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Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations – 2016 Update. Geneva: World Health Organization; 2016.

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Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations – 2016 Update.

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Annex 5Case examples of programmes serving the needs of key populations

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2014

1. BACKGROUND

The five key populations—men who have sex with men, people who inject drugs, people in prison and confined settings, sex workers and transgender people are disproportionally affected by HIV; they have an increased risk of infection, and yet are the least likely to have access to HIV prevention, testing, and treatment services because of widespread stigma and discrimination. One in two new HIV infections worldwide are in these populations.

HIV/AIDS will never be controlled without respectful and targeted engagement with these communities. 1

In July 2014, the World Health Organization Department of HIV released the Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations2 (henceforth referred to as the Consolidated key population guidelines) and a series of technical briefs, HIV and Young Key Populations: Technical Briefs (henceforth referred to as the Technical briefs)3 Case studies documenting programmatic good practice were collected to supplement these documents.4

The Consolidated key population guidelines brings together existing WHO guidance on HIV prevention, diagnosis, treatment and care for men who have sex with men, people in prisons and other closed settings, people who inject drugs, sex workers and transgender people. The Technical briefs describe in detail the needs of young people in key populations; spotlight critical gaps in services to address those needs; identify areas that require further research; and examine complex and contentious issues in need of leadership and action from all stakeholders. For both documents, the case studies provide important real-world information on the challenges that programmes are facing and the successes they have achieved—especially at the community level—in their efforts to understand and serve the needs of the people who are at the greatest risk of acquiring and transmitting HIV.5

This annex to the Consolidated key population guidelines presents case studies of good practice from national, community-based and community-led programmes around the world that work with key population groups who often experience structural and societal barriers to health and social services. These case studies offer practical examples of how the community and health-care providers can deliver accessible and acceptable services to key populations.

The case studies presented here describe work on the critical enablers6 that facilitate access to services and create an enabling environment for key populations to access services. The case studies also illustrate innovative approaches to service delivery that increase uptake of HIV services, harm reduction services and retention in care. Many of the programme descriptions feature practical details on implementation strategies. Contact information is provided for all programmes listed. All of the selected case studies demonstrate that focusing on critical enablers and improved service delivery for key population groups can have a positive impact on individual and public health outcomes.

The information in these case studies from a broad range of settings is intended to contextualize and animate the guidance and recommendations presented in the Consolidated key population guidelines and the Technical briefs.

1.1. Objectives

This compilation of case studies represents the achievement of 5 objectives:

  1. Identify successful prevention, diagnosis, and treatment and care services and interventions that address the specific needs of key population groups.
  2. Identify key aspects of good practice with regard to design, implementation and monitoring of programmes focused on critical enablers and service delivery.
  3. Identify programmes that demonstrate good practice in addressing the needs of young people and adolescents in key populations.
  4. Highlight gaps in reaching key population groups, including young and adolescent members of key populations.
  5. Complement the Consolidated key population guidelines and the Technical briefs with practical, ‘how-to’ examples for strengthening critical enablers and service delivery for key populations.

1.2. Methodology

Online survey for solicitation of prospective case studies

An informal review of current literature shaped an online survey that solicited examples of programmes providing services to key population groups, including both adults and young people. Prospective contributors were invited to participate via a web link sent to a wide network of relevant parties, including: WHO regional offices and focal points; UN partners; key population and civil society networks; international and national NGOS; and individuals managing or implementing programmes. Initial contacts were requested to circulate the survey to their wider networks. The online survey7 took approximately 20 minutes to complete and included questions on general programme characteristics (e.g. key population group, country, region, organization; type of programme) and more detailed programme-specific information (e.g. description of activities, results/achievements, and monitoring and evaluation).

Participation was voluntary, and an option to exit the survey at any time was available. Organizations could also elect to maintain anonymity in publicly available documents. The survey was available in English in October 2013, and in Russian, Spanish and French in November 2013. The survey, in all languages, was closed on 24 December 2013.

Initial screening and draft submissions

Surveys that were not complete, did not provide programme name or contact information were excluded. The remaining surveys were translated into English, when needed, and exclusionary criteria were applied to all data collected from the online survey: programmes with fewer than 10 clients accessing their services per month, programmes that did not address any of the five key populations or monitor and evaluate their interventions, and other issues that deemed the data provided unsuitable for inclusion as a case study.

Potential case studies were then screened to maximize regional, national, key population and intervention type representation, as well as for evidence of appropriate monitoring and evaluation. Each programme example was reviewed to identify a ‘focus area’, which usually reflects a particularly interesting or innovative approach to provision of accessible, acceptable and affordable services for key populations. Around 20 programmes from each region were then provided a template and requested to submit a written case study (approximately 400 words), which included a description of their programme purpose, details regarding challenges, lessons learnt and successes, and where possible, information on the monitoring and evaluation that is used to measure progress.

Review and selection

Submitted case studies were reviewed and edited to improve standardization and quality. These studies were then reviewed by the Guideline Development Group and a Virtual Review Group for the HIV and young key populations technical brief series. While reviewing the studies, the two groups highlighted focus areas within the submitted case studies. Organizations were then contacted for additional information to address these focus areas. WHO writers worked closely with all organizations to finalize the case studies and ensure that the content was accurate and representative. Consensus was reached through a final selection process to include 38 case studies within the Consolidated key population guidelines and/or HIV and young key populations technical brief series. This web annex includes those 38 plus an additional 31 case studies.

1.3. Selection process results

There was an enthusiastic response to the online survey, with over 400 programmes submitting general information,8 of which around 380 programmes met the criteria for consideration. Programmes responding to the survey presented interventions supported by government, UN agencies, bilateral partners, international and national non-governmental organizations and community-based organizations. Of the programmes that responded to the survey, 32% primarily serve communities of men who have sex with men, 27% serve sex worker communities, 21% serve people who inject drugs, 13% serve transgender communities and 7% serve individuals in prisons or other closed settings. A range of services are offered by these programmes, broadly including HIV testing and counselling, sexually transmitted infection (STI) screening and treatment, antiretroviral therapy (ART), needle and syringe programmes (NSP), opioid substitution therapy (OST), advocacy and social and economic support. Nearly 75% of submissions reported that they undertake monitoring and evaluation activities, while only around half were able to provide an internal or external evaluation report.

Submissions were then screened for geographical and programmatic representation, and follow-up information was requested for further consideration. Around 100 programmes serving adults or young people were requested to submit a written case study following a defined format, and nearly 90 programmes submitted draft case studies. Further follow-up questions and editing resulted in the inclusion of 38 cases studies in the Consolidated key population guidelines and Technical briefs and an additional 31 case studies that are included in this annex.

Figure 1. Selection process.

Figure 1

Selection process.

1.4. Case study profiles

This section presents summary profiles of programmes that contributed selected case studies. The programmes represented by case studies offer a range of services and interventions including HIV/STI testing, counselling, treatment and care, harm reduction (including OST and NSP), SRH, support (social, psychological, legal and peer-led outreach), training and advocacy.

Figure 2. Regional representation.

Figure 2

Regional representation.

Figure 3. Programme type.

Figure 3

Programme type.

In the figure below, programmes serving young key populations (YKP) address all 5 of the key population groups covered in the guidelines and target individuals from 10-24 years of age. Programmes serving more than one group are usually serving MSM and TG, or MSM, TG and SW. Several groups also serve PWID along with other groups and a few serve all 5 KP groups.

Figure 4. Primary key population group/s served.

Figure 4

Primary key population group/s served.

2. CASE STUDIES

This section is organized into two sub-sections that reflect the presentation of the case studies in the Consolidated key population guidelines– those that address critical enablers and those that illustrate different approaches to service delivery. Each case study provides a brief description of the programme, including the purpose, focus area and important elements of programme activities. Most of the case studies also note key successes and challenges, in some cases mentioning how challenges were addressed and/or resolved.

An asterisk (*) denotes case studies that also appeared in the guidelines document or in the technical briefs on young key populations.

2.1. Programmes addressing critical enablers

2.1.1. Men who have sex with men

Canada. Community engagement and risk reduction*
YouthCO HIV and Hep C Society – Mpowerment

http://www.youthco.org/mpowerment

Mpowerment targets young gay men through a community engagement model in which educational programming on HIV, sexual health and harm reduction is provided within a wider context of social events. This approach aims to support young men who have sex with men to think of themselves as part of a community, and to strengthen community norms for sexual health, coping with stigma, and risk reduction.

Social events provide a calmer environment than bars and clubs for young gay men to learn from each other and to form friendships. Events are publicized through social media, and between 10 and 20 men typically attend. Film viewings can be used as a springboard for discussion about community values and experiences. Alongside films, games and picnics, discussions are held on topics such as healthy relationships, experiences with shame, and HIV prevention. Through these events young men are invited to attend YouthCO workshops that support their education around HIV, safer sex and sexual wellbeing. Young gay men are the core organizers and leaders of all Mpowerment events, backed up by YouthCO staff members who are under 30 years of age.

The project has successfully reached hundreds of young gay men throughout British Columbia by empowering volunteers to become leaders within their own social networks. As the project also relies on staff to tap into their own social networks, it can be hard to maintain personal and professional boundaries, and YouthCO has found it important to support staff in their own self-care to avoid burnout. Mpowerment has also learned the importance of an accessible and youth-friendly community space (with condoms and lubricants freely available) where participants feel welcome and accepted.

2.1.2. People who inject drugs

Afghanistan. Improving acceptability of harm reduction services
National AIDS Control Program

http://www.nacp-moph.org

The National AIDS Control Programme (NACP) works at the national and local levels to increase community acceptance of harm reduction services for people who inject drugs.

The NACP aims to provide a comprehensive package of harm reduction and social services for people who inject drugs in Afghanistan. The programme runs a fixed facility in an area with a high concentration of injecting drug users, and supports an outreach team to serve the needs of the community in surrounding areas and to reach people who are reluctant to use formal services. However, stigma, discrimination, detention and police violence are major challenges to service delivery. At the central level, NACP meets with law enforcement officials and ministry representatives to increase awareness of the issues that people who inject drugs face, and to help them understand the importance of harm reduction for the injecting community as well as for society in general. In the provinces, NACP conducts training and sensitization for police officers, community elders and ‘mollahs’ (religious leaders). Actual service providers are involved in these events to improve engagement between local stakeholders and the harm reduction services. Stakeholders are also involved as much as possible in the planning and implementation of harm reduction services.

To date, NACP efforts have reached 8 of 34 provinces, and around 800 police officers have been trained; anecdotal reports indicate that harm reduction services appear to be better understood and accepted by communities in areas where NACP activities have taken place, and there are fewer reports of police harassment or violence. The high turnover in police departments, especially in the provinces, is an ongoing challenge that requires continuous work with those who are newly hired.

Nepal. Meaningful participation in advocacy for protection of rights*
Naya Goreto

http://www.nayagoreto.org.np

Recognizing the lack of specific laws or policies in Nepal to support people who inject drugs and the lack of services at the community level, Naya Goreto created Bridging the Gap: Health and Human Rights Programme for the Key Population. The programme aims to engage stakeholders across the spectrum, from parliamentarians to local councillors, public health officials to health volunteers, in advocacy on issues of concern to the community of people who inject drugs.

Naya Goreto emphasizes the meaningful participation of injecting drug users at all levels of the programme. More than 200 people from the community have been trained to lead activities ranging from situation analysis to advocacy campaigning and programme monitoring. The programme has brought together key stakeholders to establish a committee that lobbies for the health and human rights of people who inject drugs. Empowerment activities have included advocacy in small-group environments; forming advocacy networks for broader reach; linking people who inject drugs with experts and other concerned stakeholders for information on programmes and budgets; mobilization of community representatives to participate in consultation meetings with key government officials; lobbying duty bearers for the health and human rights of the injecting community.

Naya Goreto has built strong partnerships between people who inject drugs, creating a sense of solidarity to collectively address the issues that directly affect them. Such issues are now included in the yearly action plans of local government and civil society organizations. Annual budgets have been secured from local government bodies to conduct drug awareness programmes. A member of the injecting community now sits on the District AIDS Coordination Committee. Overall, there is greater community awareness of issues that affect people who inject drugs.

Portugal. Decriminalizing drug use*
Agência Piaget para o Desenvolvimento – GIRUBarcelos

http://www.apdes.pt/en/

As of 2012, 21 countries had taken steps to decriminalize drug use and possession.9 For example, Portugal changed its legislation in 2001 to turn possession of controlled drugs into an ‘administrative offence’—those caught with drugs for personal use are sent to a ‘dissuasion board’ rather than face prosecution and possible incarceration. An independent study10 examined the impact of the changes and found that:

  • The number of drug users in treatment expanded from 23,654 in 1998 to 38,532 in 2008.
  • Between 2000 and 2008 the annual number of new cases of HIV among drug users fell from 907 to 267, a decrease attributed to the expansion of harm reduction services.
  • Contrary to predictions, major increases in drug use did not take place; instead, evidence indicated reductions in problematic use, drug-related harms and overcrowding of the criminal justice system.

Community organizations continue to be essential to tackling stigma and discrimination and improving access to services. Agência Piaget para o Desenvolvimento, founded in 2004, works with vulnerable people and communities on access to health care, employment and education, seeking to empower these populations and reinforce social cohesion. They run GIRUBarcelos, a multidisciplinary outreach team working primarily with heroin and cocaine users and sex workers in northern Portugal, focusing their efforts on harm reduction. Through their efforts, discrimination towards people who use drugs, including by health-care professionals, has been reduced following regular meetings, mediation efforts between communities and service providers, debates and a local radio programme entitled ‘GIRU Conversations’. The presence of a peer educator on the team and the constant involvement of people who inject drugs are the cornerstones of programme interventions and considered critical to its success.

Romania. Building bridges: advocacy for community acceptance
CARUSEL – Roma Harm Reduction Advocacy Project

http://www.carusel.org

In 2012 CARUSEL developed an advocacy project to sensitize the National Agency for Roma (NAR) and other major Roma NGOs to the drug use situation in the community, especially regarding the vulnerability, stigma and discrimination that Roma drug users face. In order to build political will and commitment on these issues, CARUSEL recognized that community acceptance was the first step.

CARUSEL's advocacy strategy includes dissemination of key human rights and public health messages, trainings for sensitization and capacity building and field visits for data collection, outreach to community leaders and supervision of activities. Drug users themselves are involved in all project activities. A scholarship programme supports young people to attend the Roma Harm Reduction Summer School to develop outreach and harm reduction advocacy skills.

As a result of this work, NAR and other Roma NGOs are becoming more understanding of drug use in the Roma community, and there is greater acceptance of the users themselves. Roma NGOs are now providing financial assistance for CARUSEL to purchase harm reduction supplies and to provide technical expertise for reporting cases of human rights violations against all drug users. The needs of Roma drug users—including culturally appropriate harm reduction activities—are now addressed in the national strategy and action plans of the National Anti-drug Agency.

2.1.3. Sex workers

India. Addressing violence and legal literacy*
Karnataka Health Promotion Trust

http://www.khpt.org/

Karnataka Health Promotion Trust (KHPT) has been working on HIV prevention among sex workers for 10 years. Violence against the community served by KHPT is a particular concern, and addressing violence against sex workers requires partnership among like-minded organizations. When sex worker community members strongly expressed the need to prevent and address violence, KHPT responded by working closely with law enforcement and justice officials, sensitizing them to the realities faced by the community and to their needs for protection and services, while advocating that society's duty bearers not perpetrate or condone violence against sex workers. In partnership with KHPT:

  • The State's Women and Child Welfare Department made services addressing violence against women available to sex workers.
  • Community-based organizations worked with sex workers in 30 districts to alert them to their rights.
  • The Alternative Law Forum and the National Law School of India developed and conducted legal literacy training for sex workers.
  • The Centre for Advocacy and Research, a non-governmental organization, conducted media advocacy and trained sex workers as media spokespersons to talk about the violence they face, their resilience and their actions to prevent and respond to violence.
Latin America and the Caribbean. Regional collaboration for rights of sex workers
Red de Mujeres Trabajadores Sexuales de Latinoamérica y el Caribe (RedTraSex)

http://www.redtrasex.org

Red de Mujeres Trabajadores Sexuales de Latinoamérica y el Caribe (RedTraSex) is a regional network founded in 1997 by a group of national female sex worker organizations in Latin America and the Hispanic Caribbean for the defense and promotion of their rights. The network seeks the legal recognition of sex work; the elimination of social and institutional violence against female sex workers and the impunity that contributes to it; the repeal of legislation that criminalizes sex work; engagement with judicial and public civil servants to sensitize them to the problems of female sex workers; and participation of community members in spaces where decisions on issues that affect community are made.

Since 2012, RedTraSex has been working to reinforce the technical capacity and critical enablers that reduce the vulnerability of female sex workers to HIV through a regional strategy supported by the Global Fund. National organizations, led by female sex workers, coordinate activities within countries, while sub-regional units provide additional technical support as needed. Training of female sex workers strengthens knowledge and capacity for HIV prevention and increases the capacity of national partners for programme coordination, implementation, policy review and development, and review of the legal frameworks affecting the community. RedTraSex also works to ensure the participation of community members in the decision-making process, and to increase the awareness of strategic stakeholders, including law enforcement and health service providers, around gender issues and sex work. In addition, communication campaigns aim to influence public opinions around sex work and to reduce stigma, discrimination and violence. Partnerships with other organizations help to optimize the use of resources and to strengthen the overall impact of national and sub-regional efforts.

Monitoring and evaluation are conducted at the national and regional levels against country-specific baseline data that were collected in 2012. Impact of programme activities is measured in terms of female sex workers reached, contacted and trained as well as broader impacts on community attitudes, policy changes and legal reforms. Over 30,000 female sex workers from 14 countries have been reached by RedTraSex activities in 2013. However, stigmatization of the community and the lack of sex work regulations continue to fuel violence and police aggression. RedTraSex works to compel government accountability on these issues and to establish sex work regulations that will help to recognize and protect female sex workers throughout the region.

Tanzania. Income generation for young sex workers
Kimara Peer Educators and Health Promoters Trust Fund

http://142.177.80.139/kimara/

Kimara Peers, a community-based NGO, implements HIV prevention programmes in a low-income area of Dar es Salaam. Many programme participants are young adults (18–25 years) who sell sex. Kimara Peers also offers them the opportunity to take part in income-generating projects, which are seen by participants as a way to supplement their sex work income or to replace their source of income as they seek to transition from sex work.

Almost 1,000 programme participants have been involved since the initiatives were first offered in 2007. In groups of up to 30, young people learn about a variety of issues, including health, self-management and how to spend, invest or borrow wisely as individuals and as a group. Twenty-five sex workers volunteer as trainers for the groups. Groups who save together can take out small loans to finance other income-generating projects. Some programme participants work individually selling snacks, raising poultry, or working as hairdressers, while some income generation is done as a group. In either case, the young people work together on project design and other planning and they agree on how to manage the resources they have acquired.

All programme participants are expected to demonstrate a commitment to the group's goals and the ‘constitution’ that the group draws up for itself. They also participate in weekly meetings where progress is discussed and problems are addressed.

2.1.4. Transgender people

Kenya. Creating an environment for protecting transgender rights
Transgender Education and Advocacy

http://www.transgenderkenya.com

Transgender Education and Advocacy (TEA) aims to raise awareness and advocate for the human rights of transgender people, and to educate the community on sexual and reproductive health and risks.

TEA facilitates consultations between transgender people, their families, relevant stakeholders, duty bearers and service providers to increase understanding and tolerance of transgender people. TEA addresses the discrimination, abuse, social and legal exclusion and health issues faced by transgender people through legal and policy channels in order to reduce the incidence and prevalence of HIV and other diseases that affect this community and to support the specific needs of transgender people, such as gender reassignment. Some key advocacy goals have included:

  • Official recognition of transgender peoples' names and gender identity in national ID cards, passports and other official documents;
  • Preparation and implementation of a national guideline on gender reassignment that will facilitate inclusion of transgender health issues in mainstream health services;
  • Publication of objective, sensitive and accurate articles in the national media;
  • Anti-discrimination practices and policies.

To reinforce this advocacy work, TEA builds the capacity of transgender people to advocate for their rights, to take on leadership roles, and to confront the personal and structural challenges they face, particularly those within public health and social service settings. TEA also educates the transgender community on how to avoid social and sexual risks, to embrace healthier lifestyles and to forge stronger links with their families.

TEA interventions have helped to increase the self-confidence of transgender individuals to confront social and legal challenges and to reduce cases of sexual violence and exploitation, especially among transgender women. The Medical Practitioners and Dentists Board of Kenya is in the process of developing guidelines for gender reassignment, an effort supported by TEA advocacy activities. However, transphobia is still a major constraint to progress in many areas.

2.1.5. Programmes that serve more than 1 key population group

Asia/Africa. Training health providers on the needs of young key populations *
International HIV/AIDS Alliance – Link up

http://www.link-up.org

The Link Up project aims to improve the sexual and reproductive health and rights of young people living with and affected by HIV with a focus on increasing access for young key populations to integrated sexual and reproductive health and HIV services. The programme does this by linking peer educators and their clients with community- or clinic-based integrated services. The project is implemented in 5 countries—Bangladesh, Burundi, Ethiopia, Myanmar and Uganda—by a consortium of community-based and service-delivery organizations, led by the International HIV/AIDS Alliance.11

Consultations with young key populations identified stigma by service providers as one of the main barriers to accessing services. In response, Link Up implemented a 5-day training programme for service providers in each country, with the objective of sensitizing them to the needs of most-at-risk young people, and thereby decreasing stigma and increasing client satisfaction. Members of young key population communities were involved at the country level to review the training material. Topics included service integration and linkages, as well as gender, sexuality, stigma and discrimination. Young people participated in the trainings and helped lead different sessions, including a lively panel discussion where they shared their experiences. This particular session had a great impact on providers, all of whom had worked with young people, but not necessarily with young men who have sex with men or young people who sell sex. The participants learned that they must take time to hear and understand the experiences of young key populations, and they appreciated the opportunity to address any feelings of discomfort about working with them.

Link Up has organized further capacity building for peer educators, social workers, midwives, nurse counsellors and clinical officers. All of these trainings include components on youth participation and gender and sexuality to ensure that services are youth- and key population-friendly and non-stigmatizing.

Asia-Pacific. Leadership and advocacy training*
NewGen – Youth LEAD

http://www.youth-lead.orghttp://www.youth-lead.org

In 2011, Youth LEAD, a regional network of and for young key populations in 20 countries across Asia and the Pacific, created NewGen Asia, a five-day leadership course for YKP leaders. A technical working group, supported by young key populations, leaders of Youth LEAD, academic experts and UN partners developed the course over a period of a year.

The NewGen curriculum uses a range of participatory activities to build capacity to understand the personal, familial, institutional, structural and cultural influences that lead to HIV vulnerability; improve personal leadership strengths and skills for teamwork; develop presentation and public speaking skills on sexual and reproductive health, HIV and related issues; and understand and use data and evidence to inform advocacy. More than 200 young key population members have participated in NewGen training in Bangladesh, Brunei Darussalam, Indonesia, Myanmar, Philippines and Sri Lanka. More than 50 trainers have been trained regionally, and NewGen courses are planned for Cambodia, China and Thailand.

All stages of programme development were evaluated through multiple methods, including rapid feedback through video interviews of consenting participants; focus group discussions; in-depth interviews; and pre- and post-course evaluations. The Indonesia National AIDS Commission has adopted NewGen to train peer educators nationwide, and the International HIV/AIDS Alliance has integrated the training into its Link Up programme for young key populations on sexual and reproductive health. New community networks of young key populations have since been established in several countries, including Myanmar, and social media are used to sustain connections and support for participants.

Asia-Pacific. Addressing stigma through an awareness campaign*
Youth Voices Count – Loud and Proud

http://www.youthvoicescount.org

Loud and Proud is a regional advocacy campaign led by Youth Voices Count, addressing the issue of self-stigma and highlighting its links to the HIV vulnerabilities faced by young men who have sex with men and young transgender people in Asia.

Through the campaign, Youth Voices Count aimed to draw attention to the need for more timely services that tackle psychosocial issues and promote self-acceptance, self-confidence and health-seeking habits for young men who have sex with men and young transgender people. The campaign took place in four countries—Indonesia, Mongolia, Philippines and Viet Nam—and featured a series of in-country activities, community-friendly events and the production of four short videos. Loud and Proud built the capacity of young men who have sex with men and young transgender people to do advocacy using multimedia platforms and to leverage high-tech and social networks.

A core working group identified priority countries for the campaign and allocated a budget of approximately US $1,000, as well as a small amount of additional funding for community events and activities. The campaign was launched to coincide with the International Day against Homophobia and Transphobia. It was disseminated online using e-list servers and social media including Facebook, as well as through national partners. The videos were also displayed at a number of community events and international conferences.

Indonesia. Training for positive prevention
Australia Indonesia Partnership for HIV – HIV Cooperation Programme for Indonesia

http://aid.dfat.gov.au/countries/eastasia/indonesia/Pages/health-init3.aspx

The HIV Cooperation Programme for Indonesia (HCPI) supports training for positive prevention with the aim of empowering people living with HIV through improved self-esteem, confidence and ability to live healthier lives, with reduced exposure to infections for themselves and others.

HCPI supported the formation of a small collaborative team of seven people from national networks of people living with HIV and key populations formed to develop Positive Prevention facilitator training materials, based on their own experiences and knowledge. Positive Prevention facilitators are trained to incorporate the information and skills they learn into routine activities of existing peer support groups and NGO programmes. The materials target people who inject drugs and their partners; male, female and transgender sex workers and their partners; and men who buy sex and their partners. Four modules cover prevention of HIV and other sexually transmitted infections, disclosure of HIV status, adherence to antiretroviral treatment, and self-acceptance and coping with discrimination. External experts reviewed the modules, and they were field tested and launched in 2012.

Fifty-four people from 23 provinces—almost all of whom were key population community members—were trained using the four main modules as well as materials on sexual and reproductive health for people living with HIV and facilitation skills. Follow-up training for group facilitators and training of trainers for female sex workers was also conducted. Following a workshop for young members of key populations, the sex workers who had participated demonstrated increased knowledge and enthusiasm during regular peer support group meetings. They shared new knowledge with those who had not participated in the workshop, the information was correct and clearly explained, and they were able to articulate Positive Prevention concepts and principles. They demonstrated a higher comfort level speaking in front of others, and there was a greater sense of solidarity and empathy among the group.

A series of advocacy and socialization meetings with a broad range of stakeholders was also critical for support and integration of Positive Prevention in the national programme through the efforts of the National AIDS Commission. The training modules will need to be revised based on implementation experience and integrated into the next National Strategy and Action Plan. Results of facilitator training evaluations showed that all learning and skills indicators had improved significantly. A simple survey for assessing post-training behavioural and attitudinal change has been developed and will be distributed by the networks nationally in early 2014.

Indonesia. Engagement of young key populations on HIV and SRH*
Fokus Muda – Indonesian Young Key Affected Population Forum

https://www.facebook.com/FokusMuda ; http://fokusmuda.wordpress.com/

Fokus Muda promotes the meaningful involvement of young key populations in the HIV and broader sexual health and rights response in Indonesia. The programme brings together young people aged 15–27 years for advocacy, capacity building and technical assistance, and to help them be effective leaders in representing young people's issues and securing rights for themselves.

To develop an advocacy toolkit for use by young key populations at the local level, the programme conducted extensive consultations and capacity building with young people who inject drugs, young people who sell sex, young men who have sex with men, young transgender people, and young people living with HIV from 11 provinces with high HIV prevalence. Capacity building sessions were held separately because of the differences between the profiles and interests of the various key populations. Each participant represented a local community-based organization and had been actively engaged with their community for at least one year. An additional national consultation meeting for young key population members was held.

Participants were encouraged to identify the issues of greatest concern for them. For young people who inject drugs for example, the issues were the lack of services specific to their needs and relevant harm-reduction programming. Outcomes and recommendations from the consultations were fed back to the participants and to other stakeholders, and formed part of the data used in advocacy about the government's 2015-2019 National Strategic Plan on AIDS.

Uruguay. A national dialogue supports legislative change*
HIV Law Commission

http://www.hivlawcommission.org

In 2010 the United Nations Development Programme (UNDP) launched the Global Commission on HIV and the Law to develop actionable, evidence-based recommendations for a response to HIV that protects and promotes the human rights of people living with HIV, and who are more vulnerable to HIV. The Commission's work focuses on generating constructive dialogues between civil societies and governments on issues related to HIV and the law, going beyond identifying problems to develop and share practical solutions.

In Uruguay a national inter-sectoral commission was organized by the Ministry of Health, the Ministry of Social Development, trade union organizations, the National Council for HIV/AIDS Response (CONASIDA), the Federation of Sexual Diversity and the Parliamentarian Commissioner for Prisons. This commission called for a national dialogue on HIV and human rights to harmonize and improve national legislation related to the HIV response. Conducted with the strong support of the UNDP Regional Office, UNFPA and UNAIDS, the two-month initiative provided an opportunity for people affected by and vulnerable to HIV to present evidence on issues that have been silenced by restrictive legal environments. Individuals and civil society organization presented almost three-dozen cases of human rights violations. Those involved: HIV-related issues of sexual orientation and gender identity; discrimination in health services, employment and education; sex work; police brutality; access to treatment; intellectual property; and the human rights of people living with HIV.

This national dialogue contributed to the development of a new, comprehensive HIV law. The final report of the dialogue, presented to parliament in May 2014, identifies gaps in legislation, laws detrimental to the HIV response and negligence in applying laws that would promote the response. In addition, it suggests best practices and makes recommendations from a human rights perspective. Advocacy and mobilization of civil society and lesbian, gay, bisexual and transgender groups have driven this dialogue, along with the concerted efforts and the partnerships of UN agencies, government and academia.

The CONASIDA Country Coordinating Mechanism will implement and follow up the main recommendations from the dialogue to support the HIV Law Project. Additionally, the recently developed National Institute on Human Rights in Uruguay, also affiliated with the dialogue, is now committed to advocating for and monitoring implementation of the updated laws.

USA. Support services for homeless LGBTQI youth*
MCCNY Homeless Youth Services

http://www.mccnycharities.org

The Metropolitan Community church of NY (MCCNY) Homeless Youth Services provides emergency housing each night for 14 lesbian, gay, bisexual, transgender, queer, or intersex (LGBTQI) young people aged 18–24 years. The programme is integrated with supportive services including HIV testing and counselling (HTC), mental health, medical care, syringe access, case management, anti-violence education and job training.

Services are developed through conversations with programme clients, who are considered the experts on their own experiences, and who understand the services they need. Staff attends a weekly ‘house meeting’ where clients talk about successes as well as gaps in services. Programmes are then developed in response to these conversations. For example, after transgender participants expressed a need for reliable, ongoing access to health services, the programme arranged for an on-site enroller to help them access benefits through the Medicaid programme. Transgender clients also expressed a need for hormone therapy, which led to a partnership with an HIV/AIDS coalition that takes referrals for hormone initiation and maintenance without waiting lists. Focus groups are conducted annually with programme participants to evaluate services. The clients are also encouraged to discuss programming needs with the executive director. Feedback is incorporated into programme monitoring and evaluation processes and reports.

In 2013, the programme assisted over 200 LGBTQI homeless youth to access transitional or long-term housing, and HTC and referrals were provided for 145 clients. Many former clients have returned to work with the programme as volunteers; some have become street outreach workers, volunteer nutrition advisors, facilitators for self-defense training, and even programme staff: the current HIV testing coordinator and case manager are former programme clients.

USA. Youth-led advocacy against discrimination*
Streetwise and Safe

http://www.streetwiseandsafe.org

Streetwise and Safe (SAS) builds and shares leadership, skills, knowledge and community among lesbian, gay, bisexual, transgender, queer and questioning (LGBTQQ) youth of colour aged 16 to 24 years who experience criminalization, including youth who are—or are perceived to be—involved in selling sex. Many of these young people have experienced homelessness or are currently homeless, and many of them have sold sex for the things they need to survive.

SAS youth leaders conduct ‘know your rights’ workshops specifically tailored to LGBTQQ youth to share essential information about their legal rights as well as strategies to increase safety and reduce the harms of interactions with police and the court system. SAS also creates opportunities for youth to participate in policy discussions, speak out on their own behalf, and act collectively for their rights. SAS has been a leader in a campaign to end the discriminatory use of ‘stop and frisk’ procedures and other police misconduct. SAS youth testified before local and state government and successfully lobbied for changes to the New York City Police Department Patrol Guide to address violations of the rights of transgender and gender non-conforming people.

Currently, SAS is campaigning as part of the Access to Condoms Coalition to end the use of condoms as evidence in all laws penalizing the sale of sex under the New York Penal Law. Condoms found by police during stop and frisk encounters are sometimes confiscated or used as evidence for charges related to the sale of sex or trafficking. This practice particularly affects youth who are homeless or without a stable place to live. As a result of SAS advocacy, in May 2014 the New York City Police Department announced that it would discontinue the use of condoms as evidence in certain of these offenses, although SAS wants to see more far-reaching policy changes. As an SAS campaign staff member points out, “Police and courts are never an appropriate solution for youth who are selling sex, let alone police practices that put youth at risk for HIV, STIs and unwanted pregnancies.”12

2.2. Approaches to service delivery

2.2.1. Men who have sex with men

Ghana. Using social media to reach men who have sex with men*
SHARPER (Strengthening HIV/AIDS Response Partnership with Evidence-based Results)

http://www.fhi360.org/projects/strengthening-hivaids-response-partnership-evidenced-based-results-sharper

The SHARPER project tested use of social media by community liaison officers (CLOs) to identify unreached men who have sex with men. The project launched ‘MSM.net’ in two locations, through informal mapping of the community's networks. CLOs were selected from networks not previously reached by peer educators, and they received training on HIV, health information and services. The men were then reached by CLOs through social media using smart phones and laptop computers. ‘Reached’ is defined as receiving a risk assessment, information on HIV prevention and a referral to HIV testing and counselling (or another HIV service).

In 2013 more than 15,000 men who have sex with men were reached through Facebook (45.6%), WhatsApp (13.4%) and other social media platforms. In Accra 82% of the men reached by this approach had not had previous contact with a peer educator. In Kumasi 66% had never been reached before by any intervention. The CLO in Accra identified eight male sex worker brothels and networks previously unknown to the project and other organizations that serve the MSM community.

Social media proved to be an important means to reach the community that peer educators would not usually reach. This group tended to be older, more educated, single, have a higher monthly income, and (in Accra) to report a larger social network of men who have sex with men than those reached by peer educators. Key challenges included the selection of the ‘right’ community members to lead social media outreach, i.e. individuals who were already well networked with many entry points to the target communities.

Malawi. HTC services for men who have sex with men
Centre for the Development of People

http://www.cedepmw.org

The Centre for the Development of People (CEDEP) was established in 2006 to address the needs and challenges of minority populations in Malawi in the context of human rights, health and social development. One of their projects aims to provide services that are friendly to men who have sex with men in an environment where homophobia and criminalization of same sex practices marginalize the community, resulting in poor access to services.

CEDEP peer educators identify and mobilize men who have sex with men through the snowballing technique. During outreach activities, they provide accurate HIV prevention information, distribute condoms and lubricants and provide referrals for cases that require a professional health provider and facility-based services. In addition, peer educators promote safer sex practices and support empowerment and self-efficacy to combat ‘self-stigma’.13 Sensitization of health service providers and other key stakeholders helps to improve access to HIV services, as well as the quality of those services, for men who have sex with men. Advocating for both a public health and human rights approach to the delivery of health services for community members enables health providers to understand the importance of non-discriminatory services. Men who have sex with men in the CEDEP target area report that stronger linkages with health providers have reduced stigma, and the use of peers has proven effective in mobilizing the community.

As of August 2014, CEDEP has trained 80 peer educators to work with the MSM community; this has led to greater mobilization of a previously hidden group of people and increased partnership with vital health services. CEDEP has supported the development of IEC materials in collaboration with peer educators, ensuring the appropriateness and effectiveness of information and messages. During CEDEP-facilitated focus group discussions, men who have sex with men have demonstrated strengthened confidence and capacity for activism, demanding information and increased access to services that address their specific needs, such as condom-compatible lubricants. More community members are now visiting the health facilities to access services, and health-care workers provide quantitative feedback through the peer educators on referrals and uptake of services.

Nigeria. HIV prevention, care and support
The Initiative for Equal Rights

http://www.initiative4equality.org

The Initiative for Equal Rights (TIER) was established in 2006 as a response to the discrimination and marginalization of lesbian, gay, bisexual and transgender people in Nigeria, especially regarding access to health services. One of TIER's projects is the Integrated MARPs14 HIV Prevention Programme (IMHIPP)15 with a priority focus on men who have sex with men. IMHIPP seeks to reduce the impact of HIV on men who have sex with men, their sexual partners and their dependents by ensuring the provision of HIV prevention, care and support services in a legally constrained environment.

IMHIPP uses advocacy, communication and capacity building to address the needs of the community. Advocacy with key stakeholders promotes a better understanding of the human rights and needs of men who have sex with men and their families. Social media and community outreach are used to disseminate HIV information and education to the MSM and broader communities. Some men who have sex with men are selected for training in mentorship to serve as peer educators and supporters. To support uptake of services, referrals are made to pre-screened services with sensitive and knowledgeable providers who understand the needs and issues facing men who have sex with men; when individuals are uncomfortable seeking services alone, IMHIPP offers accompanied visits to health facilities. For MSM community members with AIDS-related illnesses, IMHIPP-trained providers deliver palliative care. Monthly field visits monitor the accuracy of prevention messages that clients are receiving. Field data are validated through telephone calls to verify that clients understand a minimum of three HIV prevention strategies.

Over 50 volunteers have been trained as peer educators, and over 5,000 members of the MSM community living with HIV have received HIV information and services, including ART and psychosocial support. An impact evaluation survey conducted in 2013 revealed that 73% of men who have sex with men reached through IMHIPP services reported correct and consistent use of condoms from November 2012 to April 2013 compared to 43% at the inception of the programme in 2009. Passage of the Same-Sex Marriage (Prohibition) Act in 2013 has prevented information dissemination and MSM community gatherings, resulting in the temporary suspension of some IMHIPP activities. This legislation is also likely to have caused a drop in the minimum number of clients reached each month from 250 to 80. As an initial response to this situation, TIER has added safety and security tips—e.g. avoiding the risks of cyber dating and secluded social venues; minimizing vulnerability to blackmail, extortion and arrest; and emergency hotline numbers—to its trainings and outreach events.

Philippines. Mobile outreach to young men who have sex with men
Re-You – Cebu Plus Association

https://www.facebook.com/re.you.9

In 2012, 41% of reported cases of HIV in the metropolitan area of Cebu, Philippines, were among young people. In response, Cebu Plus Association created a youth wing, Re-You, which runs Responsible Youth-on-the-Move, a community-based mobile education programme offering education and voluntary counselling and testing for HIV and other STI to young key populations. The great majority of those served are young men who have sex with men (aged 15–24 years).

Supported by Youth LEAD through the Robert Carr Civil Society Networks Fund, the programme uses a minivan to reach different locations within the metropolitan area and provide young people with services on the spot. Outreach areas include cruising sites and other places where young men who have sex with men gather. Services are usually offered at night, when community members are out and about and easier to contact. Outreach staff are themselves young MSM community members.

Some of the challenges faced by the programme include the cultural stigma associated with seeking professional help, and concerns about confidentiality. This has been addressed by securing referral agreements with HIV-proficient physicians and social workers at government clinics and other health-service providers. Re-You observed that most young men who have sex with men lack knowledge about available services, especially for STI management, while others were afraid to take an HIV test, doubting their ability to cope with a positive diagnosis. Re-You works to gain their trust by emphasizing that testing is voluntary and offering referrals to support services.

Russia. Anonymous counselling in a constraining environment*
menZDRAV – Positive Life

http://www.menzdrav.org

In partnership with the NGO Phoenix PLUS, the menZDRAV Foundation offers services to young men who have sex with men who are living with HIV, ages 18–25, in six regions of the Russian Federation. As many young men are reluctant to attend support groups for fear that their sexual orientation or HIV status will be publicly identified, the Positive Life programme offers individual counselling via phone, social media and Skype.

In each of six cities, peer counsellors maintain a telephone hotline with a publicized number. Counselling is also offered via Skype, and young men can send questions to counsellors via email, Facebook, Vkontakte or via a counsellor's profile on gay-oriented web sites. Counsellors offer callers information on sexuality, safe sex, STIs, adherence to ART, ARV side effects and disclosure of HIV status to sexual partners. Callers are also informed about project services and encouraged to visit the project office for assessments or referrals. Those who are reluctant to visit for fear of being identified can be referred to one of 20 medical specialists across the six regions that have been trained and sensitized to the specific needs of men who have sex with men who are living with HIV, and who will provide services without stigma or discrimination. There are about 80 trained peer counsellors, both project staff members and volunteers. All Positive Life counsellors take part in a centralized training. They receive further training and supervision at the project's regional offices as well as from central office staff that travel to the regions.

Since the start of the project in 2012, around 3000 MSM community members living with HIV received informational materials, and around 15,000 individuals are regular users of the programme website. In 2013 Positive Life counsellors provided almost 1900 phone consultations and 1350 online consultations.

South Africa. Expanding competence to serve men who have sex with men*
Anova Health Institute – Health4Men

http://www.anovahealth.co.za

The Health4Men project addresses men's diverse sexual health needs, particularly those of vulnerable and marginalized groups including men who have sex with men. The project's goal is to institutionalize competence in serving the MSM community in existing public clinics. The process involves:

  • Sensitization, to change attitudes;
  • Medical training to expand knowledge;
  • Mentoring to translate knowledge into skill;
  • Ongoing technical support, including consultation, training and mentoring and provision of educational materials.

Under the leadership of the Anova Health Institute, Health4Men has developed two Centres of Excellence for men who have sex with men, in Cape Town and Johannesburg each supported by satellite clinics. The clinics provide services for the MSM community, while outreach activities stimulate demand for services.

Health4Men has developed innovative training content and materials to equip nurses, counsellors and medical officers to respond to the special needs of men who have sex with men in a sensitive and empathic manner. In partnership with provincial departments of health, the project establishes at least one Regional Leadership Site in each province to serve as the hub for competency development; nurse mentors and outreach teams operate from these sites. As of mid-2014, over 3000 health workers have been trained, 584 clinicians have been mentored and 64 clinics in four provinces have been declared medically competent to serve men who have sex with men. By the end of 2014, there will be over 120 competent sites across six provinces and, by the end of 2015, over 160 sites nationally.

South Africa. Increasing access, coverage and quality of services
MOSAIC Men's Health Initiative

http://icap.columbia.edu

In 2012, ICAP at Columbia University in South Africa launched the MOSAIC Men's Health Initiative to increase access, coverage and quality of HIV prevention services for men who have sex with men.

The programme supports MSM organizations to develop peer-led outreach and community-based HIV prevention activities. A complementary capacity building programme sensitizes health-care workers to the needs of men who have sex with men; those providers then form the programme's referral network. Communities of practice including governmental agencies, civil society and MSM community organizations have been established to guide and lead the efforts. Peer outreach workers were recruited and trained on evidence-based HIV prevention interventions including use of HIV post-exposure prophylaxis (PEP). In addition, clinicians received training to bolster their knowledge and skills around MSM-related health issues, followed by on-the-job mentorship. MOSAIC offers a package of services that includes HIV counselling and testing (through mobile services, couples testing and home-based testing), STI diagnosis and treatment, substance abuse treatment, mental health services, male and female condom distribution, PEP, and linkage of HIV-infected men who have sex with men to HIV care and treatment programmes.

Since the inception of the programme, 13,980 men who have sex with men have received HIV prevention services, 2,010 health-care workers have received sensitization training, 269 clinicians have received clinical training, and 24 health facilities are being provided with ongoing mentorship. Anecdotal evidence suggests that the MSM community has become more aware of the availability of PEP. MOSAIC activities are implemented in line with plans that are linked to an M&E framework that specifies various indicators and targets; ongoing monitoring allows for performance appraisal and addressing gaps and challenges. The programme has demonstrated that local engagement platforms, such as communities of practice, can be used to increase coordination, and therefore, effectiveness of MSM-focused programming. Partnerships between stakeholders, MSM peer workers and the MSM community as well as sensitized and skilled health-care workers can overcome the barriers to the provision and accessibility of relevant HIV prevention services for men who have sex with men.

Spain. Community-based HIV and STI detection centre*
BCN Checkpoint – Projecte dels NOMS-Hispanosida

http://www.bcncheckpoint.com/

BCN Checkpoint is a community-based detection centre in the gay district of Barcelona that provides HIV, STI and sexual health services for men who have sex with men. Managed by the NGO Projecte dels NOMS-Hispanosida, BCN Checkpoint offers free rapid HIV and syphilis testing by peers, vaccination against hepatitis A and B, referrals and promotion of sexual health.

For those with HIV-positive results, the programme offers immediate peer support and information (by trained, HIV-positive peer counsellors) and referral within one week to the hospital's HIV treatment unit. To ensure linkage to care, all recently diagnosed individuals are followed through a register. To encourage annual repeat HIV testing, BCN Checkpoint uses email, text messages and telephone reminders.

Between 2007 and 2013 the programme performed over 22,000 HIV tests, detecting 756 new infections. Currently, nearly 90% of clients are linked directly to care, while 5% find their own care, and about 4% are in Barcelona only temporarily and obtain care in their home countries. Less than 2% of clients are lost to follow-up.

Thailand. Online channel to increase uptake of services*
Thai Red Cross – Men's Health Clinic

http://en.trcarc.org , http://www.adamslove.org

The Men's Health Clinic in Bangkok provides comprehensive and friendly services to men who have sex with men. One of the clinic's tools to increase uptake of HTC is the first bilingual (Thai/English) ‘edutainment’ website for men who have sex with men (http://adamslove.org), launched in 2011.

The purpose of the website is to encourage regular HIV testing for men who have sex with men. To link website visitors to HTC services, a section titled ‘HIV Testing Site Near You’ offers information about how to obtain HTC at sites that are friendly to men who have sex with men in Bangkok and in other provinces. Other means of continuous demand creation for HTC services include mass media and targeted media activities such as regular columns in gay magazines, peer-driven interventions and celebrity meet-and-greet HIV testing events.

The number of clients who have obtained HTC services has increased almost fivefold, from 967 in 2008 to 4371 in 2012. The Adam's Love website attracted more than 500,000 visitors in two years and has its own Facebook page as well, with more than 15,000 fans. Twenty-five per cent of Men's Health Clinic clients report seeking HTC services because of the site.

2.2.2. People who inject drugs

India. Community distribution of naloxone*
Social Awareness Service Organization

http://www.sasoimphal.org

Since 2000, the Social Awareness Service Organization (SASO) in Manipur has provided, among other services, opioid overdose management with free naloxone, through outreach (e.g. at shooting sites) and at drop-in centres. Through small meetings, individual contacts and counselling, SASO also provides information and education about drug overdose and its management to people who inject drugs and their family members.

The programme was scaled up and strengthened in 2008–09 to ensure wider coverage by involving key stakeholders to facilitate community distribution of naloxone. Ethical concerns about non-medical staff dispensing a medication to people who inject drugs have been overcome through demonstration of the life-saving nature of overdose management. Between 2004 and 2012 more than 450 overdoses were managed at five centres, and over 90% of those lives were saved. In addition, more than one-third of overdose clients have increased access to drug treatment and other health care, such as HIV/HCV testing and ART.

Indonesia. HIV prevention for PWID
Australia Indonesia Partnership for HIV – HIV Cooperation Programme for Indonesia

http://aid.dfat.gov.au/countries/eastasia/indonesia/Pages/health-init3.aspx

HIV Cooperation Programme for Indonesia (HCPI) provides comprehensive HIV prevention and harm reduction for people who inject drugs.

Building links with and support for government health services is an essential part of the prevention model supported by HCPI, especially with regard to health services that operate at a community level. This approach facilitates access to early HIV testing and treatment, basic health care, methadone maintenance treatment (MMT), needle and syringe programmes, sexual and reproductive health services, and other services as required. Programme activities are implemented through partnerships that maximize the comparative advantages of community-based organizations (CBO) and government structures. CBOs are ideally positioned to conduct critical outreach in hotspots during peak activity periods, encouraging uptake of harm reduction services and providing condoms, prevention information and referrals to services. Linked closely with this work, public health centres and hospitals deliver therapeutic and preventive services such as MMT and NSP services, which are delivered along with safe injecting advice. Strong partnerships with the police, the National Narcotics Board, Ministry of Social Affairs and the justice system provide further engagement with key stakeholders and duty bearers.

Spreadsheet data of programme activities are provided by all partners on a monthly basis. Partners conduct an annual behavioural and client satisfaction survey of programme participants that uses an anonymous self-administered questionnaire in addition to questions about having had an HIV test, serostatus and satisfaction with CBO and health services.

In 2013, HCPI supported 18 CBOs in eight provinces to provide services to over 14,000 clients; 6,000 clients also obtained services at 103 HCPI-supported government health centres (Puskesmas) and four government hospitals. Needle and syringe sharing has decreased progressively, with 85% of people who inject drugs reporting in 2010 that they had not shared in the previous week, and 91% in 2013.16 After initial reluctance, the MoH is now taking responsibility for NSP, but they still have to commit to the funding for the millions of needles and syringes required by the programme annually. MoH increasingly provides most of the funding for MMT, ensuring its availability at a large number of government health services.

Kenya. HIV and SRHR services for female drug users
Muslim Education and Welfare Association

http://www.mewa.or.ke

The Muslim Education and Welfare Association (MEWA) provide HIV prevention services and treatment for drug dependence in Mombasa and Kilifi counties on the northern coast of Kenya. The project aims to improve access to HIV prevention by providing clean needles and syringes, treatment, care, and socio-economic support services, along with advocacy for opioid substitution therapy and for the human rights of key populations.

One program focus is reunification of female drug users (85% of whom live in the street) with their families as this can be very supportive of engagement and retention in care. The program also provides free meals—often an incentive for uptake of services—alongside harm reduction services. In addition, clients have access to free reproductive health and basic social services. For clients on ART and TB treatment, free accommodations are available to support treatment adherence. Entrepreneurship training and work placement opportunities are also offered to interested clients, as well as referrals to government agencies for access to micro-financing and job placement programmes. MEWA builds trust with their clients through consistent contact, strong referral systems to services not provided by the program and community-based mobile services. MEWA also provides support for children of people who use or inject drugs. In such cases, MEWA arranges for temporary custodial care and provides health, nutritional, material and psychosocial support for the child's care and education, while providing referrals for the parents to services that can support the improvement of parenting skills related to education, hygiene, health care and family planning.

Reunification with family has been achieved with half of MEWA's clients. Hotspot-based outreach services and individualized tracking have facilitated access to program interventions for over half of female drug users in the MEWA project area, increasing service coverage from 36% to 84%. Despite achievements, the program has also faced challenges. There has been resistance to needle and syringe services from the police force due to their perception that these promote drug use and crime, and current laws do not conform to new national guidelines and policies aimed at facilitating, promoting and improving service delivery to key populations. Through outreach, community dialogue and training workshops for police officials, MEWA is working to promote human rights, introduce policy changes and provide accurate information that dispels myths around harm reduction services. In addition, the physical presence of outreach workers in hotspots is helping to forge bonds between the community, law enforcement, people who inject drugs, and MEWA staff.

Lebanon. Scaling up harm reduction services
Soins Infirmiers et Développement Communautaire (SIDC) - Escale

http://www.sidc-lebanon.org

Soins Infirmiers et Développement Communautaire (SIDC) is a non-profit organization that has provided harm reduction services since 1996 and outreach interventions since 1999. Through comprehensive service delivery paired with outreach and advocacy, SIDC is working to scale up services, increase uptake among the community of drug users, and support retention in care.

The first drop-in center (DIC) in the Middle East for people who inject drugs, Escale, was launched in 2010 in Beirut. Escale offers a variety of harm reduction interventions including HTC, referral and support for needle and syringe programmes and opioid substitution therapy, as well as psychosocial and legal support. In parallel to service provision, Escale encourages parents to support OST for their children. Advocacy is undertaken to counter stigma and discrimination against users and to promote drug law reform and referral to support and treatment centres instead of prison. Escale works with the Middle East and North Africa Harm Reduction Association (MENAHRA) and other agencies to run training workshops for stakeholders and service providers in order to strengthen understanding and tolerance of the PWID community.

From 2010 to 2012, Escale reached around 1,600 people who inject drugs, the majority of whom were aged 20-35 years, and 17% of OST patients in the country are managed by Escale. However, OST is not free in Lebanon, and many people in the PWID community cannot afford to pay for the service. Recruitment and retention of NSP outreach workers has been a challenge—hotpots are difficult to access, injecting drug users fear the police when carrying syringes on their person, and many are reluctant to ask for help due to long-term alienation.

Mexico. Disseminating information through multiple channels*
Espolea, A.C. – Programa de Política de Drogas

http://www.espolea.org

Espolea, a youth-led organization in Mexico City, established a Drug Policy and Harm Reduction Programme in 2008. As part of their education activities, they use online and face-to-face channels of communication to provide practical, objective information about drugs and risk reduction to young people aged 15–29 years.

The organization has found that information is most effective when disseminated at places where young people use drugs, particularly electronic dance music festivals, rock concerts and cultural gatherings. Espolea sets up a stand as a safe space where young people can access information about drugs that may be consumed at these events. The materials reflect a pragmatic and realistic approach, emphasizing the risks, harms and recommendations for less harmful practices. The organization also facilitates workshops in schools and in communities where there are concentrations of most-at-risk young people. Espolea implements an active outreach strategy through social media, including Facebook and Twitter, and they maintain blogs on a variety of programmes and topics. One blog (http://www.universodelasdrogas.org) serves as a databank on drugs and drug use; it has become the axis of the programme's harm reduction campaign. Information is produced by staff and collaborators, and by other young actors in the region. Printed materials that are attractive to young people are also a part of outreach; those provide useful information and recommendations about nightlife, alcohol consumption, risky sexual behaviours, HIV and other STIs.

There remains a lack of political will to address these issues openly and with sensitivity due to continued stigma around drug use. Espolea seeks to address these negative attitudes through sensitizing, evidence-based publications (available on the website) and workshops with key stakeholders and policymakers that promote internationally accepted standards and practices. Through this work, Espolea hopes to see the needs and preferences of young people reflected in policy and governmental action.

Pakistan. Increasing access to services
Nai Zindagi Trust

http://www.naizindagi.org

The Nai Zindagi Trust has been providing comprehensive and evidence-based services to street-based people who inject drugs, their wives, sexual partners and children in selected districts of Pakistan for 25 years. They work in cooperation and collaboration with the public health-care system to avoid creating parallel services, and 60% of services are provided by Nai Zindagi partner organizations.

The main principle of Nai Zindagi work has been the involvement of PWID community members in programme design, implementation, evaluation and re-design to adjust to changing needs and trends—30–40% of outreach workers and field supervisors are former injectors. The programme prioritizes outreach over facility-based service delivery approaches. Comprehensive harm reduction (including needle and syringe programmes, and excluding opioid substitution therapy)17, HIV and STI prevention, diagnosis, treatment, care and support services are offered, as well as a residential 2-month ART adherence program for people who inject drugs who are living with HIV. Access to skills training and employment for clients is also available. HTC and diagnostics (CD4) services have been expanded using point-of-care technologies. A real time management information system monitors service delivery and trends in order to adapt programme interventions to actual needs.

Over 600 individuals have been trained to provide a range of comprehensive services since the inception of current programme activities in 2012. Consistent and expanded outreach has supported harm reduction services for approximately 13,000 street-based people who inject drugs. Inclusion of sexual partners and children has been a significant intervention for prevention. Staff from four new organizations have been trained to provide services related to drug use and HIV. District AIDS Councils have been established in selected districts to reduce stigma and engage government and the public sector in order to facilitate access to health, social welfare and HIV-related services for Nai Zindagi clients.

Human resources are an ongoing challenge for the programme, along with the continued stigma, discrimination and harassment of people who inject drugs, including from law enforcement, which discourages uptake of services in the public sector. Nai Zindagi is currently sharing experiences and technical information with programmes in Nepal, Indonesia and Kenya.

Tanzania. Scaling up harm reduction services*
Médecins du Monde (MdM)

http://www.medecinsdumonde.org

Médecins du Monde in Tanzania (MdM) provides comprehensive harm reduction services for people who use drugs, with special attention to women and to the critical enablers that facilitate uptake of services and consistent engagement with care.

Comprehensive harm reduction services provided by MdM include needle and syringe programmes and referral to opioid substitution therapy, as well as income-generating activities and referral to legal services. More broadly, MdM is involved in building the capacity of non-governmental and community-based organizations to run harm reduction services, especially drop-in centres with a range of support and services, including NSP. In addition, MdM encourages the establishment of dedicated centres and shelters for women, with additional health and support services offered for their children. The programme has supported the creation of national and district-level harm reduction committees with representation from governmental and non-governmental institutions, which take responsibility for resource mobilization among other activities. A continuous dialogue with municipal, district and national authorities and sensitization sessions for police, health providers and journalists have been important elements of the work. Partnership with all members of society is considered essential for scaling up harm reduction throughout the country.

Since 2011 more than 6000 people who use and/or inject drugs have received harm reduction services and in 2013 more than 2000 stakeholders were trained in harm reduction approaches and interventions. The establishment of the Tanzania Network of People Who Use Drugs and audiovisual training for peer educators support empowerment and advocacy activities.

Ukraine. Advanced strategies to increase coverage of interventions
International HIV/AIDS Alliance in Ukraine

http://www.aidsalliance.org.ua/

Since 2000 Ukrainian NGOs led by the International HIV/AIDS Alliance have provided essential harm reduction services, which reached up to 23% of the estimated population of people who inject drugs by 2007. Further scale-up included interventions that have been effective in bringing new clients to prevention and care services.

In 2007 the Alliance introduced Peer Driven Intervention (PDI), an advanced approach to outreach that uses the strength of social networks of PWID through incentive-based chain-referral recruitment and peer education. This methodology extended harm reduction services to underserved groups of people who inject drugs such as women and adolescents. PDI incorporates research component and collects data required to tailor services to specific sub-populations. PDI is also used to reach sex workers and street children.

In recent years new clients have been brought into the programme by shifting from individual to group level work, as well as working with couples that use drugs. Group-level interventions facilitated establishment and maintenance of contacts with many young people who use stimulants, while couples counselling assisted in reaching out to sexual partners of people who inject drugs.

In addition to NGO-based stationary points, pharmacies have been involved as secondary outlets for distribution of injecting instruments, other prevention commodities, and information for PWID community members who are reluctant to contact specialized harm reduction services. In certain parts of Ukraine involvement of pharmacies allowed the programme to increase overall coverage by as much as 10% within a year of introduction. The introduction of rapid HIV testing in community settings and a case management approach allows for earlier identification and linkage of those in need of HIV care. This has significantly reduced the time between HIV acquisition and treatment enrolment.

Application of these strategies has helped to improve harm reduction coverage, to extend services to different sub-populations of people who inject drugs and to meet their specific needs. The overall coverage of HIV prevention programmes in Ukraine, which includes harm reduction services for the PWID community and access to rapid testing for HIV, HCV and HBV, has now exceeded 60% of the estimated PWID population, and a significant reduction in the number of new HIV cases (from 771 cases in 2007 to 212 in 2013) has been observed among people who inject drugs aged 24 and younger.

Ukraine. Gender-sensitive HIV services
Women for Women – UNODC

http://www.unodc.org/unodc/en/

The Women for Women initiative was developed to provide gender-sensitive HIV and harm reduction services for women who inject drugs, female partners of people who inject drugs and female ex-prisoners. The programme, initially piloted with the support of UNODC, was handed over to the municipal services in November 2013.

Six local NGOs that provide harm reduction services were awarded grants to incorporate gender-sensitivity into their services in order to provide comprehensive HIV and harm reduction services. These services include a wide range of tailored services for vulnerable women beyond standard harm reduction services such as gender-based violence prevention (including counselling for male sexual partners), legal assistance, child care, hygiene and food supplies, shelter, self-esteem skills building and job placement. Peer involvement is important to the delivery of many of these services, while linkages have also been established with local government clinics and social services. Women for Women helped to establish an ongoing dialogue between civil society organizations and local administrative structures that contributes to the sustainability of such services.

Training for the NGO staff as well as some government representatives included a study tour to Vienna to familiarize participants with the day-to-day running of HIV and harm reduction services for women and workshops on how to develop these services. Participants also received capacity building in outreach techniques, leadership and empowerment, advocacy, and fundraising.

Over the project grant period (2011–2012), 2036 women received services through the programme. The involvement of municipal service providers in harm reduction services for women in their own communities has helped to reduce stigmatization and discrimination. The challenge of financial sustainability is addressed by incorporating the programme activities into local service delivery structures; intensive training ensures that those NGO and government providers have the advocacy, management and fundraising skills needed for long-term sustainability of the services.

Vietnam. Decentralization facilitates earlier access to HIV services*
Vietnam Authority of HIV/AIDS Control, Ministry of Health and WHO Vietnam

http://www.vaac.gov.vn/

In 2012 the Vietnam Authority of HIV/AIDS Control in the Ministry of Health started pilot-testing a project to expand earlier access to HIV services for key populations, particularly for people who inject drugs, thus maximizing the therapeutic and preventive benefits of ART by enabling people to start treatment as soon as possible. The pilot project involved decentralizing HTC services from district facilities to commune health stations in Dien Bien and Can Tho provinces. The pilot project introduced such innovations as a fixed dose combination ARV formulation, point-of-care HIV and CD4 testing, and decentralized follow-up. The project actively engaged community partners, including peer educators, self-support groups and village health-care workers, providing them with community mobilization trainings and holding regular meetings to discuss outreach activities and challenges. Commune health station staff received training on HIV service delivery, including HIV testing using rapid tests, pre- and post-test counselling, adherence support, basic care and dispensing ARV drugs.

This decentralized, community-based model has been shown to promote earlier diagnosis and treatment. People diagnosed at communes have significantly higher median CD4 counts when starting ART (median 294 cells/mm3) than those diagnosed at district facilities (median 88 cells/mm3). Community outreach and building trust are recognized as critical to facilitating earlier access to HIV services among people who inject drugs.

2.2.3. People in prison or confined settings

Afghanistan. Harm reduction for female prisoners who inject drugs
Afghan Family Guidance Association

http://www.afga.org.af

Recognizing the acute risks faced by people in prisons and other closed settings, the Afghan Family Guidance Association (AFGA) provides comprehensive HIV prevention, treatment and care services for female prisoners, with a particular focus on harm reduction for female injecting and non-injecting drug users in prison settings.

Around 13% of the people who use drugs in Afghanistan are women, 18.8% of whom were living with HIV in 2010. AFGA undertakes advocacy through monthly meetings and other awareness-raising events with government, legislative bodies, prison staff and law enforcement to promote gender sensitivity and rights-based programme approaches to reduce stigma and discrimination toward female injectors. As part of the programme, support groups for female prisoners have been established and peer educators for people who inject drugs have been trained in harm reduction approaches. As there are no health facilities or health staff on prison premises, AGFA has facilitated, since 2008, close coordination between the Ministry of Public Health, prison officials and the Ministry of Counter Narcotics to ensure that vital health services are available to female prisoners, and to identify injecting drug users in order to provide appropriate harm reduction services to them.

AGFA coordination activities have resulted in significant improvements in the prison health care delivery system and strengthening of the referral network for female prisoners, including those who inject drugs.

Albania. Using incentives to increase uptake of harm reduction services*
STOP AIDS

http://www.facebook.com/stopaids.albania

STOP AIDS, an NGO in Tirana, implemented an incentives programme with a group of young people who inject drugs to assess whether small incentives could motivate reduction in higher-risk behaviours associated with drug use, and increase alternative or less risky behaviours. These included getting clean needles and returning used ones, being tested for HIV, bringing new clients to the programme, and allowing home visits by STOP AIDS staff.

For six months, vouchers and coupons were used as incentives, redeemable for a variety of retail goods such as pre-paid phone cards, food, fuel, clothing and haircuts. Vouchers were accumulated in a clinic-managed bank account and distributed to clients once a week. The standard reward for participants ranged from 1 point (equivalent to US $1) for receiving harm-reduction kits, to 5 points for those who introduced a new client to the programme.

The programme was successful in significantly improving clients' attendance and uptake of some harm-reduction services, especially NSP, HIV and hepatitis testing and introducing new clients and sexual and injecting female partners to the programme, compared to a control group who did not participate in the programme. More than half of the clients introduced programme staff to their family members and allowed home visits or counselling. However, voucher incentives seemed less effective for changing certain behaviours such as returning used needles, switching from injecting to non-injecting behaviours or adherence to opioid substitution therapy. Further study is needed to determine the sustainability of health-seeking behaviour change through incentives.

Indonesia. Methadone maintenance treatment in prison*
Australia Indonesia Partnership for HIV (AIPH) – HIV Cooperation Program for Indonesia (HCPI)

http://aid.dfat.gov.au/countries/eastasia/indonesia/Pages/health-init3.aspx

Methadone maintenance treatment for incarcerated injecting drug users was pilot-tested in Kerobokan Prison, Bali, in 2005 after prison officials visited MMT programmes in Australian prisons. Accomplishments of the Kerobokan Prison pilot project include:

  • Establishment of comprehensive harm reduction services (including MMT) and high levels of participation among prisoners with opioid dependence.
  • The scaling-up of MMT, education and care, support and treatment services in 11 other prisons, detention centres and parole services; Kerobokan prison provides ongoing mentoring to many of these facilities.
  • High levels of integration with other community health services in Bali, ensuring smooth transition from prison to community MMT programmes (and vice versa) and early or continuing access to HIV treatment

Additionally, HIV testing and treatment now have been efficiently implemented in many prisons. More than 90% of high-risk prisoners have been tested, and a high proportion of those testing positive have begun ART.

As part of mainstreaming this initiative, in 2013 the Ministry of Health (MoH) and the General Directorate of Corrections signed a memorandum of understanding that the MOH would fully cover the cost of methadone. HCPI continues to provide training and limited financial support.

Iran. Methadone maintenance treatment as HIV prevention
National OST Programme of the National AIDS Control programme

http://www.menahra.org/en/

Iran has a concentrated HIV epidemic largely driven by injecting drug use. In 1996 an outbreak of HIV among people who inject drugs in prisons resulted in advocacy efforts targeting government, community and religious leaders for a policy shift from a zero-tolerance approach to harm reduction. The main harm reduction strategy used in Iran is opioid substitution therapy, mostly with methadone maintenance treatment.

There are an estimated 200,000 people who inject drugs in the country. By February 2014, 4275 drug treatment centres offered OST under the supervision of medical science universities, state welfare organizations or prison organizations. More than 95% of these centres are managed by private sector physicians. In 2013, approximately 480,000 opiate users (injecting and non-injecting) received MMT.18 The 2007 bio-behavioural surveillance survey revealed that among individuals who had injected opioids during the past year, 33% received MMT; this proportion rose to 42.6% in the next bio-behavioural survey of 2010. In addition, the number of opiate-dependent prisoners receiving MMT steadily increased from 100 in 2002 to more than 38,000 in 2011.19 It is likely that this programme, along with other harm reduction services provided to Iranian inmates, has contributed to a decrease in HIV prevalence in this population from 3.8% in 2002 to less than 1.3% in 2011.20

Ukraine. Ensuring access to HIV services in juvenile detention
All-Ukrainian Public Center Volunteer

http://www.volunteer.kiev.ua

All-Ukrainian Public Center Volunteer runs a programme that provides access to critical HIV prevention services for adolescents in juvenile detention. The programme targets adolescents considered most at risk for HIV infection, with a focus on underage individuals registered with law enforcement authorities and those who are incarcerated in juvenile detention centres.

One Volunteer intervention involves capacity building of providers who are working with vulnerable and confined adolescents to increase understanding of and sensitivity to their particular needs, to strengthen communication skills with this age group and to improve referral to appropriate services. A significant area of success was the introduction of courses for working with vulnerable adolescents in conflict with the law into the professional development training plan for the Bila Tserkva Academy of the Criminal Executive Service of Ukraine. To date, 1300 specialists have been trained, including psychologists from juvenile correctional and detention centres and criminal-executive inspectors (probation officers/staff) from all regions of the country.

Provider concerns about testing children under the age of 14 (the age of consent in Ukraine) were addressed through consultations with health managers and providers. However, legislative change to address age-related restrictions to services is problematic during political instability.

2.2.4. Sex workers

Cambodia. A branded approach to HIV services for sex workers
SMARTgirl

http://blog.usaid.gov/2012/07/smartgirl-empowers-women-in-cambodia

SMARTgirl, a national HIV programme, originally developed by FHI 360, aims to prevent and mitigate the impact of HIV and improve the sexual and reproductive health of the estimated 35,000 entertainment workers nationwide, many of whom are sex workers; among some groups of entertainment workers, HIV prevalence is as high as 14%.

SMARTgirl is a branded HIV prevention and SRH programme that seeks to create loyalty, to provide easy access to referrals and to be recognized as a source of trustworthy information delivered through trained peers. Through individual and group-level outreach, SMARTgirl peers provide HIV prevention information, commodities and referrals. Some locations also benefit from mobile STI screening and HIV testing services as well as family planning services. Recognizing the overlapping risks of many entertainment workers, SMARTgirl also supports harm reduction approaches including counselling and linkages to methadone maintenance treatment and needle and syringe programmes for entertainment workers who inject drugs. Since 2009, SMARTgirl has also been working to reduce stigma and discrimination by giving entertainment workers a voice at the national and local level through its health and social network.

SMARTgirl reaches nearly half of all entertainment workers in Cambodia in their workplaces. The programme's health and social network now have approximately 10,000 members. In the year up to March 2012, 15,680 SWs received services, a coverage of 92% of the targeted group.

Ghana. Peer-led outreach with young women who sell sex*
FHI360, SHARPER project (Strengthening HIV/AIDS Response Partnership with Evidence-based Results)

http://www.fhi360.org/projects/strengthening-hivaids-response-partnership-evidenced-based-results-sharper

To strengthen outreach to young women selling sex in Accra, the SHARPER project, through local implementing partners, recruited young female sex workers who were considered leaders within their peer group to work as peer educators in order to increase uptake of services and engagement in care.

Selected individuals took part in a 1-week training, followed by weekly supportive supervision meetings and monthly reviews with programme staff to discuss implementation challenges. Peer educators were paired with older women in the community, known as ‘peer protectors’, who provided them with guidance and support in handling difficult situations, making referrals and in planning their futures. Peer educators received a monthly stipend to cover transport and communication costs. Microplans helped peer educators to focus on priority issues and needs faced by young people selling sex. These included negotiation skills for safer sex, family-planning services and commodities such as male and female condoms and water-based lubricant, and referrals to HIV testing and counselling, STI and other sexual and reproductive health services. Information and services were also provided in relation to preventing and addressing violence, whether by intimate partners, clients or the police.

Each peer educator worked with 10–15 young female sex workers each month. A significant challenge was the frequently chaotic and highly mobile lives of young female sex workers in Accra, which made regular contact difficult. In response, the programme offered peer-accompanied referrals to services and established linkages with other organizations that could provide critical support, for example in cases of human rights abuses and sexual violence, child care and parenting skills-building, nutritional support for young children and enrolment in the national health insurance scheme. In addition, the frequency of supportive supervision was increased from once to twice weekly.

Kenya. Community-based HIV and STI services
Sex Workers Outreach Programme – Nairobi, Kenya

http://swopke.blogspot.com

Affiliated with the University of Manitoba/University of Nairobi, the Sex Workers Outreach Programme (SWOP) promotes the health, safety and wellbeing of sex workers in Nairobi County and affirms their occupational and human rights. There are an estimated 30,000 sex workers in the project area, and the programme has grown from 3 to 9 service sites since 2008.

Working closely with the National AIDS and STI Control Programme (NASCOP) of the Ministry of Health, SWOP uses peer-led, hotspot-based mobilization and outreach services to provide acceptable and friendly HIV and STI prevention and care services to sex workers. Seven sites serve sex workers, and two facilities provide services to HIV-infected family members, friends and clients of sex workers. All clinics provide a comprehensive HIV prevention and treatment package and offer cervical cancer screening. Community members participate in decisions about where to locate service sites, with discretion and acceptability in mind. The outreach team coordinates and implements activities with a peer support team. Programme services, which include behavioural, biomedical and structural interventions, are free and adhere to national guidelines. Periodic trainings and performance reviews of peer leaders enhance the quality of services. As sex work is illegal in Kenya, linkages and partnerships with other organizations and government agencies working with key populations is critical.

In 2013, SWOP outreach activities made 103,000 (initial and repeat) contacts with sex workers, and HIV testing and counselling services were provided with 31,000 tests (initial and repeat) conducted. Strong peer networks and sharing of data between clinics through a virtual private network (VPN) helps reduce problems caused by the mobility of sex workers. SWOP has been instrumental in establishing clinical guidelines for the syndromic treatment of STIs, and syndromic management is now part of the NASCOP health policy. However, there are challenges in supporting men who have sex with men who are also sex workers as they suffer double stigma and considerable hostility and persecution in the community. A high HIV incidence of 10.9 per 100 person-years has been noted among these male sex workers and SWOP is working closely with NASCOP and other stakeholders to address their specific needs. Another challenge is attrition of trained peer educators who move to other programmes, and constant retraining is necessary.

Myanmar. Outreach to young people who sell sex*
AIDS Myanmar Association Country-wide Network of Sex Workers

http://www.nswp.org/members/asia-and-the-pacific/aids-myanmar-association-national-network-sex-work-projects-ama

AIDS Myanmar Association (AMA) is a network of more than 2,000 female, male and transgender people who sell sex. The programme focuses on capacity building and community mobilization to advocate for the health and human rights of the sex worker community.

Working within a restrictive political environment, members of AMA have had to find innovative ways of reaching out to young people who sell sex to provide peer support and access to information and services, particularly in relation to their health. AMA community mobilization workers are trained to be particularly sensitive to the needs of young people and do not ask for any identifying information, such as their real names or ages, when conducting outreach activities. They provide STI and HIV prevention tools and strategies, links to sex worker-friendly health facilities for testing and treatment, and follow-up counselling and care for young people who sell sex who are living with HIV. In a context of stigma and discrimination, young people who sell sex are often reluctant to access services for fear of arrest or disrespectful treatment by health-care professionals. Follow-up care takes place in a safe and supportive environment and focuses on support for adherence to treatment; community mobilization workers also offer to accompany young people to their clinic appointments. AMA also provides support to people who sell sex who are imprisoned, particularly ensuring that young people, who have often been abandoned by their families, are given nutritional support while in prison. Upon release from prison, AMA works to reconnect young people with their families and friends to ease the transition back into the community.

Philippines. Contacting hard-to-reach males who sell sex*
River of Life initiative (ROLi)

http://www.projectpage.info/my-river-of-life

ROLi is an HIV risk reduction programme that uses a self-assessment toolkit, workshops and peer group work to help adolescent males who have sex with men assess and reduce their risk behaviours as individuals and groups, using the support of their peers and service-providers. The programme serves 6,000 young people in the Philippines, the majority of whom are males aged 13–17 years. Approximately 80% are out of school and 90% live in poverty. Almost all of them sell sex and use drugs, and almost all identify as straight (heterosexual).

Because young males who sell sex are highly stigmatized and difficult to reach, the programme uses several channels for outreach on a peer-to-peer basis. One-on-one interactions and group activities take place through contact with young people in their communities, including on the street and in areas where men seek sex with young males. They are given the opportunity to take a risk self-assessment on the spot, or to sign up for a workshop held at a partner health facility. Peer outreach workers also do outreach online through SMS text messaging and through private chats with members of their social and peer networks.

Programme participants can join Facebook groups for moderated peer-to-peer discussions about behaviour change. In addition, peer groups organize campaigns showcasing inspiring stories of change through forums, film viewings and discussions, and awareness-building activities take place around village fiestas, festivals, World AIDS Day and anti-drugs events. Government-run clinics that partner with ROLi also provide one-on-one counselling and other services. The ROLi programme has been adapted to serve other young key populations, including females who sell sex and young people who inject drugs.

South Africa. Mobile outreach to female sex workers*
Re-Action! Consulting

http://www.re-action.co.za

In conjunction with the Department of Health, Re-Action! runs a programme that aims to reduce new HIV infections among female sex workers and their clients in two rural districts of Mpumalanga Province. The programme also seeks to reduce the vulnerability of female sex workers to violence, exploitation, substance abuse and social exclusion through life skills mentoring for the women along with sensitization and outreach for the community and other stakeholders.

A nursing team runs a mobile clinic that offers free services including health risk screening, counselling and testing (including point-of-care CD4 testing); HIV treatment and care; and referral to other health and social services. To encourage retention in care, the team visits clients at least twice per week, at locations and times convenient to the women. A 28-day calendar helps to inform the FSW community when they might need emergency services and where they can obtain them. Nurses are trained in initiation and management of ART; if needed, most services, including ART and support for adherence to treatment, can be provided in clients' workplaces. When clients default on treatment, outreach workers provide assistance, support and follow-up as required. To ensure confidentiality, outreach workers from outside the clients' communities are assigned to provide HTC and referral services.

Re-Action! has reached about 4100 female sex workers with services. Client satisfaction is high, and the programme's low default rate of 2.3% is largely attributed to women moving elsewhere. Female sex workers report increased knowledge of the legal system and their basic rights and they are more aware of other organizations that provide support and services for sex workers. Nurses have overcome the security risks of working at night by building a good rapport with the local police force and with those who control the brothels.

USA. Separate, peer-led services for sex workers
St. James Infirmary

http://www.stjamesinfirmary.org

St. James Infirmary, located in San Francisco, USA is run by and for current and former sex workers, offers free, confidential and non-judgmental medical and social services. Services provided by the programme include primary medical care, HIV and STI testing, peer counselling, hormone therapy, acupuncture, massage, support groups, needle exchange and Narcan (naloxone) trainings. Services are supported by the Department of Public Health, private donations and foundation support.

The programme was developed to respond to the criminalization and stigma that sex workers experience, often resulting in inadequate or prejudicial healthcare, to the extent that many people will avoid seeking care in response to negative experiences. A peer-based, non-judgmental environment was created based on harm reduction principles so that sex workers are welcomed into a space where they can be honest about their lives and their needs. By prioritizing positive patient-provider dynamics, the clinic promotes and demonstrates an understanding of healthcare as a collaborative process that empowers as it heals. Many participants are referred from other medical establishments, social service organizations and prison programmes. Outreach and supply distribution is undertaken at strip clubs, commercial sex venues, massage parlours, and in the street. In 2011 a media campaign was organized to raise awareness of sex workers' rights.

Since 1999, over 3,500 clients have accessed care and community space at the clinic, with an additional 30,000 contacts made with sex workers through St. James outreach and needle exchange; many clients have only accessed healthcare in emergency settings previously, and they express an unwillingness to seek services that are not specifically identified as serving the sex worker and/or transgender communities. Over 1,000 copies of a resource guide—covering sex work, harm reduction and transgender issues—have been distributed to community members and have been used as a training tool for service providers. Yearly evaluations are conducted using participant surveys and staff interviews.

Zimbabwe. Comprehensive services for HIV prevention*
Centre for Sexual Health and HIV/AIDS Research – Sisters with a Voice

http://www.ceshhar.co.zw

Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe runs the Sisters with a Voice programme, which provides integrated services for sex workers in multiple sites across Zimbabwe on behalf of the National AIDS Council. Collaboration with key government ministries (AIDS, Health, and Social Welfare) and the involvement of sex workers in implementation have contributed greatly to the programme's successes.

Supported by a network of peer educators trained in participatory community mobilization and empowerment, the programme offers HTC, syndromic STI treatment, contraceptives, health education and legal advice. Cervical screening is being rolled out; nurses are being trained in visual inspection and treatment of pre-cancerous lesions using cryotherapy. Peer educators run community mobilization sessions that cover issues that concern sex workers (self-worth, behaviour change, contraception, HIV and cervical cancer), issues relating to clients and partners (communication, assertiveness, serodiscordance, sexual networks and multiple concurrent partnering) and issues relating to the ‘sisterhood’ (advocacy, stigma, rights and support).

Since 2009 the programme has expanded from 5 sites to a national network of 36 sites (6 fixed facilities and 30 outreach sites). By 2013 the programme had served more than 14,000 women. Moreover, at a site where two population-based surveys were conducted, the proportion of HIV-negative women who reported having a recent HIV test increased from 35% in 2011 to more than 70% in 2013. Over the same period, the proportion of women living with HIV who were obtaining ART increased from 28% to 45%.

2.2.5. Transgender people

Dominican Republic. Increasing access to services for transgender sex workers
La Comunidad de Trans-Travestis Trabajadores Sexuales Dominicana

http://www.cotravetd.blogspot.com; http://www.focusright.org

The Community of Dominican Transgender and Transvestite Sex Workers (COTRAVETD) is a sex worker-led collective formed in 2002 that prioritizes the issues and needs of transgender and transvestite sex workers, who face significant discrimination, abuse and detention in Dominican society, and whose rights are routinely violated.21

COTRAVETD provides human rights-based training for peer educators who engage with sex workers, gay and transgender people, and men who have sex with men. Peer educators provide information and support for a wide range of skills, services and referrals that address the sexual health needs of the community. They also help to build solidarity and trust between transgender sex workers through a support group that brings together younger transgender women with older and more experienced transgender women. In 2012, COTRAVETD piloted a sexual health approach to peer education, training 12 peer educators in principles of sex positivity (i.e. the view that sexual expression is essentially good and healthy), self-determination, autonomy and fairness. The personal nature of this approach helps peer educators to understand the complexity of their lives and the psycho-social and structural risks of HIV, and in turn, fosters outreach which goes beyond negative, disease-focused messages.

COTRAVETD interventions have significantly strengthened the capacity of peer educators and volunteers to address the needs of transgender and transvestite sex workers for appropriate services and referrals. COTRAVETD has also participated in a national consultation on sex work and broken down barriers of discrimination and misunderstanding by doing 12 radio and television interviews. With nearly 1300 sex workers reached through peer education, a reported increase in solidarity amongst sex workers and a reported increase in uptake of mobile clinic services it is clear that COTRAVETD approaches are effective.

Ecuador. Healthy transitions for young transgender people*
Silueta X Association

http://www.redsilutax.wordpress.com/la-institucion/

Faced with the absence of an integral health policy covering the specific needs of the transgender population, and a lack of experienced and specialized health-care providers, the Silueta X Association started a programme to promote health among young transgender people and to prevent the health risks involved in non-professional feminizing hormone regimens.

A participative process was followed to design a project to meet demand for information regarding transition. Because doctors and nurses in the public-health sector would not facilitate workshops at times when transgender community members were available, the project used a private-sector doctor and an Ecuadorean endocrinology specialist based in Chile to train the Association activists and the target group. Around 160 young transgender people aged 15–29 years benefited directly. Existing peer communication was the main strategy to spread the word about the programme, via invitations on social networks and other virtual communication channels. This allowed the project to identify a new generation of potential users of feminizing hormone regimens.

Education on the risks of feminizing hormone regimens is still needed, including with other transgender organizations in Ecuador. After project funding ended, Silueta X continued to incorporate information on proper feminizing hormone regimens as part of its training for those involved in HIV prevention, as well as in recreational and social events, such as beauty pageants.

USA. Creating a welcoming environment for young transgender people*
Callen-Lorde Community Health Center – Health Outreach To Teens

http://www.callen-lorde.org/our-services/hott/

The Health Outreach to Teens programme (HOTT) in New York City serves lesbian, gay, bisexual, transgender and queer (LGBTQ) adolescents, homeless or unstably housed youth, and those living with HIV, through an on-site medical suite and a mobile medical unit. HOTT provides acute and primary care, mental-health services, HIV testing, case management and health education.

Around 11% of the 1,100 young people receiving services in 2013 identified as transgender, many of them being of colour, homeless or at risk of homelessness, and facing other psychosocial stressors. To engage and support these youth, the programme provides a trans-affirming environment, free care, and rapid access to appointments. HOTT staff also monitor risks and resiliencies, and connect clients to preventative services that emphasize a harm reduction approach.

To provide a trans-affirming environment, all HOTT staff (medical providers, nurses, case managers and HIV test providers), many of whom identify as members of the LGBT community, are trained in transgender-competent service provision. Trans-inclusive programme literature and health education materials are available. Providers use a harm reduction, trauma-informed approach to care, show clients how to manage transphobia in multiple environments (e.g. in workplace and correctional settings), and teach them self-harm prevention strategies. HOTT's weekly transgender women's support group, ‘The Girls Room’, successfully engages this hard-to-reach population and provides a safe space to explore and support transition. A Youth Advisory Board and The Girls Room provide feedback on transgender services, and annual clinic-wide surveys evaluate services.

USA. Capacity building for transgender community services*
Center of Excellence for Transgender Health – University of California, San Francisco

http://www.transhealth.UCSF.edu

The mission of the Center of Excellence for Transgender Health is to increase access to comprehensive, effective and affirming health-care services for transgender and gender-variant communities. The ultimate goal is to improve the overall health and wellbeing of transgender people by developing and implementing programmes in response to community-identified needs. Core faculty and staff with diverse backgrounds and experience offer programmes informed by a national advisory board of 14 trans-identified leaders from throughout the United States of America.

The projects of the Center of Excellence address a wide range of health issues for transgender people. One activity is developing guidelines on a range of primary care topics, including primary and preventive care, hormone therapy, mental health, youth and surgery. Protocols have been published online (http://Transhealth.UCSF.edu/protocols). In addition, the Transitions Project helps build the capacity of community-based organizations to adapt, implement and evaluate evidence-based HIV prevention interventions for transgender communities.

USA. Comprehensive transgender services in a community-based clinic*
Community Healthcare Network

http://www.chnnyc.org/

The Transgender Family Program was established in 2004 at the Community Healthcare Network (CHN) clinics in New York City to improve access to HIV prevention and linkages to primary health care. To understand how best to integrate comprehensive transgender services into a community health clinic, CHN undertook community mapping, consultations and forums and review of similar programmes. Importantly, the programme asked patients to form the Client Advisory Board to help guide integration and implementation of services for the transgender community.

Integrated services include transgender care, HTC, medical case management, support for treatment adherence, STI screening and treatment, prevention interventions and mental health and nutritional services. In addition, the programme provides risk reduction counselling, support groups, outreach, bilingual educational workshops and referrals to legal and social services. Recruitment strategies of staff members and trained peer leaders include face-to-face contacts, community-based activities and online methods including advertising and social media tools. Clients are encouraged to engage family members. This has proved to be an important strategy to encourage access and attendance.

Over 750 people have received transgender-specific services. Identified benefits of integrated transgender services include:

  • Improved tolerance and long-term acceptance of, and sensitivity to this population in the broader community;
  • Improved accessibility through convenient location of services;
  • Flexible hours as a result of extended service capacity;
  • Increased access to a range of in-house support services.

In addition, in-depth evaluation has found significant decreases in sex work, needle sharing and unregulated hormone injections, and increased likelihood of regular condom use.

2.2.6. Programmes that serve more than 1 key population group

Albania. Health and human rights for young key populations
Aksion Plus

http://www.aksionplus.net

Founded in 1992, Aksion Plus was the first youth NGO to address HIV through education of youth and awareness raising activities for the general population. The programme now supports health and human rights interventions in 6 cities for young people who inject drugs, young sex workers and young members of the LGBT community.

Aksion Plus provides direct services and referrals for HIV and other STI services, as well as the provision of opioid substitution therapy, including to young people in prisons and closed settings. Since 2000, Aksion Plus outreach workers also provide a needle and syringe programme along with condom distribution. Through information, education, life skills, counselling and capacity building Aksion Plus aims to empower young key populations. The participation of young members of key populations as peer educators has been identified as essential to ensuring the success of the interventions. Additionally, outreach workers are critical for creating and reinforcing the link between the YKP community and Aksion Plus while providing condoms, information materials, counselling and referrals. The programme also provides harm reduction training for other NGOs and government bodies specifically focusing on the needs of young people.

Belgium. Using social media for demand creation
Boysproject

http://www.boysproject.be , http://www.info4escorts.be

Boysproject is a social organization for male and transgender sex workers in and around Antwerp, Belgium. Boysproject uses social media to create demand for social and medical services and to provide information and referrals to services.

To reach their target group, Boysproject, hosts an online forum specifically for male and transgender sex workers. The site offers information and chat boxes where individuals can ask questions and receive answers about sexual health and other related issues. Boysproject also provides a drop-in centre each Wednesday afternoon that is advertised online and via SMS; along with services and referrals from a social worker and a doctor, the drop-in centre offers a Dutch language course, a space for conversation, sharing experiences and food. Boysproject also works with the Institute of Tropical Medicine to provide HIV post-exposure prophylaxis, which is not well known by the sex worker community. Social workers play an important role in informing and accompanying individuals through the PEP process.

Boysproject services reached 298 sex workers (165 were new contacts) in 2013, up from 229 (140 new contacts) in 2012. Around 1,130 invitations to the drop-in centre were sent out via social media in 2013, and 15–30 sex workers attend the Wednesday drop-in centre each week.

Central America. Increasing access to HIV services for key populations
PASMO/PSI – Combination Prevention Program for HIV in Central America

http://www.asociacionpasmo.org

The overall objective of the PASMO/PSI Combination Prevention Program is to increase access to HIV prevention interventions for key populations in six Central American countries.

The programme seeks to reduce prevalence of high risk behaviors; decrease hostility in social environments that foment and tolerate homophobia, stigma and discrimination; increase access to a minimum package of essential prevention and health services; and strengthen strategic information through research and monitoring. A comprehensive package of interventions is provided for each target population under each of the three combination prevention components: behavioral, biomedical, and structural. The minimum package of services includes participation in at least three behavior change communication interventions, referrals to screening and treatment of STIs and opportunistic infections, as well as referrals to medical care and referrals to structural services such as family planning, stigma and discrimination support groups, legal support and treatment for alcohol and drug abuse. These services are provided through close coordination with a diverse set of partners including, Ministries of Health, donors, local NGOs, private laboratories and public and private clinics. Hostility and discrimination are addressed through sensitization and training of health providers, community mobilization and sensitization of the media for accurate and balanced reporting on HIV and key populations. Methods used to reach key populations include mapping hot zones through existing databases and filed visits; ‘sweeping the zones’ activities in which all partners travel to hot zones to ensure that targeted KP communities have access to all the combination prevention interventions; and use of technology.

A total of 78,547 individuals have been reached since the start of the programme. Furthermore after close coordination with key stakeholders and through technical assistance on the Combination Prevention strategy materials and methodology to NGOs, to the El Salvador Ministry of Health and to the Global Fund prime recipient for HIV programming in El Salvador, the Combination Prevention strategy and methodology were adopted in El Salvador at a national level. Turnover in government poses challenges to increasing momentum to strengthen HIV prevention programming for key populations, and increasing insecurity in Central American countries causes a high level of movement of key populations, making it difficult to ensure that follow-up services are provided.

EECA region. Collaborative client management
AID Foundation East-West

http://www.afew.org

AID Foundation East-West (AFEW) is an NGO currently working in Georgia, Kazakhstan, Kyrgyzstan, the Russian Federation, Tajikistan and Ukraine to reduce the impact of HIV on key population communities. Through client management initiatives, AFEW strengthens the capacities of local governmental, non-governmental and community providers, and supports coordination of local service provider networks and resources.

HIV client management is a collaborative process between the individual, the client manager, and local service providers aimed at improving access to appropriate and timely health and psycho-social care. Client managers assist individuals in assessing their specific needs and developing strategies to best address these needs. Due to high levels of discrimination against members of key population groups, clients are often accompanied to hospitals and government offices when seeking health, social or administrative services. Social workers and client managers usually come from key population communities; they are regularly trained on human rights issues, ethics and new approaches to working with target groups. AFEW regularly organizes national or regional workshops and other mass events for key populations to provide opportunities to share experiences and best practices.

Programme participants have noted improved collaboration and integration of services due to AFEW initiatives. The requirement of a local residency permit for access to services is a major obstacle to providing care to those from key populations. However, NGOs like AFEW have signed memoranda of understanding with local providers to ensure that those without local residency permits can access vital services.

Egypt. Peer-led SRH services for young key populations*
Egyptian Family Planning Association

http://www.efpa-eg.net/en/home.php

The Egyptian Family Planning Association (EFPA) uses outreach as an extension of its clinical services to engage with young people most at risk of acquiring HIV. Volunteer peer educators provide comprehensive, gender-sensitive, rights-based sexual and reproductive health education. Each clinic has two male and two female educators aged 18–25 years who are trained in comprehensive SRH education, HIV and other STIs, and communication skills; they are supervised by clinic staff and by an EPFA reproductive health officer and youth officer. Of the 56 EFPA educators, 30 have been trained to work specifically with young key populations, and some are themselves members of key populations.

The peer educators conduct outreach sessions with young people less than 18 years of age, primarily at government institutions for street children and orphanages. The sessions are offered at a location away from the clinic so that the participants do not appear to be seeking clinic services and to preserve confidentiality. The educators explain the services offered at the clinics, encourage the young people to attend and distribute condoms. Outreach is also done with members of young key populations who are not connected to specific institutions, such as truck and minibus drivers. In 2012, 81 peer-to-peer sessions reached almost 2,300 people, one-third of whom were men who have sex with men or young people who inject drugs. A youth committee meets on a quarterly basis to follow up with the implementation of the activities and to discuss obstacles and lessons learnt.

Parallel to this work, EFPA also endeavors to influence policy change that prioritizes the SRH needs of young people within the national health system.

India. Strengthening MSM, transgender and hijra community systems
Pehchan – India HIV/AIDS Alliance

http://www.allianceindia.org

India HIV/AIDS Alliance and consortium partners implement the Pehchan programme in 17 states with the aim of building and strengthening the capacity of 200 community-based organizations (CBOs) to provide HIV prevention programming to more than 450,000 men who have sex with men, transgender people and hijras (collectively, MTH).

Pehchan develops CBOs to serve as implementing partners with the National AIDS Control Programme, fosters community-friendly services within the health system, and engages in advocacy to improve the lives and wellbeing of MTH populations in India. The programme leverages and complements the government's HIV prevention strategy for MTH community members by providing a broad range of additional services that support an enabling environment that encourages healthy behaviors. Partnership with government is key to programming at national scale. Pehchan has filled critical gaps in community capacity necessary to support the government to achieve significant HIV prevention coverage for MTH populations. The active involvement of MTH community members as programme managers and technical advisors has also enabled Pehchan to rapidly build trust in environments that are often inhospitable and to create high levels of community ownership.

Societal attitudes against homosexuality remain significant in India and discourage MTH community members from accessing HIV and other health services. The re-criminalization of homosexuality in India in late 2013 has created additional resistance and led to further stigma, discrimination and violence. Pehchan has developed Crisis Response Teams that work rapidly with victims of violence to ensure that police and other authorities respond appropriately. The programme has also initiated a national advocacy campaign to support decriminalization of homosexuality. HIV stigma within MTH communities is another challenge, and the programme's outreach and counselling include efforts to reduce it.

Pehchan has coupled a coherent, comprehensive and sustained effort of capacity building and systems strengthening with effective community mobilization tied directly to HIV prevention services. The programme approaches that have worked can be adapted to other contexts and countries where sexual minority communities are underserved by HIV interventions.

Kenya. Peer-led, community-based service delivery
LVCT Health

http://www.lvcthealth.org

For men who have sex with men and sex workers, LVCT Health provides essential services outside of traditional delivery settings and schedules in order to overcome the barriers to services and to consistent engagement in care faced by these key populations.

LVCT Health work is peer-led and involves communities in meaningful ways at all stages of the programme cycle. In order to effectively target project interventions, hotspots were mapped with community leaders and service providers who were sensitized to the importance of non-judgmental and appropriate services for key populations. Focus group discussions and client exit interviews with participants from key population groups informed the concept and design of the innovative programme. Engagement with bar owners and staff supported buy-in from these key collaborators, leading to the availability of condoms and lubricants in convenient dispensers.

Clients who receive an HIV diagnosis through LVCT Health testing services are linked to treatment and care services. HIV risk factors, types of STI and HIV status are entered into a national database, and cohort data are analyzed for trends, such as HIV prevalence by geographic location. Female sex workers receive routine STI and cervical cancer screening using visual methods; immediate diagnosis is provided, and those with lesions are referred to specialized centres for further management Male sex workers are screened for STIs and other lesions and offered on site syndromic management and followed up in a facility setting.

LVCT Health reaches approximately 5,000 key population clients with HIV and sexual and reproductive health services every year, and over 80% of clients who are diagnosed HIV-positive are effectively linked to post-test services. LVCT Health has achieved above 85% retention in care and treatment for men who have sex with men and over 90% adherence to treatment (HAART). LVCT Health advocacy has led to the inclusion of key population issues in the HIV National Strategic Plan in Kenya, potentially opening the door to national scale-up of services. Consistent follow-up with this mobile population is done through telephone calls from counsellors and through a static site close to all hotspots for follow-up services or services between scheduled appointments. Collaboration with Ministry of Health and security agencies overcomes problems associated with providing services in insecure locations, ensuring the safety of staff and clients.

Kenya. Integrated drop-in centre services
National Organization of Peer Educators

http://www.nope.or.ke

The National Organization of Peer Educators (NOPE) provides sexual and reproductive health and social services in a wide variety of settings. NOPE developed the Drop-In Service Centre (DiSC) model as a ‘one-stop’ approach for delivery of essential HIV services for female sex workers and men who have sex with men in 7 locations in Kisii and Kiambu counties.

Consultations and focus group discussions with FSW and MSM community members identified service gaps; this was followed by social and hotspot mapping and population size estimations. Stakeholder meetings—including bar owners, police, provincial administrators, religious and community leaders, along with FSW and MSM community representatives—took place within identified hotspots to provide information about the project and to encourage community buy-in. Following focus groups discussions, female sex workers and men who have sex with men participated in the selection of DiSC locations. Peer educators were selected and trained on how to run a DiSC, including setting it up, using a client flowchart, the referral and network pathway and the minimum services package. NOPE worked with the District Health Management Team to source commodities and for quality assurance of services. NOPE follows a performance-monitoring plan aligned with the national AIDS strategic plan and PEPFAR Next Generation Indicators. Routine data quality assessments and audits, supervision visits, data sharing forums and project progress meetings all ensure that robust monitoring and evaluation mechanisms are in place.

DiSCs have served 20,000 individuals who identify as members of FSW or MSM communities. Based on their experiences with this model, NOPE has contributed to the national guidelines for key populations and led the development of the national MSM peer education curriculum. Technical assistance from NOPE has allowed other organizations, such as Ishtar MSM and Keeping Alive Societies' Hope, to assume responsibility for three of the DiSCs. One of the key lessons learned in establishing the DiSCs is that gaining the trust of key populations is imperative, especially in environments where laws and policies criminalize female sex workers and men who have sex with men for their behavior. While freestanding facilities are critical for key populations, sustainability will require integration of service delivery for these groups into the national health services as the communities and providers become more responsive to the needs of key populations. In the meantime, NOPE has successfully mobilized county health management teams to provide medical supplies and to second medical staff to DiSCs. Additionally, NOPE plans to partner with the private sector for eventual co-ownership of some of the DiSC sites.

Lebanon. Anonymous services and outreach for key populations*
Marsa Sexual Health Center

http://www.marsa.me

Marsa Sexual Health Centre (Marsa) in Beirut offers sexual and reproductive health services to the public in a welcoming environment free of stigma and discrimination against age, sex, gender and sexual orientation. The center targets young people, unmarried sexually active women, and marginalized communities with limited access to SRH services, including men who have sex with men and transgender people. Assuring clients of anonymity and confidentiality plays a key role in encouraging uptake of Marsa services. The center uses a unique file number for each client as a form of identification, and the client decides if they would like to provide further identifying information for their file. In addition, the staff of experienced and sensitized professionals is required to maintain confidentiality. Clients feel comfortable to open up to their care providers, disclose intimate details about their lifestyles and seek information from specialists, knowing that their identity will not be disclosed, even among staff members. Marsa does not advertise publicly; to share information about their services, the programme uses social media and the Internet, as well as street outreach campaigns and word-of-mouth.

Myanmar. Comprehensive harm reduction services
Médecins du Monde

http://www.medecinsdumonde.org

Médecins du Monde (MdM) implements a project focused on STI and HIV prevention, treatment, care and support along with other harm reduction interventions for female sex workers and men who have sex with men in the capital, Yangon, and for people who use drugs in Kachin State.

The programme strategy is based on the provision of a comprehensive set of high quality services provided free of charge at drop-in centres and clinics run directly by MdM. The programme was developed in close collaboration with the targeted key populations, with peers playing a crucial role not only participating in the activities but also in ensuring that the programme continues to meet their needs. A significant outreach component has been set up with social workers and peer educators in order to reach out to key populations in those locales where risky practices are taking place (e.g. place of work, sex establishments, injection sites, etc.). Provision of education, information and supplies helps to build trust and confidence; individuals can then decide if they want to visit the facilities where they can access more services. Strong relationships are also being built with local authorities to influence the operational framework and contribute to the adoption of evidence-based policies.

There has been a steady decrease of HIV prevalence among men who have sex with men, people who use drugs and sex workers in Myanmar in recent years. However, in the rural context, where the general population has very limited access to primary health care, offering a wide range of health services to people who use drugs only can be problematic. MdM has found that addressing the most basic health needs of the community, in addition to those of key populations, should be seriously considered when possible, in order to help strengthen programme acceptance and reduce resentment and misunderstandings. The greatest challenge will be to reinforce the emergence of local NGOs and other community-based groups so that most of the harm reduction effort, which currently depends on international NGOs, can be taken over by local organizations. Beyond service delivery, skills transfer and capacity building are becoming the priorities in Myanmar.

Pakistan. Community-based drop-in centres*
Naz Male Health Alliance

http://www.apcom.org/spotlight-naz-male-health-alliance-pakistan

Naz Male Health Alliance (NMHA) is a community-based organization in Pakistan addressing the health and psychosocial needs of young males who have sex with males22 and transgender people. As part of its ongoing work to empower these communities, the organization operates six service delivery centres in five cities, with 47,000 registered clients. Each site is divided into a clinic and a drop-in centre that provides a safe and relaxing atmosphere for low-income males who have sex with males and transgender clients. The centres are strategically located, close to hotspots for the MSM community and near concentrations of ‘hijra deras’ (dwellings of transsexual people). Drop-in centres and outreach activities are complementary; drop-in centres allow the establishment of long-term relationships with the clients, and outreach provides linkage to the drop-in centre. Service sites are separate for each key population group in order to effectively address their specific needs. Each centre has a multidisciplinary staff of around 15 people, including physicians who are STI specialists, a psychologist, and peer educators. The teams consist primarily of community members and more than 95% of staff are members of the MSM community and transgender people.

The Government of Pakistan has publicly stated that NMHA was responsible for a significant increase in newly registered HIV-positive males who have sex with males and transgender people in their public HIV treatment centres. NMHA makes special efforts to create strong linkages and partnerships with groups such as the National AIDS Control Programme, Rahnuma-Family Planning Association, the Asia-Pacific Coalition on Male Sexual Health, the Asia-Pacific Transgender Network and Youth Voices Count, along with other stakeholders.

South Africa. Training health-care workers to work with key populations*
South African National AIDS Council (SANAC) and the SA Department of Health (DoH)

http://www.health.gov.za/ , http://www.sanac.org.za/

Discriminatory attitudes of health-care providers towards people from key populations and “unfriendly” health facilities are barriers to access and uptake of services, contributing to poorer health outcomes.23 A multi-partner project led by SANAC and the DoH has developed an integrated approach to sensitize health-care providers on issues affecting key populations and to empower public health staff to interact appropriately (in terms of attitude and clinical expertise) with people from these communities. Trainings have been conducted in preparation for the implementation of the rollout of the National Operational Guidelines for HIV, STI and TB Programmes for Key Populations in South Africa. The full programme includes in-person training and mentoring.

Thirty trainers participated in an initial training of trainers workshop and were linked to local training centres and health facilities. In turn, they trained 420 health-care workers in six months. Where these trainings took place, people from key populations have reported improvements in health-care workers' attitudes. Community trust in health providers has increased, as has the use of health facilities where the sensitization training has been linked with peer outreach and the HIV prevention education activities of civil society organizations. Further evaluation is planned to inform scale-up.

Tanzania. Reaching young people through a drop-in centre*
Kimara Peer Educators and Health Promoters Trust Fund

http://142.177.80.139/kimara/

Kimara Peers, a community-based NGO, implements HIV prevention programmes in a low-income area of Dar es Salaam. Kimara opened 2 drop-in centres (DIC) near state-run health centres and dispensaries to provide outreach and services to people who use drugs (with a focus on injectors), including those aged 16–24 years. The DIC also serves young people who sell sex, as there is an overlap between the two populations.

The Kimara Peers staff at the DIC includes trained community outreach workers from the local area and a professional social worker. Outreach workers publicize DIC services when they are in the community as well as during larger public gatherings, such as for World Drug Day. Services offered at the DIC include individual and group psychosocial therapy and support, basic information on harm reduction, prevention of HIV and other STIs, condom use and prevention of viral hepatitis. Referrals are made for methadone-assisted therapy and treatment of STIs. Education and materials specially designed for young people on sexual and reproductive health, including HIV, are available. Referrals to government hospitals are made only with a young person's consent, and confidentiality is maintained unless the young person gives permission for their parents or other family members to be informed and/or involved. The programme is seeking government approval for provision of clean needles and syringes at the DIC and by outreach workers.

Thailand. Using ICT to reach young men who have sex with men and transgender people*
Save the Children Fund

www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.6234243/k.C392/HIVAIDS.htm

Save the Children uses information and communication technologies (ICT) to enhance HIV prevention outreach to young men who have sex with men and transgender people in Chiang Mai, Thailand. The city is a major destination for sex tourism and has large numbers of migrants from minority ethnic groups and from Myanmar. The project provides information on HIV prevention, treatment, care and support by tapping into social media most commonly used by the MSM community. These include Facebook, Line (a mobile phone application) and other websites and forums frequented by young men who have sex with men.

The project's research indicated that non-HIV related content such as personal grooming, religious instruction and topical news would be an effective way to engage young men who have sex with men and young transgender people. Content is devised by project staff based on discussions with volunteers and other members of the MSM community, and is changed regularly to keep it fresh and topical. Outreach workers promote Mplus Chat, an app developed by a local NGO working with MSM groups; the educators then use this to establish a relationship with the young men who have sex with men and young transgender people. The project provides outreach workers with tablet computers, which help to engage the attention of young members of MSM and TG communities and makes communication easier in noisier environments like bars and clubs. The tablet is used to show the project's website, provide content for discussion and to record contact details for later follow-up.

After initial contact is established, outreach workers continue to use ICT platforms to disseminate information on HIV prevention, treatment, care and support. Young men who have sex with men and young transgender people value continued online contact as a way to establish a trusting relationship with a counsellor while maintaining a degree of anonymity. This relationship enables outreach workers to promote accompanied referrals to free HIV testing.

USA. Low-threshold services for young key populations*
Test, Connect & Treat – AIDS Institute of the New York State Department of Health, Specialized Care Centers and Youth Access Program

http://www.health.ny.gov/diseases/aids/general/about/hlthcare.htm#specialized

The Test, Connect & Treat programme of the New York State Department of Health recruits high-risk adolescents and young adults (aged 13–24 years) for HIV testing. Young males who have sex with males are the population with the majority of new HIV diagnoses in the state. The programme emphasizes a broad range of low-threshold services. Those who are HIV-positive are immediately linked to care, while those who are HIV-negative are provided with risk reduction and prevention information and referrals to community services.

The programme is run through 14 Specialized Care Centres across the state, where multidisciplinary staff teams provide comprehensive and coordinated HIV and primary health care, mental health and supportive services on-site. Clinic services are made as accessible as possible through evening and/or weekend hours and walk-in appointments. Services are provided regardless of the young person's ability to pay, and those without health insurance are assisted to apply for benefits and enrol in a managed care plan. For those who have eligibility through their parents, providers work to ensure services are confidential. If a young person tests positive for HIV, they are given a medical appointment and linked to a social worker and a medical case manager.

The programme has formed partnerships with youth-friendly clinical-care and social-services providers. Case management assessments focus on the young person's strengths and self-management skills, including his or her ability to attend medical appointments and adhere to treatment, which may be impeded by significant mental health, trauma and substance abuse issues. Case management has been found to be critical for adherence to treatment plans and positive health outcomes.

3. CONCLUSION

Around the world, in very different settings, hundreds of programmes are addressing the needs of key population communities who often live outside the reach of formal health and social welfare systems. They are working to ensure access to essential HIV and STI prevention, diagnosis, treatment and care that have been available to the general public for decades in many places. When faced by an array of social, legal and logistical constraints, programmes are developing innovative ways to reach and encourage uptake of services by individuals who are reluctant to expose themselves to the harassment, discrimination and legal consequences that often accompany delivery of health and social services.

The interventions featured in this compilation represent the leading edge of a new front in the response to HIV that recognizes the vital importance of critical enablers as well as innovation and courage when delivering services for key populations. While there are limitations inherent in presenting only a sample of case studies, and by limiting the length and content of the case studies, readers are encouraged to contact these programmes for more information and for inspiration to move this work forward.

ACKNOWLEDGMENTS

The development of this document would not have been possible without the help of the organizations that submitted case studies.

Afghan Family Guidance Association (Afghanistan), Agência Piaget para o Desenvolvimento – GIRUBarcelos (Portugal), AID Foundation East-West (Eastern European and Central Asian region), AIDS Myanmar Association Country-wide Network of Sex Workers (Myanmar), Aksion Plus (Albania), All-Ukrainian Public Center Volunteer (Ukraine), Anova Health Institute – Health4Men (South Africa), Australia Indonesia Partnership for HIV – HIV Cooperation Programme for Indonesia (Indonesia), Muslim Education and Welfare Association (Kenya), BCN Checkpoint – Projecte dels NOMS-Hispanosida (Spain), Boysproject (Belgium), Callen-Lorde Community Health Center – Health Outreach To Teens (USA), CARUSEL – Roma Harm Reduction Advocacy Project (Romania), Center of Excellence for Transgender Health – University of California, San Francisco (USA), Centre for Sexual Health and HIV/AIDS Research – Sisters with a Voice (Zimbabwe), Centre for the Development of People (Malawi), Community Healthcare Network (USA), Egyptian Family Planning Association (Egypt), Espolea, A.C. – Programa de Política de Drogas (Mexico), SHARPER project, FHI360 (Ghana), Fokus Muda – Indonesian Young Key Affected Population Forum (Indonesia), HIV Law Commission (Uruguay), International HIV/AIDS Alliance (Global), Karnataka Health Promotion Trust (India), Kimara Peer Educators and Health Promoters Trust Fund (Tanzania), La Comunidad de Trans-Travestis Trabajadores Sexuales Dominicana (Dominican Republic), LVCT Health (Kenya), Marsa Sexual Health Center (Lebanon), MCCNY Homeless Youth Services (USA), Médecins du Monde (Myanmar), Médecins du Monde (Tanzania), menZDRAV – Positive Life (Russia), MOSAIC Men's Health Initiative (South Africa), Nai Zindagi Trust (Pakistan), National AIDS Control Program (Afghanistan), National Organization of Peer Educators (Kenya), National OST Programme of the National AIDS Control programme (Iran), Naya Goreto (Nepal), Naz Male Health Alliance (Pakistan), NewGen – Youth LEAD (Asia-Pacific region), PASMO/PSI – Combination Prevention Program for HIV in Central America (Central America), Pehchan – India HIV/AIDS Alliance (India), Re-Action! Consulting (South Africa), Red de Mujeres Trabajadores Sexuales de Latinoamérica y el Caribe (Latin America and the Caribbean), Re-You – Cebu Plus Association (Philippines), River of Life initiative (Philippines), Save the Children Fund (Thailand), Sex Workers Outreach Programme (Kenya), Silueta X Association (Ecuador), SMARTgirl, FHI360 (Cambodia), Social Awareness Service Organization (India), Soins Infirmiers et Développement Communautaire - Escale (Lebanon), South African Department of Health (South Africa), South African National AIDS Council (South Africa), St. James Infirmary (USA), STOP AIDS (Albania), Streetwise and Safe (USA), Test, Connect & Treat – AIDS Institute of the New York State Department of Health (USA), Thai Red Cross – Men's Health Clinic (Thailand), The Initiative for Equal Rights (Nigeria), Transgender Education and Advocacy (Kenya), Vietnam Authority of HIV/AIDS Control, Ministry of Health and WHO Vietnam (Vietnam), Women for Women – UNODC (Ukraine), Youth Voices Count – Loud and Proud (Asia-Pacific region) and YouthCO HIV and Hep C Society – Mpowerment (Canada).

Additional support was provided by

Guideline development group of the WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations, Inter-Agency Working Group on Key Populations, Virtual review group for the HIV and young key populations technical brief series, and the following WHO staff, consultants and interns: Alice Armstrong, Rachel Baggaley, James Baer, Pramudie Gunaratne, Mary Henderson, Cadi Irvine, George Mugambi, Michelle Rodolph, Graham Shaw and Annette Verster.

Overall coordination: Alice Armstrong and Cadi Irvine

ACRONYMS

ART

antiretroviral therapy

ARV

antiretroviral drug

FSW

female sex workers

HIV

human immunodeficiency virus

HTC

HIV testing and counselling

KP

key populations

MMT

methadone maintenance treatment

MSM

men who have sex with men

NGO

non-governmental organization

NSP

needle and syringe programme

OST

opioid substitution therapy

PWID

people who inject drugs

STI

sexually transmitted infection

SW

sex workers

TG

transgender

UN

United Nations

YKP

young key populations

Footnotes

1

The Lancet, Volume 384, Issue 9939, Page 207, 19 July 2014.

2

WHO. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. WHO; Geneva: 2014. http://www​.who.int/hiv​/pub/guidelines/keypopulations/en/ [PubMed: 25996019]

3

Inter-Agency Working Group on Key Populations. HIV and Young Key Populations: Technical Briefs. UNAIDS; Geneva: 2014.

4

The case studies presented in this annex include those that appeared in the guidance document and in the technical briefs.

5

For detailed definitions of key populations, please see the Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. WHO; 2014. http://www​.who.int/hiv​/pub/guidelines/keypopulations/en/ [PubMed: 25996019]

6

‘Critical enablers’ here refers to reviewing laws, policies and practices (including decriminalization and age of consent); reducing stigma and discrimination; preventing violence; and empowering the community.

7

Survey Monkey software was used.

8

Around 80% of initial responses to the survey came from Africa, the Americas, Europe and Southeast Asia regions, while 5% of programmes had a global reach.

9

Rosmarin A, Eastwood N. A quiet revolution: drug decriminalization policies in practice across the globe. London: Release; 2012.

10

Hughes CE, Stevens A. What can we learn from the Portuguese decriminalization of illicit drugs? British Journal of Criminology. 2010;50(6):999–1022.

11

Link Up is led by the International HIV/AIDS Alliance (IHAA). Its partner organizations in policy, research, and programme development are the ATHENA Network, the Global Youth Coalition on HIV/AIDS (GYCA), Marie Stopes International (MSI), Population Council, and STOP AIDS NOW! Implementing partners include local IHAA and Stop AIDS Alliance branches and linking organizations, including the HIV/AIDS and STD Alliance Bangladesh (HASAB); Organization for Support Services for AIDS (OSSA) in Ethiopia; Community Health Alliance Uganda (CHAU); and Alliance Burundaise contre le Sida (ABS) in Burundi.

12

Mora M. New York City Council Public Safety Committee hearing on resolution 0264-2014, in support of AO2736/SB1379, New York State legislation that would prohibit the use of condoms as evidence of any prostitution-related offense. Jun 9, 2014. [16 June 2014]. http://www​.nocondomsasevidence​.org/wp-content​/uploads/2013/06​/SAS-Mitchyll-Mora-Testimony.pdf..

13

Many individuals from key populations experience self-stigma, which occurs when they internalize the social myths and prejudices that family members, friends, health workers and society in general exhibit toward key populations. Self-stigma can cause shame and a loss of self-esteem, and it can provoke thoughts of self-harm and suicide.

14

MARP is the acronym for ‘most at-risk populations’; people at risk and/or criminalized for their behavior are now more widely referred to as key populations.

15

IMHIPP is funded by USAID (2009–2014) through Heartland Alliance International, which provides technical support, training and mentoring. http://www​.heartlandalliance​.org/international/

16

KPAN & HCPI (2013) Injecting Drug User Behaviour and Service Satisfaction Survey

17

OST is not yet allowed in Pakistan; this remains a major gap and a challenge in serving the needs of the PWID community. For PWID in need of ART and with a CD4 below 500, Nai Zindagi offers a residential drug treatment programme.

18

UNAIDS Global AIDS Response Progress Reporting 2014 (2013 data)

19

Shahbazi M, Farnia M, Rahmani K, Moradi Gh. Trend of HIV/AIDS prevalence and related intervention in Iranian Prisons in 13 years. Iranian J of Publ Health. 2014 April;43(4) [PMC free article: PMC4433728] [PubMed: 26005657]

20

Farniaa Marziyeh, Ebrahimia Bahman, Shamsa Ali, Zamani Saman. Scale of MMT in prisons in Iran. Int J of Drug Policy. 2010 [PubMed: 20413287]

21

Focus Right: Diversity and Commonality – A look at Female and Transgender Sex Workers in Three Caribbean Countries. 2012. http://focusright​.org​/files/SEX_WORKERS_BASELINE​_STUDYsmallpdf_com.pdf.

22

Many clients served by NMHA are under 18 years of age, and so this term is preferred to ‘men who have sex with men’.

23

Policy brief: key populations, key solutions: a gap analysis and recommendations for key populations and HIV in South Africa. Pretoria, South African National AIDS Council. 2011. [3 June 2014]. http://www​.sanac.org​.za/resources/doc_download​/40-sanac-kay-population-policy-brief..

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