Effective HIV & SRH Responses Among Sex Workers and other Key Populations Module 2: A Comprehensive Package of Services for Key Populations

Session 2 A Comprehensive Package of Services for Key Populations GLOBAL GUIDANCE AND RECOMMENDATIONS

 Global guidance for HIV and SRH among key populations  National guidelines and the comprehensive packages for sex workers MSM and transgender people in the Philippines Overview

WHO, UNAIDS, UNDP, UNFPA and UNODC (2014) HIV Prevention, Diagnosis, Treatment and Care for Key Populations. Consolidated Guidelines. Brings together existing WHO guidance on five key populations:  MSM  PWID  People in Prisons & other closed settings  Sex Workers  Transgender People Consolidated Guidelines

The Consolidated Guidelines aim to: 1.Provide comprehensive package of evidence-based HIV related recommendations for key populations 2.Increase awareness of the needs of, and issues important to key populations 3.Improve access to, uptake and coverage of effective and acceptable services 4.Focus greater national and global commitment to adequate funding and services Consolidated Guidelines

The Comprehensive Package: Essential Strategies for an Enabling Environment 1.Supportive legislation, policy and financial commitment 2.Addressing stigma and discrimination 3.Community empowerment 4.Addressing violence against people from key populations Consolidated Guidelines

Essential Health Sector Interventions: 1.HIV prevention (condoms, lubricant, PrEP, PEP) 2.Harm reduction interventions for substance use (NSP, OST) 3.HIV testing and counselling 4.HIV treatment and care 5.Prevention and management of co-infections and other co-morbidities, including viral hepatitis, TB and mental health conditions 6.Sexual and reproductive health including STI management, access to reproductive options and cervical cancer screening Consolidated Guidelines

Condom & Lubricant Programming COMPREHENSIVE CONDOM & LUBRICANT PROGRAMMING Legislation & Law Enforcement Approaches Promote Access Lubricant Information and Skills-Building

 Key populations should be provided with consistent, high quality male and female condoms and water-based lubricants  Key populations should be provided with education on correct and consistent condom use, including negotiation  An enabling environment for condom programming should be created Condom & Lubricant Programming Condoms are the single most effective available technology to reduce the sexual transmission of HIV and other sexually transmitted infections

Behavioural Interventions BEHAVIOURAL INTERVENTIONS Outreach to key populations Peer education Drop-in centres Health seeking behaviour change (referrals and linkages)

What is Peer Outreach for key populations?  Peer-led engagement with key populations where they are Where does Peer Outreach Occur?  At places people meet for social and sexual connections  In clinical settings  Via the internet  At non sex work-based venues  At formal or informal Drop-In Centres  Other Behavioural Interventions

What is Peer Education for key populations?  Members of key populations educating people from their population  How is Peer Education delivered?  Through outreach  On tailored print materials and mass-media  Using technology  As part of other health service delivery Behavioural Interventions Peer Outreach and Education provide entry points to all other HIV and SRH programmes and services.

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 population Behavioural Interventions Why Peer Outreach and Education?

Peer Education Outreach Workers support behaviour change by: Providing correct information in accessible language 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 people who inject drugs Promoting the need for regular STI check-ups and prompt treatment of STIs Behavioural Interventions

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 Behavioural Interventions

Peer Outreach and Education should promote health seeking behaviour change … Referrals for key populations can be:  Accompanied  Unaccompanied Referrals involve:  Linking people to clinical services and advocating for them as needed  Ensuring 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 Behavioural Interventions

Harm Reduction Interventions HARM REDUCTION INTERVENTIONS FOR SUBSTANCE USE Needle and syringe programmes Opioid Substitution Therapy and other evidence informed drug dependence treatment HIV testing and counselling Antiretroviral therapy with adherence support 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 Sex Workers, MSM and transgender people 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, Opioid Substitution  HIV prevention, treatment and care (condoms, HTC, ART, care and support, STI management)  Treatment for comorbidities including hepatitis and TB  Particular strategies for women who use drugs Harm Reduction Interventions

HIV Testing & Counselling HIV TESTING AND COUNSELLING Free, confidential and consensual HIV testing and counselling in appropriate settings Minimise barriers to HTC Promote the need to ‘know your HIV status’ Meaningful knowledge of HIV status

What is HIV Testing and Counselling for key populations?  Free, voluntary, confidential and readily accessible HIV Testing and Counselling with informed consent  Rapid testing where possible  Immediate links to services  Meaningful knowledge of status – HIV Testing and Counselling is essential:  Increased risk of acquiring or transmitting HIV  Life-saving, leads to diagnosis and treatment of HIV  Helps prevent onward transmission HIV Testing & Counselling

HIV Treatment & Care HIV TREATMENT & CARE Case management for PLHIV Removal of access barriers for key populations Adherence support in community Promotion of long-term relationship with clinics

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

Case Management for PLHIV includes: Regular contact with key population members living with HIV Promoting and assisting treatment, care and support access Promoting prompt management of opportunistic infections Peer education on positive living and nutrition Ensuring access to, and promotion of, commodities to prevent transmission of HIV to sexual partners (condoms, ART, PEP) Promoting sexual and reproductive health services including STI management, contraception, antenatal care and PMTCT Awareness of coinfection and co-morbidity Holistic care and support of individual and family HIV Treatment & Care

Co-infections & Co-morbidities PREVENTION AND MANAGEMENT OF CO-INFECTIONS AND OTHER CO-MORBIDITIES HIV testing in TB clinics, TB testing in HIV clinics Prevention, screening and treatment for viral hepatitis Attention on issues of mental health

Attention to co-infections & co-morbidities for key populations should include:  The same level of access to prevention, screening, treatment and care services as other populations at risk for:  Tuberculosis  Hepatitis B & C  Mental Health (depression and psychosocial stress) Co-infections & Co-morbidities Access to mental health services for people from key populations living with HIV aims to optimize health outcomes and improve adherence to ART.

Sexual & Reproductive Health SEXUAL AND REPRODUCTIVE HEALTH INTERVENTIONS Screening, diagnosis and treatment of STIs Access to a range of reproductive options Abortion laws and services that protect health and human rights Cervical cancer screening Conception and pregnancy care

What is STI diagnosis and treatment for key populations:  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 for asymptomatic STIs  Sex workers as peer educators in clinical settings STI diagnosis and treatment is essential as:  Treating STIs reduces HIV risk  Untreated STIs can lead to complications including infertility  STI service access increases opportunity to provide HIV education, condoms, lubricants and broader SRH services Sexual & Reproductive Health

People from key populations, including those living with HIV, should be able to experience full, pleasurable sex lives and have access to a range of reproductive options.

Contraceptive methods and counselling services for key populations should 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 Sexual & Reproductive Health

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 Sexual & Reproductive Health

Condom Dual Protection and Dual Methods of Contraception Sexual & Reproductive Health

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 Sexual & Reproductive Health

Safe Abortion Services (where legal) Key populations should have access to abortion and post abortion care services to reduce related morbidity and mortality. WHO Recommendations (2012):  Safe abortion services should be available and affordable  Strengthen policies and services  Develop evidenced based national standards and guidelines for safe abortion care  Train abortion service providers  Financing of abortion services should take into account costs to the health system  Successful scaling-up requires systematic planning, management, guidance and support for the process

Maternal Child Health is essential for key populations To Protect Mother To Protect Baby Sexual & Reproductive Health

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 Sexual & Reproductive Health

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 Sexual & Reproductive Health

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 Sexual & Reproductive Health