Holistic approaches to reach women in special population groups: A PMTCT pilot initiative HIV/AIDS program, Save the Children in Bangladesh Funded and supported by UNICEF Md. Shakawat Alam

Global scenario of PMTCT Key Informations HIV and AIDS Situation in Bangladesh: National HIV Prevalence is <0.1% HIV Prevalence among KPs: 0.7%, concentrated in Chittagong, Dhaka and Sylhet (Among IDU- 5.3% in Dhaka, 0.11% elsewhere, NIDU female – 1.1%, FSW - 0.25%) National estimate of PLHIV: 9,500 433 new HIV cases in 2013 Estimated # of HIV+ women (15 – 49 years): 500 - 1,000; Reported cases: 856 Global scenario of PMTCT In 2013 an estimated 240,000 children contracted HIV In the absence of interventions, the overall transmission rate from parent-to child is as high as 35% New HIV infections among children have declined by 58% since 2001, due to PMTCT program With a strong PMTCT program in place and access to ART for parents, the majority of these infections can be avoided

National Coverage: PWID

Current GF program coverage of Female Who Inject Drugs(FWID) Estimated Female Who Inject Drugs is 3551 In Dhaka most of the FWIDs (286) are covered through 2 dedicated female DIC Rest of the FWIDs (112) covered through several Male PWIDs DICs in different Districts of Bangladesh Source: 1. National Size Estimation Report 2009: Periodic Report P-16, SC

National Coverage: FSW Total FSW: 74,300 Total Coverage of FSW: 35,400

Situation of Female Who Inject Drugs, Female Partners of PWID and FSWs Most of the FWIDs are young (age between 20-35) and 48% are married 29% are living on the street & 63% are selling sex (10 clients per week) 57% exchange sex for drugs & 14.6% are diagnosed with STIs experience high levels of poverty, gender-based violence (e.g. sexual assault) Female Partners of PWID 60% of Male PWID have multiple sex partners, 57 % are married, 36% of married male PWID have families FSW: Sexual violence and imprisonment became more common among sex workers in last year Overall consistent condom use is very low

Service delivery model of PMTCT Delivery Model 2: Universal PMTCT Services for Pregnant Women in Settings with High HIV Prevalence Delivery Model 1: Targeted Services for women in Special Population Groups Elimination of Mother to Child Transmission of HIV and Congenital Syphilis Directly contribute to MDGs 4, 5 and 6 Ref: National Program Design for PMTCT in Bangladesh

Save the Children and DI Save the Children in Bangladesh has been working to assist the children of the country since 1970 Save the Children is a dual mandate organization We respond to disasters and ensuring the survival, protection and development of affected children Save the Children directly reaches more than 12 million children and adults through implementation of over 90 projects in all 64 districts HIV/AIDS Program: Implementing Expanding HIV prevention in Bangladesh (RCC) Funded by The Global Fund. Direct Implementation: DI started on January 2011 under RCC consolidation in 3 selected site with 6 DICs; currently implementing 12 DICs in 6 districts among PWIDs and FSWs Target population: (IDU 1800; FSW 1500) DI started PMTCT project supported by UNICEF Since November 2014 for 1278 women in special population groups at three sites (Dhaka, Rajbari and Sylhet)

PMTCT: Program Goal and Objectives To prevent paediatric HIV infections and improve maternal, new-born and child health and survival in the context of HIV General objective: Increasing the horizon and scale of essential PMTCT services for the key affected population and transfer acquired experiences and skills to others Specific objectives:  Integrate effective and comprehensive PMTCT services among KPs at selected implementing sites Strengthen linkages between MNCH services, reproductive health services and HIV-related services to reduce overall maternal and child mortality among KPs Disseminate acquired experiences and skills to relevant stakeholders at national and local level.

Conceptual Framework for the Project The project is based on service delivery model 1 of National PMTCT guideline and focusing on following key components for women in special population group- HIV Prevention activities includes Awareness raising, HTC, Syphilis management Prevention of unwanted pregnancies and care for HIV Positive Women includes family planning counselling and commodities; and couple counselling Referral for ANC services, ART in pregnancy, delivery care, Early infant diagnosis for the new born and ARV prophylaxis for the baby, couple counselling

Current strategies and essential services for FWIDs General objective: Increasing the horizon and scale of essential prevention PMTCT services for the key affected population and transfer acquired experiences and skills to others Program approaches: Generate evidences for further programming Integration of PMTCT services at DIC level Engagement of KAP Establish HIV testing and counselling (HTC) centre at DIC Inclusion of syphilis testing and treatment Programme components/activities: Baseline Assessment Establish PMTCT service points PMTCT centre based activities Community based activities Home visit and family meeting with female partners of male IDUs Referral linkage Communication strategy development Advocacy and sensitization at different levels 80% of listed female IDUs, 50% of female sex partners of listed married IDUs and 80% of listed female sex workers (Dhaka, Sylhet and Rajbari)

Service Delivery Model to FSW and PWID Field based outreach activities Community development & mobilization Education and awareness BCC session & material distribution NSP, Condom, lubricant distribution On-site educational sessions Referrals Capacity building Peer education training Vocational training /income generation Local level advocacy Sensitization meeting with religious leaders, Health Service Providers & local elite, journalists Sensitization meeting with law enforcement agency Legal support through referral linkage DIC based activities (Drop-in-services) Social gathering, rest & recreation Group education session Counseling: psycho-sexual & psycho-social Audio-visual learning Condom and lubricant demo. & distribution Clinical services at DIC STI syndromic management & treatment, counseling General health treatment HIV Testing & counseling Referral to MCH, EPI and STI partner management

Component of PMTCT PMTCT Awareness FP HTC STI Mx ART Infant feeding ANC PNC ART Infant feeding EID PMTCT: Prevention of mother to child transmission of HIV HTC: HIV testing and counselling STI: Sexually transmitted infection ART: Anti-retroviral therapy

Challenges Retention of staff Offering PMTCT services to wives who live in far away from the DICs and to wives who have no contact with their PWID husband lives in street Disclose of identity by both PWID and their wives FSWs are unwilling to spent time for PMTCT and other services during their business hour

Lesson learnt Women in special population group has needs of comprehensive PMTCT services Extensive awareness building efforts is essential to mobilize KPs and their partner for PMTCT Pilot project duration need to be at least 2 years Partner, family member and community involvement is essential for successful PMTCT program for KPs Functional referral linkages is also cruitial Program design need to be customized for different geographic area and different KPs

Opportunities Strong commitment and coordination will make an initiative a success story