 2008:180). In 1998, Lambda recognized this potential source of funding and contacted the Warsaw municipal government. Lambda’s request for funding of an HIV prevention program, however, was denied on the grounds that Lambda was a gay and lesbian organization, rather than an HIV prevention organization. The following year, Lambda was able to convince the city government that they were indeed an HIV prevention organization, and had obtained funds for HIV prevention until 2002, when a conservative party was elected to power in the city. Lambda’s request for funding that year was denied, as the president of the organization at the time recounted:

We asked the municipality again for the money and the new chief of this commission responsible for the HIV prevention grants answered that we, of course, are an HIV prevention organization, but she can’t accept that lesbian and gay—that a gay man will do HIV prevention work among gay men because that’s a kind of promotion of homosexuality. So, in case you’d like to do good HIV prevention work, you need to send straight people to the gay clubs because gay people in gay clubs promote homosexuality.

In other words, for an organization to focus on both HIV prevention and social and political issues related to sexual minorities was problematic to an extent that it was unacceptable to link them in any way. Undeterred, they appealed the decision directly to the mayor and successfully persuaded him to reverse the decision. Lambda-Warszawa has been receiving money from the city for its HIV prevention program since then.

The problematic nature of linking identity politics and potential social activism with HIV prevention informs the ways in which volunteers and paid staff reflect on the broader impact of their work. Specifically, they continually assert it does not have broader social and political effects or significance. People at Lambda, for example, maintain that they do not engage in political activities, and members of this organization view their work as taking place “inside” the gay community, rather than affecting broader social or political change. As Radek, the former president of the organization, explained:

And of course, me, as a private person, I have my private political opinions, but as Lambda, we can’t be connected with any political way of thinking. We support people and that’s what’s important. So, we are not involved in political work. Of course, we can show the authorities that there is a problem of discrimination and we can communicate with them, but our work doesn’t depend on the authorities. I can tell the League of Polish Families and the Social Democratic Party [about the problems]. It’s also because to be professional is in opposition to being connected with any kind of political party.

According to Radek, political activism would undermine the efforts of organizations such as Lambda and cast doubt onto the “professionalism” of the organization. In response, they take it as their mandate to abstain from taking political stances or engaging in lobbying in order to protect their clients, maintain neutrality in service delivery, and present basic information about HIV and its prevention. Political activism risks drawing unwanted attention from the government or conservative social groups that might threaten to strip the organizations of the limited funds they do have.

Staff and volunteers of other organizations likewise downplay the connections between their work and politics. As Joanna remarked about her work with TADA:

You know, our clients are a social group. They are very closed. I think they have fear of judgment. And it’s like we tell them, it doesn’t matter who they are, what they are, and what they do: they have the right to respect. They can be important. They are normal people…. I don’t take what we do as political.

While Joanna’s mention of rights lends itself to a potential political interpretation of her work, she perceives her clients as having individual rights, but not rights based on collective identity politics. Clients’ rights are realized by treating them with respect and dignity, not by lobbying the government or society to change their laws and attitudes. Other people recognize that although politics may have an influence on HIV prevention efforts by creating laws that limit the types of activities that they can conduct, their work ultimately has neither political nor social implications, as Szymon argued:

There’s a battle with the office workers, a fight over everything. Here in Warsaw, it’s a slightly different situation because it’s a big city, a large center. Here, there’s some money, prevention. But there’s always a problem, you know, helping infected people—the people who work in the streets. And there’s always a battle between those who want to do something and those who sit behind their desks in an office.

[Do you think of yourself as a social activist?]

Really, no, probably not. Maybe there’s some element of that…but I don’t really feel that right now. Maybe in the future…. And it’s mainly the government that funds everything. They’re open to our work.

Szymon’s observations highlight the ambivalence surrounding the relationship between politics and prevention. He rejects the suggestion that his work is political or constitutes social activism, in part due to the fact that many AIDS NGOs receive financial support for their programs from local and national governments, but still sees that the shifting political tides can constrain prevention efforts.

In the formative years of AIDS NGOs in the US, the general paucity of available resources was seen as a reflection of the low priority given to marginalized populations. Adopting a more social activist model to demand funding was seen as crucial to preventing new infections and reducing suffering from the disease itself. In Poland, in contrast, funding shortages are often seen as simply a result of the nature of NGOs, which the organizations must negotiate amongst themselves. As mentioned above, the National AIDS Center holds przetarg (competitions) for HIV prevention funds. In 2005, the NAC allocated 53,000 PLN (approximately $15,000) for HIV prevention among high risk groups, open to organizations throughout Poland. Although only a small number of organizations work specifically with high risk groups such as prostitutes, injection drug users, and men who have sex with men, the przetarg system establishes competition between them. Radek, the former president of Lambda and person responsible for submitting the organization’s funding application, described the process of applying for the funds:

[W]e decided to apply for 18,000 PLN (approximately $5,100), which is 30 percent of the whole money. Because we know that there are other organizations and they need the money too…. It’s rude to send an application for the whole money because I know that other organizations apply too. And on the other hand, it will be a very difficult decision for the National AIDS Center to give 53,000 PLN (approximately $15,000) for 10 organizations applying for 1 million PLN (approximately $283,000)…. There is always a call for proposals for prevention in groups with risky behaviors, and always TADA and Lambda are applying. So we are always sending applications for 50–60 percent of the whole amount. We know that TADA will also apply, and we know that there is no sense in creating a situation in which officials will not be able to divide it.

In other words, from Radek’s perspective, the problem is not the general paucity of funds but the system of competition in which various NGSOs must look out for the interests of others in order to ensure the mutual survival of institutions whose work is seen as complementary rather than competitive.

Grzegorz describes a situation in which NGOs must simultaneously compete with one another over limited funding resources for their constituents and programs and cooperate with one another to ensure that their programs remain funded, even if at modest levels. According to Grzegorz, from TADA, the tight financial resources and interorganizational competition interfere with the ability of organizations to carry out their work:

It’s a failure that after all this time we haven’t managed to get any money for remodeling this space. That’s a big failure. Maybe now, who knows. It’s a big failure for sure that we don’t have a steady source of funding. It’s not like we always have a permanent cash flow. Sometimes there are months where we have to use our own money for rent and utilities.… Simply, no one gives money for these things and it’s hard to do it without the money. The other thing is the system of financing that relies on competition. And unfortunately, we compete. The organizations compete with each other and the organizations are made up of people.… We’re such a young democracy that when someone loses in the competition, bitterness comes out and right away he says, “That was not a fair competition. There was some cheating.” …Young organizations—each person wants the most for himself and we don’t have genuine cooperation. We don’t have any basis from which to take care of our clients.

Neither Grzegorz nor Radek, nor others with whom I spoke, saw the limited funds as a result of indifference towards at-risk populations that originate within the political sphere. Rather, they see it as a problem of the funding system and the nature of NGO work more generally, thus, deemphasizing the need for political lobbying or social activism to increase the funds available for their work.

The format of these organizations’ HIV prevention programs likewise reflect the lack of an activist model in their work. Activist-oriented HIV prevention promotes either individual or group empowerment through direct confrontation with and dismantling of social stereotypes and cultural scripts regarding marginalized populations, sexuality, and gender roles (Evans and Lambert 2008; Paiva 2000) or through the reformation of PLWHA into educated “active patients” who directly lobby governments and health care providers for their own needs (e.g., Barbot 2006; Nguyen 2005). The programs at the organizations I studied, in contrast, focused more specifically on helping clients within a limited context, particularly personal health and hygiene, mental health, and social relationships. Each organization combines a drop-in center with street-level outreach, called “streetwork.” In the drop-in centers, clients can socialize with one another; voluntarily seek one-on-one, confidential counseling in a second, private room; receive materials necessary for harm reduction, such as condoms, lubricants, and clean needles and syringes. They are also offered other resources, such as assistance accessing social services, housing, food, and work. As Iwona from MONAR characterized her work, they are simply “people helping people.” Furthermore, when the Lambda-Kraków organization was involved in an HIV prevention “scandal” that resulted in the NAC and the Kraków city government ceasing future cooperation with them, Lambda in Warsaw responded by issuing a public reminder that Lambda-Kraków and Lambda-Warsaw are two separate and independent organizations.

This lack of political engagement reflects Poland’s unique socialist past in which involvement in the nongovernmental sphere was not seen as a forum through which state-changing endeavors could be pursued. Rather, during the socialist period, oppositional groups developed a strategy of deliberate non-engagement with the state and formal politics, and instead worked to “organize citizens, to bring people together in civic activities not directly oriented to changing the state” (Ost 1990:2; see also Sierakowski 2005). As Ost (1990) described of the opposition during the socialist period, this stance of “anti-politics” does not reject politics altogether but redefines politics as “anti-state” and asserts that the state is not “all-important.” From this view, politics and “the political” are seen as something separate and resistant to change. For nongovernmental AIDS organizations, this division means that time and resources are better spent providing for clients rather than reforming the state. This anti-political stance empowers citizens to become active in shaping their worlds without waiting for state-level reform. As the interviews illustrate, disengaging from political and social activism works as a deliberate strategy for procuring resources, ensuring organizational survival in a hostile context, and continuing service provision in an unstable political climate. The “political,” in this context, highlights anti-politics as a disengagement with the government and a reaction to government animosity towards their activities and clients. In other words, procuring government resources necessary to continue their programs occurs by deliberately breaking the links between politics and prevention.

Politics, Professionalism, and Expertise in Civil Society: Individual Histories

If the organizations eschew political and social activism, what motivates people to being work in AIDS NGOs? In describing how they came to the organizations and how they view their work, staff and volunteers cast themselves as experts in particular prevention methods and guardians of marginalized and stigmatized populations,⁴ rather than as their advocates or social activists. Many of the people with whom I spoke came to these organizations accidentally, rather than actively seeking them out, and were interested in issues of social exclusion or sexuality education, rather than gay identity politics or HIV/AIDS specifically. Zofia’s trajectory of coming to work in HIV prevention is typical. Zofia had been working at one particular organization for about a year when I spoke with her. A few years earlier, she had attended some sex education workshops out of curiosity and personal interest, in part an extension of her degree in education. Several of her coworkers at her current place of employment, a social work center, also work at the same HIV prevention organization, and Zofia often engaged them in conversation about their roles at the organization. She wanted to learn about something different from “normal, everyday work.” Later, the organization was looking for a female outreach worker and the director of the program, who was also one of her coworkers, approached her and asked if she would “like to see how it looks and try it.” She only came to work at this particular organization as a result of people she knew who already worked there and the sense of safety and security such familiarity affords:

[T]his type of work is difficult. At one point, I would have even said that it’s a bit dangerous. So the people with whom you work should be people who can ensure a feeling a safety. I think that’s why I came here without any problem.

Zofia admitted that she thinks her clients are already sufficiently educated about HIV and how to prevent infection. She decided to work in HIV prevention to teach them about things other than HIV and perhaps learn things about HIV herself that she could potentially teach her own students. In other words, Zofia came to work in HIV prevention for reasons separate from a social or political motivation, or a commitment to fighting HIV more generally. Rather, she was interested in doing something different from her “normal, everyday” work and came to this organization through social networks.

Beata also came to work in HIV prevention first through a more general interest in sexuality education, an interest that she further developed by attending a workshop conducted by a well-known Polish sexologist and joining an organization dedicated to sexuality education among youth. When an acquaintance learned of her interest, he asked her if she “had anything against gays and lesbians” and proposed that she begin an HIV prevention program at Lambda. She accepted his offer and eventually began working at several HIV programs throughout the city as a counselor, outreach worker, and educator. She explained that her decision to work in HIV prevention arose not from an interest in the disease itself but from the fact that she “always tried to work against marginalization,” and had been attracted to doing something in which few others were involved. Others, like Szymon and Oskar, found the methods of HIV prevention themselves to be appealing, particularly street-level outreach. Still others had an academic or personal curiosity about the target populations of the outreach programs. Marek, for example, was studying mental health issues among gay men as part of his psychology degree, and initially came to Lambda to recruit research participants for a study. Klaudia, who works at MONAR, was struck by the lack of dignity and respect afforded drug users, and wanted to do something to help them. In other words, people came to work at these organizations and on this particular health problem for a variety of reasons, but their motivations stemmed from personal and academic interest and curiosity, rather than a sense of justice, unity in the fight against AIDS, and shared social identity.

Zofia emphasized that work in such an organization appealed to her because it differed from “normal, everyday work,” and others echoed this view. Ewa, for example, said that she couldn’t imagine herself getting up everyday for work, putting on a suit, and sitting behind a desk all day. Grzegorz, who quit working at “the best paying job he ever had” to work in HIV prevention, commented that he “simply didn’t know how” to dress “elegantly” for work—that he was “genetically conditioned” to not do so—and that work in the nonprofit sector freed him from trying. Klaudia, in describing her family’s reaction to her role as an outreach worker with injection drug users, said that they continually ask her when she would quit this work and get some sort of “normal job, working in an office, for example.” The ability to have direct contact with clients through “streetwork” and not be sitting in an office was a motivation for this type of work with which others concurred.

Despite their efforts to minimize the characterization of their work as somehow affecting social or political change, the reaction by their friends and family to their work in these organizations belies the controversial and potentially political nature of HIV prevention. While some met with apathy or encouragement, such as Szymon who describes his family’s reaction as “positive,” Klaudia’s description of resistance and concern is much more typical:

Everyone’s against me working here…. My family was really against my studies [resocialization] and my work. My work and my studies are connected. My family wanted me to work in some sort of normal work, for example that I would work in an office or something like that. In general, they’re always asking me when I’m going to finish this or aren’t I afraid of drug addicts. Or they think that once I finish my studies, I should go work in an office somewhere and earn money, etc. They’re against it.

Zofia also describes that her work caused problems with her family, although not with her friends:

You know what, with my family there was a little bit of a problem. At first, I just told my father that I’m working on the street. That’s it. So he tried to find out [what I was doing]: am I handing out leaflets or something like that. However, in reality, I did not tell him right away. After some time, when I had been working here for half a year, then I sat down and really told him what it was all about. Of course, he was very uneasy—is it safe for me, etc. That was the problem. But with regards to my friends, they were really curious—what did I encounter, what did my work look like, how I like it—a rather favorable opinion to it.

In both these examples, friends’ and family members’ concerns with the safety partly lie in the stigma surrounding the populations with which they work, in addition to real concerns of potential dangers such as assaults and robberies. The decision to work in these organizations and with their constituents borders on a politicized stance as a result.

Staff and volunteers of these AIDS NGOs frequently mentioned the view that street-level outreach is both dangerous and challenging, and that the populations with which they worked suffered from stigma, marginalization, and hardship in their everyday lives. It followed, then, that the process of finding new people to work with these populations was a constant challenge and a task that the directors of the programs took seriously. In their recruitment efforts, directors of these programs emphasized that they sought people who can endure the emotionally taxing work of dealing with clients’ physical and mental health needs while treating clients with the respect and dignity that they thought they deserved. These skills, rather than an affinity to a particular risk group or commitment to the fight against HIV/AIDS, took precedence in finding new volunteers. Grzegorz, who is primarily responsible for finding new people to work at his organization, commented that he is actually resistant to volunteers at his organization for this reason. They only invite people to work with them whom they feel will work well with clients and in their small teams of two or three that do street-level work. Zofia echoed this view, saying that they are very careful about whom they would accept as a volunteer and that they will slowly introduce this person to clients in order to ensure that trust between clients and outreach workers is not broken.

The emphasis on specific types of people as necessary for this work was illustrated in Radek’s description of Beata:

Beata was with us since we started in 1998. She’s the reason, thanks to her efforts, this program works. She’s our expert. I can say she’s an expert. She’s perfect. She’s one of the best people in Poland—the most experienced in working in the street working method. She’s very, very good. And that’s why she’s also very good in HIV prevention because she has very good contact with people. She’s a very warm person and very open—also open minded. And at this moment, she’s also the key person in this project. And I don’t know how the project can work without her. She’s the brain of everything.

Beata herself described the challenges of finding new people, particularly volunteers, to work in HIV prevention programs:

In this type of work, when it’s important to have steady contact with clients, trust is important, and that’s a problem. In addition, I, for example, have really demanding requirements when I have volunteers. And not everyone wants to work that hard for free, right?

Beata sees the high standards and demanding requirements as necessary, given that “the work is very specific and people have to have a very specific knowledge and ability, and themselves have to be very specific types of people, in order to cope and manage and not do harm to the people with whom they are working.” As with others, Beata prioritizes particular skills and attitudes towards clients as the basic requirements for joining her and others’ HIV prevention programs.

These personal histories of involvement provide further evidence that staff and volunteers of these organizations view their work as providing a “professional” service, rather than as part of a social movement. Given the hostile social and political climate towards their clients, presenting themselves as “experts” serves as a way to politically maneuver themselves not only as gatekeepers of their target populations, but to legitimize their work and retain their organizations’ necessary role in HIV prevention. In response to my inquiry into the motivations for one of these organizations to sponsor an HIV prevention workshop based on the method of street-level outreach, two of the organizers replied that they are part of a professional organization with specific knowledge, methods, and goals, and recognize that it is worthwhile to share their expertise with others. The third organizer told me that they were motivated to hold the workshop not because they are professional but wanted to show that they are professional. In other words, to host an HIV workshop confirmed and demonstrated credibility as being expert, professional, and authoritative.

Discussion and Conclusion

From the outset of the HIV epidemic, nongovernmental organizations have been key players in shaping the response to this public health crisis. Spearheaded by politically and socially engaged AIDS NGOs in the United States, they rallied against governmental indifference towards the stigmatized groups most affected by this disease. By combining identity politics with health and rights activism, AIDS NGOs in the United States and other Western countries managed to gain access to life-saving treatments and increase the scope of HIV prevention efforts. This model of AIDS NGOs as inherently politically active and rooted in identity politics has persisted, despite processes of professionalization and shifting epidemiological patterns that have expanded both the staff and constituencies of these organizations. However, the expectation that AIDS NGOs develop somewhat antagonistic relationships with public health institutions has diminished as relationships between governmental and nongovernmental agencies has become more complex, particularly in terms of funding and service provision. Nevertheless, AIDS NGOs and the staff and volunteers who work in them continue to be characterized as fundamentally engaged in a political endeavor with the potential to affect social change, whether explicitly or otherwise.

In Eastern Europe, AIDS NGOs emerged much later than in Western countries, partly as a result of socialist-era limitations on the ability of potential NGOs to legally organize, especially gay rights groups, and partly a result of an epidemic that was slower to materialize or be acknowledged. The AIDS NGOs that did develop in the 1990s approached the epidemic from a different perspective than their Western counterparts, a reflection of the unique sociopolitical context of the postsocialist period. With the collapse of socialism and reformulation of the state from a source of goods and services to its diminished role in the processes of privatization and market development, NGOs became key players in facilitating the state’s withdrawal. The AIDS NGOs that emerged in Poland to respond both to the need to provide HIV prevention for neglected populations and perform tasks in contract with national and local governments carefully separated their service provision from political motivations. This apolitical ethos has permeated all aspects of these organizations, from the forms these programs take to how they view funding, to the way employees and volunteers perceive the effects of their work on clients and society at a broader level. The social and political implications of working in HIV prevention, especially with stigmatized populations, is evident in the ways in which friends and family reacted to staff and volunteers’ decision to dedicate themselves to this endeavor. However, this potential does not necessarily translate into a political or socially-oriented agenda within these organizations. In fact, they consciously separate themselves from potential effects by remaining distinct from those organizations that do engage in politically lobbying and focusing their efforts on clients rather than changing social attitudes towards clients. In addition, volunteers and employees are carefully selected based on skills and the ability to work with marginalized and challenging populations without causing further harm, rather than commitment to combating HIV/AIDS, affiliation with the affected groups, or engagement in social activism.

These models of HIV prevention and AIDS NGOs have implications for the development and dissemination of HIV prevention models from Western contexts to postsocialist Eastern Europe. Increasingly, prevention programs in the United States draw on notions of empowerment and community change, inherently political models of prevention. Transferring these prevention strategies to context in which an activist stance to prevention is seen as problematic could lead to a lack of acceptance of these programs and raises questions about what models of HIV prevention would be accepted. Given that staff and volunteers of these organizations cast themselves as experts on their particular prevention methods and gatekeepers to their target populations, prevention programs based on traditional outreach methods may be the most widely accepted. In traditional outreach, staff and volunteers locate, contact, and recruit members of hidden or marginalized populations that often do not regularly access health and social services (Ford et al. 2007). In many ways, the programs currently offered by the organizations constitute a traditional outreach model, and new outreach-based programs for different populations could be incorporated into already-existing organizational structures. Prevention programs based on small-group sessions could also prove to be widely accepted, particularly if staff and volunteers can draw on their knowledge of the target population and expertise in psychology and education to facilitate group sessions. Small-group HIV prevention often combines AIDS risk education, psychologically-based behavior management training, social support and self-development, and safer sex negotiation skills-building (Johnson et al. 2005). In contrast, peer-led or social network-based prevention methods may be less acceptable to these organizations because they potentially undermine or challenge the staff and volunteers’ roles as experts and gatekeepers. Those working in these AIDS NGOs in Poland are clearly dedicated to serving their constituents and committed to reducing the spread of HIV, particularly among the most marginalized and stigmatized populations of a region facing a growing HIV epidemic. By working with the existing strengths of these organizations, and offering programs that reflect their particular histories and current concerns, the staff and volunteers of AIDS NGOs in Eastern Europe can become strong allies in the battle against this disease.