Reason for Lack of participation in support groups among HIV positive immigrants in Finland 

BEZA DEMISSE
Thesis, Fall 2016
Diaconia University of Applied Sciences 
Degree Programme in Social Services
Bachelor of Social Services (UAP) 

CONTENTS
1 .Introduction
2 Background
2.1 Aims of the study
2.2 Research environment
3, LITERATURE review
3.1 HIV and immigrants in Finland
3.2 Participation
3.2.1 Empowerment and immigrants’ participation
3.3 Migration and HIV
3.4 Peer support group
4 METHOD OF DATA COLLECTION AND ANALYSIS
4.1 Methodology
4.2 Data collection
4.3 Data analysis
4.4 Ethics and limitation
5 .RESULT AND DISCUSSION
5.1 Understanding and expectation of support /peer group.
5.2 Difficulty in participating as an immigrant
5.2.1Language
5.3 The need for foreigner group
5.4 What is missing, what is needed?
5.5 Being HIV positive immigrant in Finland
6. RECOMMENDATION AND CONCLUSION
6.1Peer leader
6.2 outreach programs
REFERENCES
APPENDICES
 
abstract
The number of HIV infections among people born outside Finland or with foreign citizenship has been continuously increasing gradually since the beginning of the epidemic in the 1990s. And in 2011, for the first time, more non-Finnish than Finnish persons have been diagnosed with HIV. This high trend in foreigner HIV diagnosis calls for a better handling and screening of foreign individuals. Also, it's important to address the post-diagnosis treatment and support that include psychosocial and peer support. 
The reason for the research come from  phenomena noticed while doing the placement in positiiviset ry , a peer support facilitator association, which is the lack of participation in support group among HIV-positive immigrants .
A qualitative research was done by doing an interview with 8 HIV positive immigrants in the period of 2 weeks in march 2015. 

This paper discusses the difficulties of being an HIV-positive immigrant and the reasons for the lack of participation in support group programs designed to address the needs of HIV-positive clients. We see the point-of-view of the HIV-positive immigrants on why the lack of participation. It also discuses the possible measures that could be taken to tackle this problem
The outcome of the study states that there is a lack of knowledge about the service , cultural difference , language barrier and  a need for foreign peer facilitator .
1 .Introduction
HIV is a worldwide phenomenon affecting all type of population. At the end of the year 2011 the cumulative total of diagnosed HIV-positive individuals in Finland was 2953, Cumulatively 580 AIDS cases − including 299 AIDS deaths − had been reported. From this number most affected groups are migrants from high prevalence areas, men having sex with men people and who inject drug. (Country progress reports Finland 2010.)  
The number of HIV infections among people born outside Finland or with foreign citizenship has been continuously increasing gradually since the beginning of the epidemic in the 1990s. And in 2011, for the first time, more non-Finnish than Finnish persons have been diagnosed with HIV. In 2011, half of the reported cases were due to heterosexual transmission and  in 2012 preliminary surveillance data indicates a high proportion  Approximately 33% to 50% of these cases were reported among immigrants from countries with a generalized HIV epidemic. Most of the infections contracted by Finnish men through heterosexual contact were acquired abroad. (Country progress reports Finland 2012.)
This high trend in foreigner HIV diagnosis calls for a better handling and screening of foreign individuals. Also, it's important to address the post-diagnosis treatment and support that include psychosocial and peer support. Prevention and care need to be adapted to a changed HIV epidemiology. Most infections seem to now occur among heterosexuals, either migrants coming from high-prevalence countries or Finnish nationals with travel-associated HIV infections. It is recommended that monitoring should be strengthened and surveillance for both situations should be improved in order to address or reinforce messages around travel-associated infections, but also to review the access to treatment and care for those who are foreign-born residents of Finland (country mission Finland 2012.)
 
The increasing number of HIV-positive immigrants, like other HIV-positive groups, has many problems related to the disease. However, the lack of awareness of the country's health care system and social structure may make this segment of population vulnerable compared to their Finnish counterparts. The key elements of Finnish HIV policy emphasize on Prevention of new infections, free access to treatment and care for the HIV infected and Support to the people living with HIV .That include Social support and empowerment of persons infected and advocacy and solidarity to prevent discrimination of those affected. 
This paper discusses the difficulties of being an HIV-positive immigrant and the reasons for the lack of participation in support group programs designed to address the needs of HIV-positive clients. We see the point-of-view of the HIV-positive immigrants on why they lack in the participation of support groups and peer group activities arranged by Positiiviset ry.
This qualitative study includes the perception of HIV immigrants who live in Helsinki on the importance of self-help groups and if there is a need for immigrant specific peer support programs. It also discusses what they need from service providers in order to participate and be part of the peer programs.

2 Background 
Positiiviset ry is an institution that mainly stands for organizing peer support programs for HIV-positive people and those around them. Since the organization started its operation in 1998, it has gone through different developmental stages and managed to accomplish and progress in many ways. It has become a place that manages to meet its client needs as a place where HIV positive clients come and connect with others like them; people, who share the same kind of problems, face the same kind of stigma and discrimination and try to manage the overall situation.
But the one sector they struggle to develop is reaching the HIV-positive immigrant population, who are mainly absent in their clientele. In the association, there are many well-established peer programs for different subgroups like women, men who have sex with men and the close ones and family of the HIV positive. However, people with immigrant background fail to participate in these groups let alone form their own group. As the number of immigrants coming to Finland has increased in the last 2 decades as well as the number of HIV-positive immigrants, the association failed to incorporate the participation of this increasing segment of society into their services. It's important to mention that in the past measures have been taken to attract immigrants to come to Positiiviset but failed to do so.  Since last march 2015, when the data was collected, in the association, there have been 11 HIV-positive immigrants who came for other purposes than to participate in existing peer groups. This number includes those who visited once and didn't manage to return again.
The reason to choose this topic came from this phenomenon observed during a practical placement in Positiiviset ry. With cooperation with the association, we wanted to know why this phenomenon exists and to explore the point of view of the clients themselves on why they lack participation. It was decided to carry out this study, backed with national data and previously done researched and an interview of HIV-positive immigrant clients, to find out the reasons and what shall be done to improve the services. In this paper, I aim to find out the importance of peer programs for HIV-positive people with migrant backgrounds and what challenges they face being HIV positive migrants and how these self-participatory peer support programs can help in tackling existing problems of stigmatization and discrimination.
This study mainly targets the HIV-positive immigrant segment of the population and their numerous difficulties in reaching the health care activities. In the Literature review, some topics are discussed to clarify the aim of this research. The literature review was split into sections that describe peer support and need for service In detail. The importance of peer /support group and its impact on the physical and social health of an HIV-positive client is discussed .Also the different social burdens of the HIV positive and the meaning of participation in general and in community level. This was done using currently researched information. 

2.1 Aims of the study 
This study aims to see the main problems on why there is a lack of participation in support groups from HIV-positive immigrants. It will see the roots of the problems from the perspective of HIV-positive immigrants themselves and also seek a solution for it.
The findings of this study will help to develop a better immigrant-friendly environment in Positiiviset ry. This study will help HIV-positive immigrants in accessing support group programs which are helpful in dealing with psychological and emotional problems faced by this vulnerable group.
 Also, this qualitative study aims to explore the importance of peer support programs in helping HIV-positive immigrants to tackle their issues and their understanding of it.  Also, the paper also aims to find out what methods should be implemented in order to attract them to use the peer support programs as a tool to raise their concern in matter of discrimination, stigma and other social inequalities they are exposed to as being part of his vulnerable group. And try to find out what kind of action must be undertaken so that the already existing peer support groups would incorporate the participation of immigrants.
The main research questions this paper tries to answer to are:
What do HIV-positive immigrant people need in order to participate in peer support programs? 
Is having an immigrant-specific support group more beneficial to the immigrant than an all-inclusive support group?
2.2 Research environment 
Founded in 1996, Positiiviset ry is an association based in the city of Helsinki that operates in the entire country with the intention of supporting HIV-infected persons and their loved ones awareness HIV. Their purpose is to  work with HIV-infected people and those suffering from AIDS, to promote care and well-being for HIV-infected persons and their families, to support the infected and their loved ones, to prevent discrimination and exclusion and also improve the level of care of infected and quality of life of the general conditions.
To meet its goals the association organizes psycho-social support activities such as training sessions and lectures by experts, participating in the health care hall vocational and social debate, carry out awareness-raising activities as well as health education. Following fixed timetables, Positiiviset organizes its members recreational activities such as joint training camps, get-togethers, events, as well as work with the other infected with operating groups, agencies, and organizations.
 For operational costs, the association is able to accept donations and bequests, as well as the Superintendent implement fund-raisings and lotteries. Association is politically independent and may be a member of other associations. The main fund provider is RAY (Slot Machine Association.)
Different members of the association may include individuals, supporting members, lifetime members, and honorary members. Each member of the association has one vote at the meeting of the association. Members are required to pay annual membership fees except when having economic reasons. A member has the right at any time to resign from the association by giving written notice to the Board or its Chairman. The member may also resign by notifying the meeting of the association for the record. 'Association Board of Directors meeting may expel a member from the decision of the delivery of the association if the charge against the injured party from the association's privacy or anonymity or left the membership fee for two years.
The association has premises in Kamppi, Helsinki which is providing as a day center, has a cafeteria program that is arranged every Tuesday, Thursday, and every other Saturday. Anyone is welcome to the cafeteria program. It serves as a great media to get to know each other and to discuss issues in their life. Up to now, there are five established groups with different subgroups: family, youth or young adult, close ones, men who have sex with men and heterosexual group. These groups meet at least once a week to discuss various topics with a facilitation of food and refreshment from Positiiviset. On a 6 month base or so they organize a camping trip or another kind of refreshment activities.
3, LITERATURE review 
Several types of research have been previously carried out on peer support, support groups for HIV and the impact of HIV on immigrants in their new host country. Since the main goal of these papers is to find out the reasons for failures to participate in support groups and what are the methods that could be used to improve and meet their need, the literature review will cover the meaning of participation, definition of support groups and the special circumstance of HIV positive immigrants in Finland in general. 
According to Baumeister, literature reviews are special for a couple of reasons. He points out that first, they in combine will tell the result of many studies that gives them the upper hand that a single study can't since the later one can be biased or could have a methodological  error and risky to draw the conclusion. Secondly, the literature review gives the researcher permission to have a broad research question since single studies may be too narrow to provide answers to the researcher. (Baumeister 119-132, 2013.)
Doing a literature review is a means of showing the researchers knowledge about a particular field of study, including vocabulary, theories, key variables and phenomena, and its methods and history. While doing so it also informs the student of the influential researchers and research groups in the field. Finally, with some modification, the literature review is a "legitimate and publishable scholarly document (LeCompte & colleagues, 2003, p. 124.)
Key words:  participation, HIV-positive immigrants, support groups 

3.1 HIV and immigrants in Finland 
HIV-infection and AIDS are mandatory investigated diseases in Finland. Laboratories and physicians report cases to Infectious Diseases Register kept by the National Institute for Health and Welfare. Key populations among others which have increased risk were Persons with a migrant background, a record number of HIV infections were found among non-Finnish citizens in Finland in 2010: 79 cases, representing 42 % of the annual total. Most of the foreigners diagnosed came from areas with a high prevalence of HIV and had contracted HIV through a heterosexual contact abroad. HIV infections contracted by foreigners through sexual contacts between men and intravenous drug use have also increased, although in absolute terms the numbers are still rather low. (Country report 2012.)
  By the end of September 2012, a cumulative total of 3 070 HIV and 596 AIDS cases were reported in Finland. The HIV epidemic in Finland is characterized by a low annual incidence and prevalence. Rates of new HIV diagnoses per 100 000 population have slightly increased over time (2.8 in 2000 and 3.6 in 2010). This trend is due to an increasing number of HIV infections acquired through heterosexual contact and transmission among men who have sex with men. The number of HIV cases among persons of non-Finnish origin has increased gradually since the 1990s, and in 2011, for the first time, more non-Finnish than Finnish persons have been diagnosed with HIV. (Country mission report 2013.) 
HIV/AIDS treatment, care, and support are integrated into public healthcare – on state, regional and municipal levels. Medical treatment and care of diseases listed in the communicable disease legislation, including HIV/AIDS, is free of charge for all permanent/long-term legal residents. Specialist care is provided through regional health districts. Adherence to HIV treatment is remarkably high, shown by low viral loads in different subpopulations, especially in people who inject drugs. However, the rate of late diagnosis is rather high in Finland as 50% of newly diagnosed HIV cases already need antiretroviral treatment at the time of diagnosis. Since the beginning of the HIV epidemic, non-governmental organizations have been involved in the HIV response. The AIDS Council, run by the Finnish HIV Foundation, is dedicated to HIV/AIDS prevention, training, and advocacy work. ‘Positiiviset Ry/HIV' Finland is the only association for people with HIV infection in Finland. Its aims are to promote the well-being of HIV-positives and their families and help people infected with HIV to improve their quality of life. The main NGO addressing commercial sex workers in Finland is ‘Pro-tukipiste' which provides low threshold social support, outreach work, healthcare and legal advice. (Country mission report 2013.)
It's interesting to note that migrants remain invisible in the strategy despite the relatively high proportion of migrants living with HIV/AIDS compared to Finns. The emphasis on prevention and the reduction of vulnerability and empowerment is articulated within a cultural vacuum. Recognition of the cultural nature of all information and embarking on a dialogue with a variation affected individuals is the first step towards engaging in diverse communities. The invisibility of migrant communities and their specific needs in the Finnish national aids strategy can thus be indirect discrimination. (Clarke, 2004)
Although most migrants live in the metropolitan area which has the widest network of services for people with HIV/AIDS, they still share the same problems as Finns in the rural areas. Those problems include isolation and a lack of a social network to support them in issues related to their health status. But these immigrants face bigger problems due to their cultural, racial and language differences in the society. Therefore it's easy to notice that for them the HIV status is not the only problem but also the emotional and practical difficulties as a foreigner. (Clarke, 2004)

3.2 Participation 
Internationally, resources for social welfare services are shrinking. Population pressures, changing priorities, economic competition, and demands for greater effectiveness are all affecting the course of social welfare (Bens, 1994). The utilization of nonprofessionals through citizen involvement mechanisms to address social problems has become more commonplace (Kaufman and Poulin, 1996
Participation is a broad concept that varies with its application and definition. The dictionary puts it as "to have a share in" or "to take part in," thereby emphasizing the rights of individuals and the choices that they make in order to participate. Participation definition also depends on the context in which it occurs for instance community participation, citizen participation, political participation. (M. Mathbor 2008.)
Community participation can be defined in many ways as the process by which individuals, families, or communities assume responsibility for their own welfare and develop a capacity to contribute to its development. In the context of development, community participation refers to an active process whereby benefits influence the direction and execution of development projects rather than just receive its benefits. (Journal of social development. 1987)
In the case of the social sector and work the whole idea is not only reaching out to the society but also that the society should feel at ease with the programs that concerns them. In that way, the needs of the community will be addressed through participation in the society.
A descriptive definition of participation programs would imply the involvement of a significant number of persons in situations or actions that enhance their well- being, for example, their income, security or self- esteem. (M. Mathbor 2008.)
Participation is also a tool to educate citizens and to increase their competence, a vehicle for influencing decisions that affect the lives of citizens and an avenue for transferring power but also be a method to choose an alternate, a mechanism for ensuring the accessibility, sensitivity, and even accountability of social services to the consumers.
Community participation and taking responsibility for changes in the community suggests a counter response to the traditional sense of powerlessness felt by the general public when it comes to influencing government decisions .people often feel that health and social services are beyond their control because the decisions are made outside their community by unknown bureaucrats and technocrats. (M. Mathbor 2008). Being a member and participating in programs like a peer support programs for HIV positive can give clients a voice on creating favorable activities, addressing their needs. Most peer support programs deal with the sharing of information and meeting people with the same situations and this will empower those individuals to form an alliance and move towards achieving the common goal. In the case of the HIV positivist ry which facilitates activities for HIV positive clients, this formation of bond with the same need, will help them be heard.
Participation means joining in and getting involved – being able to have a say and including those who are affected from the beginning to the implementation and sometimes to the evaluation. If you want to succeed in getting migrants to participate, then you must deal with the cultural, moral and socioeconomic circumstances of the community's society of origin, as well as their life situation in the residence country. The participation of migrants in HIV prevention contributes to the better combating of HIV and AIDS. It strengthens and enables the involved employees, promotes community empowerment and leads to more sustainable work. Above all, participation should lead to equal opportunities for people in our society. Because participation demands a certain level of education, more resources (funds, time, premises, etc.) should be invested in health promotion and HIV prevention work. (Unger, Gangarova 2012) 
3.2.1 Empowerment and immigrants’ participation 
Empowerment is the purpose of social work (Parsons 2008). The focus on strengths and empowerment has gained considerable prominence over the last couple of decades. It also represents a major paradigm shift from the problem-based approach that has been with social work for such a long time.  (Lillrank 2013)
The basics of empowerment are a combination of traditions of mutual aid, self-help, and more recently, movements of liberation, rights and social activism, strengthened by anti-racism, feminism, critiques of inequalities and oppressions arising from social class, age, disability, sexuality, religion and other differences. The main idea of empowerment is to overcome contradictions between independence and dependence, independence and guardianship, and civil rights and the government. Particularly, empowerment focuses on enabling representation for groups suffering from discrimination. This serves the purpose of developing the clients' life management skills and their capacity for independent living.
Community work involves empowering people to analyze and manage the sources of their problems and to develop their own strategies. Empowering an organization is a process which is implemented in all the major stages of an organization's development: origination, informal organization, the emergence of leadership, beginning of formal organization, and appointment of paid staff and professional workers (empowering social work and practice 2013.)
Empowerment can refer to user participation in services and to the self-help movement generally, in which groups takes action on their own behalf, ethnic cooperation with, or independently of, statutory services. (Thomas and Pierson)Empowerment is a social action process that promotes participation of people, organizations, and communities towards the goals of increased individual and community control, political efficacy, improved quality of life, and social justice (Mathbor.2008.,)
The process of becoming integrated or "kotoutuminen" was defined as "the individual development of immigrants, with the aim of participating in working life and acting in society while maintaining one's original language and culture: Integrating ("kotouttaminen") means that the actions and resources provided by official bodies to promote the process of becoming integrated" (empowering social work and practice 2013)
3.3 Migration and HIV
People who are immigrants, refugees or those without status are one of the most vulnerable and fastest growing populations affected by HIV/AIDS in Finland.  (Country report, 2012)
There have been many researches on the impact of HIV on immigrant population and the adverse effect it has considering accessing health care system. Migration by itself has its own set back on a migrant population until they integrate and establish themselves in the new society. Finding out being HIV positive and not knowing how to deal with the sudden condition while being in this fragile state of immigration is a difficult state to be.
The health and mental wellbeing of migrant populations are influenced by complex and interrelated factors. According to Ornstein (2002), the social determinants of health, which are the socio-economic conditions that influence the health of individuals, communities, and jurisdictions, affect both physical health and mental health (Khanlou.)
Migrant populations are predisposed for risk for poor health in general and HIV infection in particular. This is due to the impact of sociocultural patterns of the migrant situation on health, their economic transitions, reduced availability and accessibility of health services.  The strain of understanding the host's country health care systems to cope with the traditions and practices of the immigrants the otherness of migrants creates often xenophobia, isolation, and hostility by the host community. In addition, as with other people living with HIV/AIDS, migrants who are HIV-positive are subject to stigmatization and discrimination, and therefore, they hide their HIV status as long as possible, thus making support services unavailable for them. (Shtarkshall 2000)
Even though a host country has the necessary health services that include hospitals, clinics, and other facilities, it may be very difficult for an HIV-positive immigrant to seek treatment. Since HIV is a lifelong infection that cannot be dealt with one quick visit to a treatment facility, it needs constant communication with health institutions and professionals. As a new member of a society with a constant thought of survival in a new place, an immigrant will find it difficult to cope with this.
There are many reasons why immigrants avoid HIV/AIDS related services that are helpful towards improving the life of individuals and groups. Shtarkshal in his study about migration and HIV discusses that Even if health and social services would be prepared to assist migrant populations, they often encounter great difficulties to reach out to them. For instance, some migrant populations still live in a legal vacuum meaning they don't have any resident or work permit for the country they are residing and live with the constant fear of deportation.  In this case contact with official government agencies, this including the hospital and any health related services increases that fear and is, therefore, often accompanied by suspicion (Shtarkshall, 2000). Many Immigrants have experienced HIV/AIDS-related stigma, racism, sexism, homophobia, trauma and loss throughout their migration process. More important, immigrants without status, their fear and  have constant stress about the overall immigration system, the uncertainty of their future and the continual barriers in accessing treatment and care, all work to risk their physical and mental health. (Compass, 2007)

 For others the economic situation of migrants gives them no choice for employment or if so happen to have it may be; many of them are forced to accept jobs far below their qualification under conditions which are in the gray area of illegality. Due to their powerlessness, they are frequently subject to all kinds of exploitation, including sexual exploitation. (Shtarkshall, 2000). But even if they manage to access formal support, they often report experiences of ill treatment from service providers that are perceived to be rooted in the ignorance and personal biases of practitioners.  In one study done in HIV-positive African women Philadelphia, a social worker employed at the health center with the highest caseload of HIV-positive African immigrants argues that men who are given a positive diagnosis often remain in denial; they don't believe they have HIV and they often disappear. She noted that given the economic challenges of working low-paying jobs, many men work two or more jobs and are unable to spend several hours waiting to see the doctor at a public clinic. (Foley, 2005)
According to (Weatherburn et al., 2003) the African population is distinct from their counterpart native UK citizens in  living with HIV mainly because of its acute needs for income, problems with housing and living conditions, lack of knowledge of anti-HIV treatment, problems with depression, and problems with interpersonal relations (Weatherburn 2003) .Needless to say, the African immigrants have unique problems, but  their situation can  mirror the other portion of the immigrant society .most immigrants may have a different culture and interpersonal communication but when it comes to accessing new country health system they face the same problem . Many also find a lack of information on services, long wait times, and language issues as barriers to their timely access to HIV-related health care and service.
According to (Foley,  2005) in his study found that American health care providers themselves have little understanding of the sociocultural context of HIV/AIDS in another part of the world , and how lack of ARV treatment and high mortality rates in their home countries shape their  attitudes to testing and treatment in the US. Providers also hypothesized that African men might be reluctant to be seen seeking medical care thinking it's a women's role to be in waiting rooms. However, many male and female focus group participants stated that being HIV-positive is a medical emergency that would require immediate medical attention. This understanding of HIV/AIDS as an emergency makes it difficult for individuals with no visible symptoms to accept that they have HIV. (Foley, 2005) .this kind of interpreting the HIV infection, on the other hand, will prevent them from seeking any other psychological, psychosocial or moral support treatments. 
Stigma is another reason that hinders from seeking treatment with the immigrant population. Stigma, itself is a social weakness that has a crippling effect on a society and living with the stigmatizing illness like HIV/AIDS can harm one's active life and social life. Because of this and many reasons more people prefer not to be associated with HIV/AIDS, and people who live with HIV/AIDS sometimes keep their infection secret. However, the stigma of HIV/AIDS is a cultural phenomenon and not set in stone. It represents a major problem in many societies and communities, but this can be changed and reduced especially when people succeed in reducing prejudices and fears. (Unger, Gangarova 2012)
According to (Foley 2005) the primary concern for many immigrants, more so than health status and impact of HIV, is their fear that other African immigrants will find out they are HIV positive. (Weatherburn et al., 2003 state that .The threat of alienation from family, friends, and neighbors weighs heavily on African immigrant women and limits their ability to seek much-needed social support. social anxiety about disclosing their status and their apparent unwillingness to disclose their HIV status to male partners or to encourage them to get testing speaks to their acute social and economic vulnerability, and the potential devastation of acknowledging that one is HIV positive.
  This ever changing and increasing numbers of people living with HIV/AIDS highlights the need for reassessment and redirecting current health and social services to be responsive and accountable towards the culturally diversified community. To provide services, education and information for migrant populations living with HIV /aids regarding prevention of HIV infection, care, and other psychosocial support and to fight underlying problem faced by this vulnerable society, it requires innovative and culturally sensitive approaches. Among many, in this paper, we shall talk about the role of peer support or support groups.

 3.4 Peer support group
Peer support, unlike other services which are set, meet the need of on a time-limited basis or only in times of crisis, individuals across a range of self-sufficiency and with varying levels of service-related need can benefit from it. It has also positive impacts on life, not only to the peer group and peer leader but also there are advantages to organizations and associations that choose to integrate peer support services into their models. For instance, some of these benefits for participant's involvement are often associated with the increase in knowledge, coping skills, self-esteem, confidence, sense of well-being and control, and a strong social network. also as an outcome it initiates in regular engagement in health care and support services, increased knowledge about HIV and HIV treatment, increased self-efficacy to manage HIV disease, improved adherence to medication regimens, enhanced self-efficacy to engage in risk reduction behaviors. (Goldman,luis,ruiz 2010)

An HIV diagnosis can be very isolating, as people frequently cut themselves off from the world when diagnosed with HIV. But the isolation in this times would make the situation worse .dealing with this situation alone could be very stressful that could lead to poor health, depression, and anxiety. It's a better to seek medical and psychosocial support in these times. This could be with the help of professional or another alternative way could be gaining support by telling family and friends about the HIV diagnosis.  Even though this may not always end up with the support needed. But Going to a support group for people with HIV is a more reliable way of getting the necessary attention and support needed. Support groups can be particularly useful for people feeling vulnerable or anxious because of ill health, lack of confidence, immigration, poverty or being unable to work.
According to (Goldman,luis,ruiz ,2010) peer support or support group for HIV could be defiend as is a set of services provided by and for individuals living with HIV/AIDS so that it enables them to empower themselves and develop effective strategies in order to live healthy lives. This can be delivered either by interaction through one-on-one communications or in groups. The idea of Peer support is based on the ground that no one recognizes the realities of living with HIV/AIDS better than someone who has been living with and has been managing it every day. members in a peer groups, since they are coping with the daily challenges of HIV/AIDS, have the power to serve as important role models and help individuals to cope with their HIV diagnosis and its resulting grief, provide opportunities to share feelings, receive helpful ideas, reverse negative thoughts, change harmful behaviors, develop a sense of stability and hope, and adhere to healthy routines of life. Peer support can be seen as an encouraging type of peer pressure which can motivate a person to pursue previously thought to be impossible deeds to be done alone. Peer programs or peer meetings also serve as a gateway to the service system for individuals who are not accessing health care, case management, or other needed services. Hence, peer support services serve a uniquely important role within the HIV/AIDS service system. 

A key way that social support groups help people is to challenge the idea that diagnosed with HIV means you are going to die. While addressing this, support groups help strengthen confidence and hope of a diagnosed person. It can be hugely inspiring if people can see other people who are 'in the same boat' doing well. Many people described the feeling of happy and being motivated to see others s with living a healthy life. Experienced people in groups sometimes tell their own stories to help build the confidence of newcomers. People come to see other HIV-positive people in groups as role models, those who have managed to do well in spite of the being HIV positive and this can motivate newcomers to participate in support groups. The assurance someone gets when they see another HIV diagnosed person  doing very well right is an important inspiration, they could discuss how they manage to do certain things what others  seem unable to do ' People then share ideas on how to solve their problems and 'move on in life.' It is vital for people to see that others diagnosed with HIV can manage their HIV and live well. (Real talk .org 2016)
People that are affected by HIV infection often say they could not manage to sustain their emotional health without a help of a certain friend or support group or doctor or counselor. In fact, they go further and say that without these people, they would no longer know how to live.  Even though this may not be true for everyone since some people are more private than others, or would rather rely on their own resources, some may be afraid that people will be tired of them. According to bartlet et al., (2006) in general, the people who do best with this or any other disease are those who have the support of their family and friends. The principal sources of support for people with HIV infection are their partners, parents, husbands, and wives, siblings and relatives, neighbors. Other sources of support are volunteer buddies from advocacy agencies, co-workers, church members, and members of any other groups to which they belong. Still, other sources are the professionals who tend the mental health of those affected by HIV infection: psychiatrists, psychologists, social workers, counselors, religious leaders— therapists of all kinds. (Barlet, finkbeiner , 2006)
One should note that, Not only for meeting and discussion but also peer-based HIV treatment interventions have been found to be less costly than other types of individual-level approaches, to effectively address social factors that may shape risk behaviors, and to be effective in recruiting members of marginalized populations to enter and remain in the health care system. These programs rely on peers to provide education regarding treatment options, adherence to care, accessing health and other support services, along with social support to HIV+ individuals in one-on-one or group settings. (Journal of Immigrant & Refugee Studies, 2008)
The effectiveness of peer support is often associated with a positive form of peer pressure which can motivate a person to pursue things previously thought to be impossible. Peer programs also serve as a gateway to the service system for individuals who are not accessing health care, case management, or other needed services. Hence, peer support services serve a uniquely important role within the HIV/AIDS service system. Studies of peer-led curriculum-based self-management groups have shown significant positive changes for participants in self-management attitudes, skills, and behaviors. Other studies indicate promise in the use of peer supports to reduce hospital readmissions, reduce the symptoms of depression. (Purlington, 2004)
When we talk about the need of social support groups for HIV-positive immigrants it's understandable that it's a very useful tool to get more information about the health system, find friends and reduce the stress that comes associated with being diagnosed. When a person finds another with the same degree of hardship or difficult situation they cold exchange ideas and gives each other a moral strength to carry on.
The family and social networks of migrants can be an important source of support in the resettlement context and promote mental wellbeing. Research findings reveal that immigrants tend to rely first on and foremost on extended family members (especially those who have been in the country longer) for settlement related needs and also for a Social support networks outside of the family tend to revolve around the ethnic community and religious organizations that cater specifically to that ethnic community. While social support can mean different things to different people within communities, Simich et al., (2005) reported common forms of social support as identified by policy makers and service providers, which include: informational, instrumental, and emotional supports (Simich et al., 2005: 262).. In order to provide different levels and types of support, there must be an attempt made towards holistic coordination of services (khanlou )
According to barlet and finkbeiner (2006), some of the best support for people affected by HIV infection comes through organized support and therapy groups.  Even though many people resist joining such groups because of the assumption that families and friends and religion are sufficient, or simply they are embarrassed to discuss with group of strangers, but ones they do, however, they find that talking to people who share the same experiences allows them to open up and say things they could not otherwise say. For people whose family and friends are unable to be much help, support and therapy groups are lifesavers. Talking to people who share your situation can reduce your sense of isolation and give you a feeling of community. Listening to them talk can also give you a different perspective on your own problems. Seeing what works for other people, and what does not, helps you decide what might work for you. Hearing your problems described by someone else as their problems is somehow reassuring, calming— you don't feel alone with your problems; you're in good company. People say that groups give them a sense of relief from their own problems, and a sense of hope. People like the thought that they might be helping others in their group.

4 METHOD OF DATA COLLECTION AND ANALYSIS 
4.1 Methodology 
The mythology for this qualitative study is a community-based participatory research. It studies a particular problem among a community and tries to find out the cause of the problem based on the understanding of the community itself. The study was carried out involving the community which the problem first hand affected; they gave their insight on how the problem arises and what should be done to tackle it. 
Action research sometimes described as action participatory research is a research method that evolved from many intellectual traditions and describes as very effective ( berg , 2004 ) research method that  directly addresses the problem of the division between theory and practice, action research integrates the development of practice with the construction of research knowledge in a cyclical process. Instead of being research on a social setting and the people within it, it is research from inside that setting carried out either by the participants themselves or researchers working in collaboration with them. It has an immediate impact since it is an integral part of day-to-day work. (Somekh, Nofkey 2013)
Community-Based Research (CBR) is a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings.  Begins with a research topic of importance to the community, in this case, an HIV-positive immigrant, with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities, this including the development of activities that will attract more specific clients to the support group service.  (Compass 2007)
Choosing these research methods would help see the Couse of a problem from the clients themselves. It would be a way for their voices to be heard and be a part of developing services which are they could help build. It's a tool for empowering a vulnerable group and raises their voice.
Community-based research engages members as active participants with an aim to generate an understanding of the community members perspective and needs as to develop the intervention that can meet the needs of community members. This research method is most appropriate addressing the needs of the vulnerable population because it encourages the direct and active involvement of them members of those populations and seeks to mitigate inequities and oppression among vulnerable groups. (olshansky 2008)
4.2 Data collection 
In this research, there were 8 interviews conducted as to see the views of immigrant clients. The interviewees were done from different nationalities, not including the point of view from Finnish clients. This variation was made in order to get different perspectives. Group interviews were avoided to not to get generalized opinions and to minimize the data analysis method and time. The interviews were semi-structured open-ended questions. The reason for open-ended   questioners was because it was important the interviewees express what they feel free. How they feel and think, on the other hand, it gives the interviewer insight into some topics not mentioned in the questioners.
The interviewees were selected in an external validity form, making it open to gender and races that fall into the category of a client with an immigrant background. Also, try to diversify it as much as possible by including the interview of peer support organizer of the association and the opinions human right worker who see the cases of immigrant HIV positive cases in Helsinki. 
Interviewing the program organizers gave an insight and the overall picture of the immigrants in the programs and the issues they raise during their sessions. Interview questions with semi-structured open-ended questions were designed for scheduled interviews with the supervision of the questions by the association. In addition to this, other supportive data was collected by consulting some feedback questionnaires answered by service users.
The Data was also collected through literature review by analyzing the previously published works on the HIV-positive immigrants, an importance of support groups and see examples of success full support programs and how they manage to increase the participation of HIV-positive immigrants to different services.  Also, data was collected from questioners from immigrants who are HIV positive. questions include have they use peer support services before, do they know the value of peer support in dealing with their HIV status, if they are willing to come for peer support what kind of environment scares them if they want to form a group what kind of facilitation they expect from the organization, 
 Even though to get contacts of HIV-positive immigrants was difficult, since this paper was done with the collaboration from positiiviset ry, the association convinced the clients on behalf of me and they persuade them to be part of the research. Also, I had made a request for the interview to the clients in a written paper explaining the aim of the research and how they could be part it. I have made full a full confidentiality responsibility and stated that I will not use their name or their identity.
The interviews were done in March 2015 on the premises of the positiiviset in the time period of 2 weeks in total.  Most of the interviews were made in the association on cafeteria day so it was easy to meet. Other interviews were done on separate occasions with an appointment. 
 
This paper was made with a full collaboration with posetiviset ry and. they have let me use the premises for an interview and arrange meetings and give insight to the association work and aces to clients.

4.3 Data analysis 
To analyse the data gotten from the data collection I used inductive data analysis by Looking for themes that reoccur. Since it was an open ended question there were different opinions about the same subject so there were repetition and an onion which they share. I have coded the reoccurring themes and generalized them into certain themes that seem to show common answers.
Since the interview was an open-ended question, the 8 interviewees, generated an abundant number of data. Some data's were unusable because they went to another direction. Because the topic was a sensitive subject, most of the clients give longer interviews covering very wide subjects which include personal problems and unrelatable subjects which may or not help the paper. The audio files later transcribed to paper and the process of finding common they began. I have read the interviewees again and again to detect every new data. After reading many times and coded the data in same categories I generated common themes. Even though the interviewees address some issues in different words, there were similarities on a number of points. These points were later categorized as themes and used to interpret the result 
The literature review described above help support the findings of the interview. The results were divided into chapters covering a variety of issues that were raided as a cause for a lack of participation and cover the advice from their perspective.
Inductive analysis means to look at a field or group of data and try to induce or create order by organizing what is observed in subgroups. The process starts as early as while collecting data. It's a system that looks for recurring themes or patterns when they emerge. Similar things should be coded and moved to initial categories, however, this category should be very flexible as data may change and composition. (Jason, put 2002)
4.4 Ethics and limitation
While doing this study, the ethical part was carefully thought. Since HIV is a stigmatizing disease and many wish to keep their identity safe from being spread outside, the paper did the interview on descript on demand of the interviewees.
Consent to interview was granted from the positiiviset ry association and confidentiality was signed. An introduction and the reason for the study was sent earlier to the interviewees so that they will come prepared for the answers when they come. 
All except one, which needed translation for better English, was done one to one in the association's premises and the interviewee's name was not used in any part of the paper.
 Even though all of the interviews were done in English, few clients didn't spoke good English to express their feelings deeply, this resulted in a shallow answer from them.  In some interviewees, there was a problem of understanding the questioners and because of that questions were answered vaguely. The language level of the clients should have been assessed before generating the questioners so that they will answer better. There was also a problem of not understanding the direction of the questioners.  Even those who understood the language, time to time tend to give a different answer than where the question was headed. This is partly due to the way the questions were generated. 
The sensitivity being identified as an HIV positive also hinders from interviewing those who had more to say. For this purpose phone call, interview should have been implemented too.
5 .RESULT AND DISCUSSION  
  5.1 Understanding and expectation of support /peer group.

 Most of the clients seem to have some sort of expectation and understanding about the support group before coming in. Since not all of them have the same reason to seek the service of the association, they were having a different mindset. From the interview of clients, some come because a friend says so , or some come because they were told to do so  While others came in searching for the service ,hoping it will help them with their situation.
… “I want to meet people with the same mentality”.
“I want to make a  friend because  the association I feel  like I can talk about my  diagnosis and in outside, I can't talk freely about my situation” .
Many disclosed their anger, frustration, and sadness when they were diagnosed and how it will leave the diagnosed person in a state of rejection and loneliness.  In this period of time, it's quite important to see and talk to others who are in the same situation and observe how they are coping with their situation. Most feel they are alone with this virus and their whole world has come to an end. And attending the support group for most clients was a chance to see and talk to other people who are also in the same situation and its place to form a bond between each other.
 
  The interviewees misunderstanding of the peer support can be seen here.   Clients were not fully aware of the purpose of the support group and its function. There seem to be missing an explanation, in detail, of the purpose, function, and importance of this kind of support groups to HIV-positive individuals. Even though most didn't understand the purpose initially, after a while they seem to enjoy being part of it.
“I didn't have any expectation, I thought it will be a very bad place, full of weirdo or monster house but it ended here I like it …”
“I expect to talk to talk someone.  I expect to find friends.  But here I feel like the people are a bit no that much communicating “…
 Most clients like the idea of the support group and the association which runs it.  They seem to get along and understanding the benefit as days goes by. Most have said they had difficulty, in the beginning, to get used to the idea but with more participation and finding their own group preference, the benefits of a support group are visible.  Discussed how people are so polite and made them feel ok.

 5.2 Difficulty in participating as an immigrant 
  From the conducted in an interview, almost all interviewees expressed their concerns as a foreigner towards participating in the support group programs. Even though all have different opinions as why they find it difficult to participate, they also show some common type of concern.
5.2.1Language 
I have a problem with the language, the group is nice but we don't understand Finnish.  That really pushes me back. I like to be with everyone if I understand the language.

Most clients who visit the association told their frustration about the groups. Since most of the oldest group members speak Finnish and also it's the common language, it is difficult to cross that barrier. Even though the clients want to visit the support groups or the association but if there is a problem communication, the whole point of being in the same support group and discussion doesn't make any sense. Some interviewees have also mentioned that some Finnish group members are able to speak English but shy to do so. Never the less they have appreciated the willingness of many who have tried. 
Also, many of the foreigners who visit the association are not necessary English speaking either. Many have a small scale of English which is not enough to communicate, which was a problem for those who speak English. But they have mentioned that those who managed to speak a bit of both the Finnish and English have managed to participate in group's discussion.
  5.2.2 Interpersonal stigma 

 "We want to be assured that we are coming not to face our discrimination but to share our experience "
An HIV aid is a stigmatization disease. Many who live with the disease have been also dealing with the stigma and discrimination associated with it for as long as they were diagnosed. The case is not different with the clients who visit the association. Here in positiiviset not mandatory to disclose the person's HIV status, sexual orientation or anything the individual don't want to disclose. Because of that when many come to the group meetings, they are afraid that they will be identified as HIV positive. But most of them, they want to be free of hiding and come freely to discuss what is in their mind with people who understand them. 
There is also a fear of being identified with by their own country people, mostly clients from African countries.  Besides those who come from African countries, Most were comfortable to see their own country people or at least people from the same culture. But the interviewees from African countries clearly expressed they don't want to meet any other HIV positive group members from other African countries let alone from the same country.
  "I have this feeling the moment they see me they will recognize me Or at least they know my friends "
  This fear is clearly driving them away in group meetings where they will risk meeting each other.  This was a sensitive subject to many; there was a clear division of opinions about it. Interviewees from African countries emphasize the fear of being identified by other people from Africa. Other interviewees from Latin America and Europe were comfortable on seeing other people from their country.  This might be the perception of HIV in their home country by the society. 

I am happy to see another immigrant when I come in the house. I feel it's not only me. Many of them are shy but I always try to make them welcome. You know it's not my fault that I got HIV . I feel pain but I don't feel shy.
"..Don't be afraid. Things will be better. I feel like no one will want me. But here I will tell them fell like another person. When I see other people don't see the HIV in his face that is what I other will say when they will look at you "...

 They explained the power of interpersonal stigma between each other. with the wonders of  modern medicine it's really difficult to show much physical evidence that on is HIV positive, and they believe that if they don't feel shy and held their head high , no one would consider them to be HIV +.
"Many Africans feel they might be recognized, but me I am happy to see them.".
 Those who are happy to see other immigrant participants are glad to see diversity in the group meetings. They talked about how it's easy to open up and make conversation with other immigrants. But they were emphasizing the importance of the confidentiality. No matter how comfortable they are in the groups, it's very scary thought that their diagnosis is discussed outside the association. Positiiviset has a rule that all employees should sign a confidentiality paper but does not expect that from the group members.

5.2.3Cultural difference 

 There was also another concern that was raised; the difference in culture has created a small misunderstanding between the foreigners and the native Finnish.
 I sometimes feel like am an outsider. The old stuff wants to give space for new members, I guess its Finnish style 
The norm in communication is different. The Finns culture of giving space to new members is somehow interpreted it as a sign of unwillingness to accept.  Their understanding of social interaction could be different from the Finns since they are from different country and different culture. Those who have been in the groups for a longer period of time but have a foreigner background seem to understand the difference and explained who others see it.

- The immigrants feel they are been intentionally been rejected by their counterparts who also have HIV, even though its Finnish culture to be shy.
These phenomena will give the wrong perception of the older members and force the younger to avoid participating. They also feel unwelcomed and most feel they don't belong there.

5.3 The need for foreigner group 

   For This question, there were divided opinion whether or not to have their own immigrant group.  Most of the interviews support the idea in some way but also expressed their concern that this separate group will leave them out of the integration process.  From the interviewees who lived in other countries, claim they have seen the good result of having this kind of separate group. They also seem to think to have this kind of group will motivate individuals to participate in support group meetings. Even though they show an interest in having an immigrant or group, they do not think it the most important; they focus on the idea of finding a group that represents the need of a person instead. 

I want an immigrant group.  Back in Netherlands, I was in Spanish group. But for me I want more of same sexuality group rather than an immigrant group. 
I have been different countries where I have participated in immigrant groups. But here I am participating in the general group, I think I like it like this.
They believe that an integrated program than separate is a better one because it's easier of for Finnish people to know about the foreigner's counterpart and learn new ways how others in a different part of the world live with HIV.
 The other half of the participants also believes having their own group is a way important and should be facilitated by positiiviset. They believe even though participating in one general group will create a bigger bond, the special connection they will have with other immigrants is different and something they are willing to explore more. Participants in the interview expressed their thoughts on how it's easier to talk to another immigrant in the group since they will have more in common plus there is a need to exchange information and learn about a different situation from each other.  Meeting people with different circumstances will give a different view on things for others. But they also emphasized the name should be an international group, not an immigrant, as the name gives a negative view.

"When someone is from another country it gives you some sort of bond that can relate to you"
"We tried to have it two times, it was nice. Even some Finns joined because they understand how it feels because they were diagnosed outside."

5.4 What is missing, what is needed?
 
Participants gave a practical opinion on what they believe is missing and what measures needs to be done to increase HIV-positive immigrants participation in the association. They mostly talk led about seeing a familiar face in the group meetings.  That means a person who facilitates or welcomes new visitors to the groups. Someone with foreigner background will be easier to talk to and makes it easier to approach. They do not mind if this person discloses his or her diagnosis but be rather be supportive and approachable.  This is not implying a facilitator only for an immigrant group but in general for the association. 

"…But it's always better to have a facilitator in the group just in case the person wants to talk personally. "

There was also a request if the association could be a source of information about the health system to them. The association in general principle, besides providing peer support services, organizes lectures from professionals and give advice. But the HIV-positive immigrants were not aware of those services. Mostly since the services are in Finnish. So mostly they were asking for the guidance and information on how the health system works.
Since it will be difficult to find a translator for every language, they asked if there will be some sort of guide for new visitor or group member, someone with the same country or similar cultural background or at least same language. This will give the feeling of closure and the newcomer will feel less comfortable as a first timer,   a tutor for newcomers.
 An update in information in English ones in a while will be beneficial for the non-Finnish speaking visitors.

5.5 Being HIV positive immigrant in Finland 

"When I come here first I was very confused. I was so sure I was going to die. I was really thinking of killing myself and counting which car I am planning to jump into. So we are not thinking about the medication and surviving. So we need someone to assure us we are going to be ok and assure as." 

 The interview participants talked about how it is to be HIV-positive foreigner in Finland feels. Most expressed the different kinds of worries and difficulties they had while they were diagnosed and now wanted to share their opinions as a first-hand experience.  They would recommend a few things to do when diagnosed with HIV. 
 
"..don't  stress too much  , everything will take its own time , even if  you feel  that you  don't  get what you need in time .  Follow the queue. Finnish people have the same problems too, to get this privilege you have to follow the rule and don't expect special treatment…"
They pointed out that many immigrants feel they are being intentionally suppressed in the health system even though native Finns go through the same health system. There seem to be a misunderstanding of how the health system works. This is one of the importance of the visiting support groups to discuss how the system works and to get the necessary information.

 They also stressed on the point that it's very important for a newly diagnosed person to seek treatment as it helps both and physically and mentally.
They also expressed the importance of support group for a newly diagnosed person.  They would like to advise any foreigner who is HIV positive to visit the association. It has more to offer to the psychology of HIV positive, which is in a dilemma on what to do.  In the case of new HIV-positive immigrant who moved here, they have a lot of worries including the fear of immigration, 
As an HIV-positive immigrant, they they would like to give advice to other who are in the same situation.  It's important to talk to someone who has gone through the same situation, for this to happen they would recommend anyone they met to visit the association.
"..Don't stay alone!!  Find a person to talk too. Since the medicine is free, try to seek medication.  Especially in Helsinki area you will get good service. When you are diagnosed you feel that it's the end of everything even though you only think about dying. You really need a peer support. "
Speaking from experience, they appreciate the importance of talking to a group who really help them when they are in need. it was a tool for coping for the heavily stressful  times 

 6. RECOMMENDATION AND CONCLUSION 
Form result of the study we can see positiiviset means different things to different persons depending on the prevailing situations in their lives at the moment of use.  It is obvious that it meant much more than just a place where they go ones a week for a lunch. It's meant  to  be  a place  that could a  build social networks, improve wellbeing,  improve or develop some meaningful bond among members , a place that offers opportunities for people to feel that they belong and are worthy to the society. Positiiviset had been a place for the HIV positive to be finding one another and give emotional and psychosocial support for one another. Regardless of its success in achieving what it stands for, there are some methods it could incorporate in its services that could develop the participation of the HIV-positive immigrants. As a conclusion, the results from the study could help the association to develop a better service for the HIV positive. This also would call for a future study for the problem and more advanced practical approach to tackling the problem. 

Here are some of the suggested points based on the need of the immigrants. Currently, majority of service users tend to be native Finns and what is needed now is to build an environment which is seen as welcoming towards the ever increasing number of multicultural and diversified society.
Some recommendation, which both collected from external data source and points suggested by interviewed individuals, are described below 
 6.1Peer leader
  The association should introduce a peer leader who has an immigrant background. Since peer leaders have personal experience in managing HIV in their own lives and employing effective self-care strategies, Someone who has been in  regular care and ability to advise other on how to cope . This does not mean that peer leaders must have conquered every challenge, but the management of the daily challenges of living with HIV is essential. This could be among the existing members who are willing to do the work. This could be a voluntary work. This peer leader would welcome and talk to HIV-positive immigrants and makes them feel welcome also could be a tutor when there is a new member or visitor. 
Another way for the association to have an immigrant background volunteer or worker who acts as a peer facilitator could be through practical placements from vocational schools. This facilitator doesn't have to be an HIV positive but would act like a worker who could facilitate programs and talk to HIV positive clients. As mentioned in the result, the members would like to see a foreigner worker whom e they would feel easy to talk to.
Ability to work with diverse groups Peer support participants come from many different backgrounds in terms of race/ethnicity, sexual orientation, gender identity, sex and drug cultures, age groups, religion, country of origin . A peer leader should have strong interpersonal skills and multicultural sensitivity, a competency that enables him or her to deliver quality services to all program participants with respect and compassion. Peer leaders must have an understanding of their own personal and cultural identities and use these characteristics to influence others with cultural diversity. (Lewis, Goldman. 2010)

6.2 outreach programs 
Positiiviset could start to reach out to HIV-positive immigrants through different means of communication. This including advertising its services in many places where the target groups are found. There should be also a clear definition of its purpose and what to expect when new members arrive. There should be a better advice from the hospitals about the association to future clients, instead of sending them just because they have to, they could elaborate the service to this vulnerable group thoroughly. The association could develop this by having a better communication with the hospitals and other HIV service associations.
The positiiviset website should have an English version to reach out to the English-speaking clients. If translating the whole page could be difficult, there should be a small introduction of the association in English and links to the employees of the association who can speak English. 
The association could facilitate its member who speaks different languages to help new clients with the same language to give advice. They don't have to meet in person if they don't want to but they could facilitate and email exchange or phone number so service explanation could be done. 
 Another good example of reaching out to HIV-positive immigrants would be to work with migrant self-organizations. These Self-organizations are voluntary associations of persons pursuing shared goals. The term migrant self-organization (MSO) is used when people with a migration background come together as a group. MSOs are not just formalized relationships – such as those in the form of registered associations – but also informal relationships like groups, projects, and networks. They provide information and offer orientation, counseling and support, as well as serving as the point of contact in cases of exclusion and discrimination. They represent the interests of the migrants and enable communication with mainstream society. (Unger, Gangarova. 2012)
Positiiviset could arrange with these organizations and help to advertise this service.  These organizations have a better communication method with the target group more than any organizations. They have grass root knowledge of the community and could motivate the target community to use the services of the positiiviset. 
Positiiviset should also work and develop its policy on confidentiality of members and visitors. From the interview, members have stressed about the fear of being identified as HIV positive outside the premises of the association. It could introduce a system whereby all the members sign confidentiality where thy will not talk about the identities of the other members. This will give a bridge of confidence between the association and the HIV-positive immigrants.

REFERENCES 
Bartlett, john g ., finkebeiner, annk  2006 guideline to living with HIV :developed at the john Hopkins aids clinic 
Clarke Kris, 2004. Access and belonging in the age of viral epidemic. Constructing migrants living with HIV aids in the Finnish welfare state 
Compass, 2007 .volume 1 issue 2 .A Community Resource in HIV/AIDS-Related CBR http://www.ohtn.on.ca/Documents/Publications/CompassWinter07.pdf. Accessed 22.5.2013
Country mission Finland: HIV, sexually transmitted infections, and hepatitis B and C , 2013 
Dublin declaration monitoring global aids response progress reporting.2012.country progress report Finland 
E .E .Foley 2005HIV/AIDS and African immigrant women in Philadelphia: Structural and cultural barriers to care. Aids care 17(8): 1030/1043
Hella von Unger, Tanja Gangarova. 2012. Hiv prevention for and immigrant,  pakomi hand book , http://www.pakomi.de/sites/default/files/PaKoMihandbook.pdf. accessed 3.6.2013
Johnson a, Puo allyn bacon.  2002. A short guide to action research 
Khanlou N.  2008 Young and new to Canada: Promoting the mental wellbeing of immigrant and refugee female youth. International Journal of Mental Health & Addiction, 6(3), 514-516.
LeCompte, M. D., Klinger, J. K., Campbell S. A., & Menke, D. W. (2003). Editor's introduction. Review of Educational Research, 73(2), 123-124
Oakley peter, marsden David. 1987 approaches to participation in rural development.
Ruiz, Lewis, Goldman. January 2010. Guide for peer support services .Massachusetts Department of Public Health Bureau of Infectious Disease Office of HIV/AIDS and Boston Public Health Commission Infectious Disease Bureau HIV/AIDS Services Division. Acceded 14 of May 2013. www.mass.gov
Shtarkshall, Soskolne. June 2000.  Migrant population and HIV/aids the development and implementation of programs: theory, methodology, and practice. UNESCO / UNAIDS
Thomas, Clarke, Kroliczak. 2008. Implementation of Peer Support Demonstration Project for HIV+ Caribbean Immigrants: A Descriptive Paper. Journal of Immigrant & Refugee Studies, Vol. 6(4)

APPENDICES 
Questioners for people with HIV + with immigrant background 
  
Question 1. What is your expectation from Positiviset to facilitate for you to be in a peer group 

Question 2   As an immigrant what  kind difficulties do you find hindering  you from participating in a group activity 

Question 3   Do you see the need to have a peer support group especially targeted at people with an immigrant background? OR should the regular group be developed to be more inclusive?

Question 4 To facilitate a peer support group for immigrant background people, what is needed to be available?

Question 5  Are you happy with the support you get from Positiiviset? Do you feel like you are in a group that understands your needs?

Question 6  Are you comfortable with seeing another positive immigrant  in the same place and having a meeting weekly 

Question 7  What kind of information would you like to pass on to other immigrants living with HIV in Finland?  

Question 8  What kind of information regarding HIV would you have wanted to receive when you arrived in Finland?