Effective HIV & SRH Responses among Key Populations in Myanmar Module 2: The Core Package for Prevention of HIV amongst Key Populations in Myanmar

Session 2 The Core Package for Prevention of HIV amongst Key Populations in Myanmar THE ELEMENTS OF THE CORE PACKAGE

 Small Group Mapping Exercise  Define the Elements of the Core Package for Prevention of HIV Amongst Key Populations in Myanmar  Look at the Cross-Cutting Issues of the Core Package  Explore Critical Enablers for the Elements of the Core Package Overview

Core Package for Prevention of HIV Amongst Key Populations in Myanmar ELEMENTS OF THE CORE PACKAGE Condom Access and Use Drug-Related Harm Reduction Services HIV Counselling and Testing Services STI Diagnosis and Treatment Services Monitoring & Evaluation Cross-Cutting Issues

GROUP ACTIVITY Mapping Exercise Core Package Mapping Exercise

Purpose of Exercise:  To establish a clear understanding of the story of current programming and access by key populations in Myanmar, based on the elements of the Core Package Instructions: 1.Break into five small groups 2.Each group is allocated an element of the Core Package 3.Work together as a group to map the programmes and services that currently exist (and are active) for key populations across Myanmar 4.Encourage participation by all members of the group. Core Package Mapping Exercise

Questions to Consider:  Where is the program or service relevant to this element being provided? What is being provided?  Who is moving in and out of these areas?  Which key populations are able to access this element through programmes and services in these areas?  Which key populations are not able to access this element through programmes and services in these areas?  Who has power in these areas that allows or creates barriers to access of this element through programmes and services?  What are other factors affect access to this element through programmes and services current available? Core Package Mapping Exercise

Core Package Condom Access and Use CONDOM ACCESS AND USE Understand condom clients and the environment Procure high-quality condoms and manage the supply chain Expand distribution systems Promote condoms at distribution points Promote condoms at community, township and national levels

Condoms are the single most effective available technology to reduce the sexual transmission of HIV and other sexually transmitted infections Core Package Condom Access and Use What and Why?

 Key populations provided with consistent, high quality male and female condoms and water-based lubricants  Key populations provided with education on correct and consistent condom use, including negotiation skills  An enabling environment for condom programming is created. Core Package Condom Access and Use

Core Package Drug-Related Harm Reduction Services DRUG-RELATED HARM REDUCTION SERVICES Needle and syringe programmes Opioid Substitution Therapy and other evidence- informed drug dependence treatment HIV Counselling and Testing Antiretroviral Therapy STI Prevention and Treatment Condoms for PWID and their partners Targeted information, education and communication Prevention, Vaccination, Diagnosis and Treatment of Viral Hepatitis Prevention, Diagnosis and Treatment of Tuberculosis

Some MSM, TG People and Sex Workers use drugs. Some injecting drug users sell sex. Therefore … All Key Populations should have access to:  Education on sexual transmission and the role of substance use in HIV transmission  Alcohol and drug-related harm reduction including:  Needle and syringe programmes, OST (MMT)  HIV Prevention, Treatment and Care (condoms, HCT, ARVs, care and support, STI management)  Treatment for comorbidities including hepatitis and TB Core Package Drug-Related Harm Reduction Services

Core Package HIV Counselling & Testing Services HIV COUNSELLING AND TESTING SERVICES Free, confidential and consensual HIV counselling and testing in appropriate settings Promote the need to ‘know your HIV status’ Minimise barriers to HCT

What is HIV Counselling and Testing for key populations?  Free, voluntary, confidential and readily accessible HIV Testing and Counselling with informed consent  Rapid testing where possible  Links to services  Meaningful knowledge of status HIV Counselling and Testing is essential for key populations as:  Increased risk of contracting and transmitting HIV  Universal Access Right Core Package HIV Counselling & Testing Services

Continuum of Care is essential … What is HIV Treatment, Care & Support for KPs?  Available, affordable and consistent access to treatment, care and support for key populations and their families HIV Treatment, Care & Support is essential for KPs as:  Quality of Life  Treatment as Prevention  Universal Access Right Core Package HIV Counselling & Testing Services

Core Package STI Diagnosis and Treatment Services STI DIAGNOSIS AND TREATMENT SERVICES Promote access to STI services for key populations and PLHIV STI testing and treatment in a variety of settings STI testing and treatment for symptomatic and asymptomatic infections Services that are friendly, non-discriminatory, voluntary and confidential Provide HIV prevention interventions through STI services

What is STI diagnosis and treatment for KPs:  Access to friendly clinics that provide highest standard of locally available care for diagnosis and treatment of STIs  Syndromic Management of STIs in absence of lab facilities  Periodic STI screening where available and affordable for asymptomatic STIs Core Package STI Diagnosis and Treatment Services

STI diagnosis and treatment is essential for KPs as:  Presence of STIs increases the risk of an individual contracting and transmitting HIV. Treating STIs reduces HIV risk  Asymptomatic or symptomatic untreated STIs can lead to complications including infertility  Reaching KPs through STI clinical testing and treatment increases opportunity to provide HIV education, condoms, lubricants and broader SRH services  Their Health is Their Wealth! Core Package STI Diagnosis and Treatment Services

Core Package Broader SRH Services Access to broader Sexual and Reproductive Health Services is described in the Core Package … “Women who are living with or at risk of HIV have the right to determine the number and timing of their pregnancies and to safely achieve their reproductive intentions”

Contraceptive methods and counselling services include:  Full access to contraceptive methods  Condom Dual Protection  Dual Method Contraception  Emergency Contraceptive Pill (ECP)  Access to counselling to prevent unintended pregnancies  Access to safe abortions where legal  Access to vaccinations  Planning for safe motherhood including spaced pregnancies Core Package Broader SRH Services

Condom Dual Protection Condoms provide dual protection against both unintended pregnancy and sexually transmitted infections including HIV. Dual Methods of Contraception Contraceptive methods can prevent unintended pregnancy but provide no protection from STIs including HIV. Condoms must be used along with contraception to provide dual method protection. Condom Dual Protection and Dual Methods of Contraception Core Package Broader SRH Services

Condom Dual Protection and Dual Methods of Contraception Core Package Broader SRH Services

Emergency Contraceptive Pills (ECPs)  Provide protection from pregnancy post-intercourse  ECPs do not protect against STIs including HIV  If there is risk of STIs including HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method  Male latex condoms are proven to protect against STIs including HIV. Core Package Broader SRH Services

Maternal Child Health is essential for key populations To Protect Mother To Protect Baby Core Package Broader SRH Services

Safe Pregnancy  If a woman plans to become pregnant, she should be provided with information about safe pregnancy, including regular antenatal care, HIV and STI prevention and testing, appropriate nutrition and safe delivery Before/During Family planning Tetanus vaccine Screening Iron/Folate Nutrition STD/HIV Management During Delivery Clean and safe delivery facility Detection and management of complications such as eclampsia and haemorrhage After Delivery (for Newborn) Hypothermia prevention Resuscitation Early/exclusive breast feeding Prevent infections After Delivery Post partum complications Post partum care Tetanus HIV/STI management Core Package Broader SRH Services

What is PMTCT for key populations:  Primary prevention of HIV  Prevention of unintended pregnancies among sex workers living with HIV  Prevention of HIV transmission from sex workers living with HIV to their children (vertical transmission)  Treatment, care and support for sex workers living with HIV and their families. Core Package Broader SRH Services

Reproductive Tract Cancer Screening:  Reproductive tract cancer screening for cervical, ano-rectal and prostatic cancers  Screening for breast cancer, ano-rectal and prostate cancer should be part of routine care. Hormone Therapy for Transgender People:  Transgender people use hormonal therapy for its feminising (oestrogen) or masculinising (testosterone) effects  A qualified practitioner should be consulted and continue to be engaged whilst considering and taking hormonal therapy. Core Package Broader SRH Services

Core Package Cross Cutting Issues CROSS CUTTING ISSUES Peer Education Referral Systems Essential Elements for an Enabling Environment Eliminating Stigma & Discrimination Building a Legal and Policy Environment Involvement and partnership of local communities in HIV prevention

What is Peer Education for key populations?  KPs educating other KPs How is Peer Education delivered?  Through Outreach  Through tailored print materials and mass-media  As part of other health service delivery. Core Package Cross Cutting Issues Peer Education Peer Education and Outreach provide entry point to all other HIV and SRH programmes and services.

What is Peer Outreach?  Peer-led engagement with KPs where they are Where does Peer Outreach Occur?  At places KPs meet for social and sexual connections  In clinical settings  Via the internet  At non sex work-based venues  Other Core Package Cross Cutting Issues Peer Education

Peer Outreach Share common experiences Trust and relationship building Comfortable discussing intimate details Follow up on referrals to services Follow up on treatment adherence and ongoing engagement in health seeking and health-protective behaviours Knowledge of the environment and KP Core Package Cross Cutting Issues Peer Education Why Peer Education And Outreach?

Peer Education Outreach Workers support behaviour change by: Providing correct information Promoting and providing male and female condoms and water-based lubricants Providing education on sexual transmission and the role of substance use in HIV transmission Promoting positive attitudes towards condom use and developing condom use and safe sex negotiation skills Promoting and providing sterile injecting equipment for KPs who inject drugs Promoting the need for regular STI check-ups and prompt treatment of STIs Core Package Cross Cutting Issues Peer Education

Encouraging HIV testing Encouraging knowledge sharing with peers to adopt safe sexual and drug use practices Promoting monitoring one’s health status for PLHIV Assisting in dealing with gender based violence Discussing and providing support related to sexuality Assisting peers in dealing with stigma and discrimination Extended Peer Outreach may also: Provide voluntary rapid testing in outreach settings Provide post-test counselling Promote, explain and record clinic visits and referrals Core Package Cross Cutting Issues Peer Education

Referrals can be: Accompanied Unaccompanied Referrals involve: Accompanying KPs to clinical services and advocating for them as needed Ensure that the quality of clinical services is high and that there is no coercion at the facility Providing required follow up for adherence support and further clinical appointment attendance. Core Package Cross Cutting Issues Referrals

Enabling Environment What is responding to stigma and discrimination for KPs?  Community Mobilisation  Structural interventions. Responding to stigma and discrimination is essential for KPs as:  Stigma and discrimination are barriers to accessing HIV prevention, treatment and care and SRH services  Stigma in the form of devaluing, discounting and discrediting KPs results in marginalisation and the inability to fully participate in community life or access health services. Core Package Cross Cutting Issues Stigma and Discrimination

Enabling Environment Key populations play an important role in informing and supporting governments through: Sharing of lived experiences Identifying challenges in legal and policy environments Working to develop acceptable solutions to legal and policy challenges. Core Package Cross Cutting Issues Legal & Policy Environment Advocacy is an individual or collective effort to raise the voices of those unable to fully exercise their basic rights as a citizen of a country, because the enabling environment to do so is lacking or absent

Advocacy and leadership building  Is essential for KPs as it aims to:  Change laws and policies that criminalise sex work and homosexual acts as well as administrative laws that are used to harass and abuse KPs – reduction in violence  Change law enforcement practices that harass or abuse KPs and deny human rights  Counters stigma and discrimination against key populations  Creates an enabling environment for key populations to engage in lifelong health seeking. Core Package Cross Cutting Issues Legal & Policy Environment

Enabling Environment What is Community Mobilisation?  A process that is central to any community and social change effort that seeks to build support and participation of individuals, groups or institutions to work towards a common goal or vision  It is the development of community action around community issues. Core Package Cross Cutting Issues Involvement of Communities