Engaging MARPs with HIV and SRH Services SESSION 3 Engaging MARPs with HIV and SRH Services Linking Services

Overview Introduce the concept of HIV/STI and SRH Continuum of Care Explore the relationship between the full range of SRH services and HIV/STI Prevention, HIV Testing and Counselling (HTC), Treatment, Care and Support services Look at innovative ways to strengthen linkages between services What are the needs of MARPs living with HIV?

Introduction to Continuum of Care Continuum of Care (CoC) is defined as a network of linked, coordinated prevention, treatment, care and support services provided by collaborating sectors

Introduction to Continuum of Care The purpose of the CoC is to: link HIV and STI prevention services often being implemented by peer outreach workers with the full range of SRH and other clinical and support services often being delivered by government and private providers provide MARPs with access to fair and appropriate STI and HIV diagnosis and treatment services linked to the full range of SRH services and care and support services for MARPs living with HIV address HIV as a chronic disease and develop systems that provide humane, effective, high-quality comprehensive and continuous care to PLHIV and their families

Continuum of Care Model HIV/STI Prevention and Other SRH Services behaviour change communication Education universal precautions STI diagnosis and treatment Full range of SRH services HIV TCS HTC Meaningful Knowledge of Status HIV negative HIV positive Community Mobilisation ENTRY POINT MARPs reached through: Peer outreach Mass media Other health services

Community Mobilization MARPs organizations usually develop by: Growing out of a community-empowerment process or other process supported by an outside organization, including national, regional or global community-led networks MARPPs independently forming an organization

Community Mobilization Ideas of ways to bring MARPs together: Organize group activities at safe spaces (drop-in centres) based on the interests of the group members Plan activities for special occasions such as the International Day to End Violence against MARPs Invite activists or community outreach workers from neighbouring areas to speak at a gathering of local sex workers, MSM or transgender people

Community Mobilization Group Check In: Innovation Brainstorm Can you think of any other innovative ways to bring MARPs together?

Community Mobilization Community Based Organisations create an entry point into the CoC by reaching MARPs Strategies for reaching MARPs include: Directly through peer outreach Creating or advocating for mass media campaigns Linking with health services

Reaching MARPs Through Peer Outreach In order to meet the needs of MARPs peer outreach needs to go beyond basic education and condom distribution to include: Providing education on violence prevention and crisis response alcohol and drug harm reduction legal rights Linking to other services such as SRH services Full range of clinical services Legal Aid services Providing Follow-up to testing and case management for newly diagnosed MARPs

Reaching MARPs Through Peer Outreach Direct Services Peer Education Condoms Education and Promotion STI Education Safe Sex Negotiation Skills Education Assistance in dealing with sexual harassment Discussion and support relating to sexuality Assisting peers in dealing with stigma and discrimination Links to Services SRH and HTC referrals Alcohol and drug harm reduction referrals Legal Aid service referrals Accompanying sex workers to clinical services Monitoring quality of services Follow-up Services On-going post-test counseling and support Support for adherence to treatment Case Management Links to community care Outreach Models

Thinking Innovatively About HIV/STI Prevention & SRH Services Principles of Effective Peer Education Peer Education should not just include HIV risk and prevention, care and support but needs to also address broader sexual and reproductive health Peer Education must be tailored to the literacy of the target audience, be in plain language, and be tailored to the concerns of the target audience Peer Education must be age-specific, addressing the concerns of the target population, and recognizing that age is an important factor of health seeking behaviour Peer Education must also be gender- specific, the needs of male, transgender and female sex workers, MSM and transgender people may overlap, but also differ in some respects

Innovation Brainstorm Thinking Innovatively About HIV/STI Prevention & SRH Services Group Check In: Innovation Brainstorm What are some innovative ways of delivering prevention education, commodities or services? What are some innovative prevention messages or services being delivered to meet the full SRH and HIV needs of MARPs?

Thinking Innovatively About HIV/STI Prevention & SRH Services Educating sex workers about the harm of douching: The facts: The vagina is a self-cleaning mechanism Douching does NOT clean the vagina Douching changes the delicate balance of vaginal flora and acidity that self-cleans and protects Douching is associated with increased bacterial vaginosis and has been linked to pelvic inflammatory disease and increased risk of ectopic pregnancies Bacterial vaginosis is linked to HIV.

Thinking Innovatively About HIV/STI Prevention & SRH Services Tailoring outreach work to individual clients through micro-mapping: Community outreach workers are trained to use tools to capture data on the vulnerability and risk of each individual they serve Community outreach workers record data at each encounter with the sex worker, and aggregate it onto a weekly or monthly reporting form Purpose is to enable community outreach workers to analyse their outreach efforts and plan their outreach according to the most urgent needs of the sex workers they are serving

Thinking Innovatively About HIV/STI Prevention & SRH Services Involving sex workers in clinic operations: STI services should promote meaningful participation of sex workers Clinics should formalize sex worker involvement by specifying how sex workers can be involved in developing, managing and monitoring services Professional development should be an integral part of community empowerment, allowing sex workers to learn and be mentored to provide clinical services In Mysore, India, sex workers have undergone formal training in nursing: 12 sex workers who have completed their degree are now employed as nurses at the clinic.

Thinking Innovatively About HIV/STI Prevention & SRH Services Empowering sex workers to monitor their own sexual health In Thailand, the Service Workers in Group Foundation (SWING) has worked with male sex workers to develop a sexual health diary as a tool to help them monitor their own sexual risk and engage regularly in self-diagnosis for symptoms of STIs The goal is to provide a way for them to track and maintain their preventive behaviour, including STI screening and treatment Sex workers fills in a weekly summary sheet in the diary and gives this to his outreach worker from the programme, and they discuss it Information is recorded in the database and used for risk assessment and to customize services for the sex workers When symptoms of STIs are reported, the sex worker is encouraged to see a doctor for testing and treatment.

Thinking Innovatively About HIV/STI Prevention & SRH Services Addressing Violence by Building Partnerships for Advocacy The Karnataka Health Promotion Trust (KHPT) in India aimed to build partnerships to prevent and respond to violence among sex workers KHPT sensitized and advocated with law enforcement (police) and judiciary not to perpetrate or condone violence against sex workers. In partnership with KHPT the following occurred: The state’s Women and Child Welfare Department made services for violence against women available to sex workers as well. Community-based organizations worked with sex workers in 30 districts to sensitize them about their rights The Alternate Law Forum and the National Law School of India developed and conducted legal literacy training for sex workers The Centre for Advocacy and Research, an NGO, did media advocacy and trained sex workers as media spokespersons

Thinking Innovatively About Linking MARPs to Services Peer Outreach Workers can form a link between the community and services by: Promoting, explaining and recording SRH clinic and HTC referrals and visits Promoting, explaining and recording alcohol and drug harm reduction services and providing referrals Accompanying sex workers, MSM and transgender 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 Provide crisis response and legal aid referrals

Thinking Innovatively About Linking MARPs to Services Developing a Crisis Response System to support sex workers who face violence or other crisis Avahan’s crisis response system in India provides rapid-on-the-spot support to sex workers A group of trained community members make up a crisis response team who can be contacted by mobile phone. They will: Assess the nature and urgency of the crisis Take steps to address immediate danger Facilitate access to medical services, psychosocial and other relevant support Provide access to a lawyer in case of arrest to support negotiations with the authorities Provide counselling Report and document incidents of violence and the team’s response Assist in resolving family or community issues affecting sex workers Report back to the community on a regular basis on incidents that have occurred and their resolution (while respecting the confidentiality of those who have experienced violence)

Thinking Innovatively About Linking MARPs to Services Reaching hard to reach male sex workers and other MSM- providing referrals and accompanied HTC visits (CAP3D in Thailand) Outreach with HIV testing as the main aim Develop relationship with testing centres to assist access for KAPs Immediate case management following testing – reduces loss to follow-up Assist with registration for ARV/other health services Target male sex workers when they are solicalising, not when they are working

Thinking Innovatively About HTC, Treatment, Care and Support In an effective CoC model, prevention activities and services should be linked to and lead to an increase in regular HTC of MARPs Increased HTC services should lead to more sex workers, MSM and transgender people with a Meaningful Knowledge of Status MARPs who are HIV negative should remain linked to prevention and regularly access HTC services MARPs living with HIV should be linked to treatment, care and support services and remain linked to prevention

Thinking Innovatively About HTC, Treatment, Care and Support HIV TREATMENTS CASCADE- CURRENT MARPs living with HIV MARPs with HIV access testing MARPs with HIV know and understand their result MARPs with HIV are linked to treatment, care and support services MARPs with HIV start ART MARPs with HIV maintain viral suppression Proportion decreases

Thinking Innovatively About HTC, Treatment, Care and Support HIV TREATMENTS CASCADE- DESIRED Of the MARPs living with HIV 100% MARPs with HIV access testing MARPs with HIV know and understand their result MARPs with HIV are linked to treatment, care and support services MARPs with HIV start ART MARPs with HIV maintain viral suppression

Thinking Innovatively About HTC, Treatment, Care and Support MARPs with HIV access testing Not enough sex workers, MSM and transgender people know their HIV status HTC services need to be accessible, MARPs friendly, safe and confidential, linked to ongoing HIV treatment and support Laws that prohibit sex workers with HIV from working act as a disincentive for testing Breaches of confidentiality can lead to violence, expulsion from community, arrest, death Lack of a sense of future (e.g. migrant workers with no health service access) act as a disincentive to knowing HIV status

Thinking Innovatively About HTC, Treatment, Care and Support Methods of delivery HTC services can be provided in a variety of settings, including: Mobile community outreach Health facilities Drop-in centres Bars, clubs and brothels Homes or households Finger-prick blood sample or mouth swab are preferred collection methods because: These methods can be performed by a trained outreach worker They may be more acceptable to people who have injected drugs and have difficulty with venous blood access or have concerns about drug use disclosure

Meaningful Knowledge of Status Thinking Innovatively About HTC, Treatment, Care and Support Group Check In: Meaningful Knowledge of Status Does anyone know what meaningful knowledge of status means?

Thinking Innovatively About HTC, Treatment, Care and Support MARPs with HIV know and understand their result Meaningful knowledge of HIV status – telling a person their result does not mean that they know and understand its meaning Testing services need to be directly linked to ongoing support so newly-diagnosed sex workers are not lost to follow-up This requires HIV peer support, counselling, case management Diagnosis can trigger increase in drug and alcohol use, depression – need to ensure access to services Information needs to be reinforced – build a sense of future

Thinking Innovatively About HTC, Treatment, Care and Support MARPs with HIV are linked to treatment, care and support services There is often a gap between people being diagnosed and then getting on to ARV treatment This gap is life-threatening Peer support needed to assist newly-diagnosed people to access treatment, care and support services Late HIV diagnosis often means that ART needs to be started at HIV diagnosis Fear, as testing may be anonymous but treatment is not Health system can be bureaucratic, hostile – need advocates

Thinking Innovatively About HTC, Treatment, Care and Support MARPs with HIV start ART Advocacy needed to ensure MARPs can get onto long-term ART programmes Problems with access to low-cost treatment – need proper identity/legitimacy papers – need advocacy Need TB and OI prevention, diagnosis and treatment Need flexible arrangements around supply of ART – flexible clinic hours, flexible appointments systems for people running low on supplies, supply tracking and follow-up mechanisms

Thinking Innovatively About HTC, Treatment, Care and Support MARPs with HIV maintain viral suppression Sustained low viral has health and HIV prevention benefits Other parts of the person’s life need to be supported to assist in maintaining health: Long-term adherence is supported by Safe and secure housing Good nutrition Treatments literacy, Financial security Access to peer support, Mental health Stable care and case management team Absence of violence and fear, sense of purpose and future

Group Exercise How do we improve the outcomes for MARPs down the treatments cascade? Each group allocated one level of the cascade Identify key barriers to achieving higher proportion of MARPs at this level Identify key strategies for removing barriers Report back

Needs of MARPs Living with HIV Health needs Voluntary counseling and testing ART and clinical services Contraception and assistance with planning pregnancies Reproductive health Livelihood needs Assistance (without coercion) to move out of sex work Microfinance Vocational training Community support needs Family support Access to community care service Safe and secure housing Good nutrition Absence of violence HIV prevention needs Access to condoms and lubricant STI prevention and treatment Assistance with disclosure of status PMTCT if diagnosed with HIV during pregnancy

Monitoring & Evaluation Sample qualitative indicators used to monitor sex worker belief in their own ability to protect themselves and fellow sex workers against HIV: How confident are you in your ability to use a condom with each client: even if he gets angry? even if he offers more money for sex without a condom? even if you have been using alcohol or drugs? How confident are you about going to the clinic for STI services, even if health workers: know that you are a sex worker? treat you badly? don’t provide the specific service you need (e.g. no anal exam, no drugs)? How confident are you about going to the clinic for VTC services, even if health workers: will not keep your visit confidential? How confident are you about giving advice to fellow sex workers, or speaking your opinion in front of a large group of people?

Monitoring & Evaluation Have you negotiated with or stood up to the following individuals in order to help a fellow sex worker: police? brothel owner/manager? gang member? client? regular partner? Have you worked together with other sex workers to: keep each other safe from harm? increase condom use with clients? speak up for sex workers’ rights? improve sex workers’ lives? How fairly do you think sex workers are treated: at hospitals? at banks? at post offices? in other public places? by the police?