Access to Stigma-Free Healthcare Settings for Key Populations: Challenges and Opportunities Dr. R. Cameron Wolf Senior HIV/AIDS Advisor for Key Populations U.S. Agency for International Development IAS 2017 - Paris, France #DoingTheRightThing July 25, 2017

Conflict of Interest “No conflicts of interest to declare”.

We know that if any one of our populations is left behind, if any one of us is left behind, all of us are left behind and we won’t be able to control the pandemic. -Ambassador Deborah Birx, MD, U.S. Global AIDS Coordinator

Better Understanding the Pandemic 44% 25% 80% UNAIDS, 2017

A Defined Comprehensive Package for Key Populations Condom and lubricant programming Harm reduction interventions Behavioural interventions HIV testing and counselling HIV treatment and care + PrEP Prevention and management of viral Hep, TB and mental health conditions Sexual and reproductive health interventions Supportive legislation, policy and funding Addressing stigma and discrimination Community empowerment Addressing violence Health Interventions Clear Recommendation and Tools Structural interventions Source: WHO Consolidated Guidelines for KPs (2016)

We Must Confront Stigma and Discrimination To Get to 90/90/90 The WHO KP framework can be operationalized here through this cascade developed by the LINKAGES Project, which is USAID and PEPFAR’s largest program for Key Populations, now working in 30 countries globally -- addressing MSM, TG, SW and PWID. The steps for KPs considered here are needed to Identify, Reach and Offer them Testing – providing a continuous cycle of Comprehensive Prevention services -- which is increasing including PrEP. And for those diagnosed HIV+, to immediately Enroll them in Care and Treatment programs and continually support them for Adherence, Retention and ensure their Viral Suppression. All of these steps must be Differentiated for Key Populations in order to reach UNAIDS ambitious goals of 90/90/90 and decrease the burden of HIV on Key Populations, who bear disproportionately high prevalence and who have significant challenges and vulnerability. A key consideration for KPs is always to recognize the pervasive stigma, discrimination and violence that many experience, as well as lack of political will and often low capacity of health systems to address their specific needs and at times hostility from the providers who are their gatekeepers to lifesaving treatment. This creates barriers (or leaks) within each step of the cascade, where people disappear or are hidden after abusive treatment or simply fear damaging experiences related to their healthcare services. KPs may change their name, move around, and be lost to follow up requiring attention from targeted programs. Some have intersecting stigmas from their gender, sexual orientation, criminalized behavior or HIV status. Thus, numerous data challenges exist for KP programs --- and we must not forget that the need for effective patient and program monitoring must be balanced with vital need for respect of the confidentiality, safety and security of our KP beneficiaries. KPs are rightfully cautious of authority, and may be slow to trust HCWs, which why strong community engagement and leadership from KPs and KP CBOs is so critical to the success of programs. We have seen here at the conference from the recipients of the IAS MeAndMyHealthCareProvider Awards that building strong and effective relationships between HCW and KPs can be done – with dedication, commitment, passion and trust.

Disaggregation

“While many people with HIV are now enjoying strong, healthy, full lives; urgency and collaboration are needed to ensure dignity, decency, and survival for the many more people living with HIV and key populations still struggling.” GNP+ Executive Director, Dr. Laurel Sprague

PEPFAR Implementation Cameroon Thailand Uganda PNG. Jamaica Cote d’Ivoire Viet Nam Guyana Malawi Ghana Namibia Dominican Rep Botswana Zambia Rwanda India Nigeria Ukraine Barbados Ethiopia Tanzania Angola DR Congo Mozambique Cambodia Burma South Africa Haiti Zimbabwe Kenya Lesotho Swaziland Guatemala Honduras Nicaragua Tajikistan Kazakhstan PEPFAR Implementation Implemented in 38 Countries --- 50% USG staff with PEPFAR, the rest were IPs staff, and 10% were others (govt, multilat development partners, and civil society) The trainings were led by a core team of four facilitators 1 -Epidemiology, policies, PEPFAR Gender strategy 2. GSD concepts and terminology 3. Panel with local advocates and Legal expert 4. Meaningful engagement (with local communities)

PLHIV Stigma Index The PLHIV Stigma Index measures trends in S&D to promote action addressing stigma Administered by and for PLHIV, with strong involvement from Civil Society 10 years since its creation, 100,000 PLHIV have been interviewed in >90 countries With PEPFAR support in partnership with UNAIDS, the Revised PLHIV Stigma Index is being updated to reflect the new dynamics (i.e., treatment and PrEP) in the response – and targeted sampling of Key Populations

Pilot PLHIV Stigma Index Data for Key Populations MSM Sex Workers Senegal (n=100) Uganda (n=37) Senegal (n=87) Uganda (n=130) Excluded from family activities 17% 11% 9% Family members made discriminatory remarks 37% 24% 29% 27% Afraid to seek health services 12% Avoided seeking health services 26% 14% 15% 8% Verbally harassed 44% 32% 40% 30% Blackmailed 33% 41% Physically harassed 28% 19% 21% Forced to have sex 16% Preliminary data from pilot testing the updated PLHIV Stigma Index, led by the Population Council through Project SOAR, in collaboration with UNAIDS, GNP+, ICW, and Johns Hopkins University.

Systems for Monitoring Human Rights

Building Partnership in Confronting Violence LINKAGES Thematic Advisory Group on Violence, Stigma and Discrimination Against Key Populations Prevention and Response to violence Consolidate best practice and guidance for responding to KP human rights abuse (building off HIV/AIDS Alliance / Elton John AIDS Foundation) Integrating violence prevention, detection and response systems into PEPFAR country programs and dashboards

Partners Sharing Tools for Violence, Stigma and Discrimination LINKAGES project and core partners

Implementation Science presented at IAS: Integrated Stigma Mitigation Intervention Framework for Key Populations INTERVENTION STIGMA OUTCOMES COMMUNITY (Preclinical) Peer-based approach Peer led groups sessions Increase participants efficacy in preventing HIV infection Reduction of perceived and anticipated stigma Improve effectiveness of existing HIV services Increased uptake of these services by key populations Decrease in reported experienced and perceived stigma Increased consistent use of condoms and condom compatible lubricants Increased adherence to HIV treatment regimens Decreased community HIV viral load CLINICAL Training of healthcare workers Reinforce cultural and clinical competency in service provision to key populations Reduction of experiences of stigma in health settings POSTCLINICAL (Web-based) Peer-to-peer anonymous referral system Information on health services and prevention Reduction of individual stigma Baral et al., IAS 2017

Combining Assessment with Training Multiple curricula and tools for sensitization and clinical training have been developed and tested (Nyblade, HP+) Piloted in 6 countries… Current work in Ghana, Jamaica and Tanzania

Integrating KP Feedback with Innovative Service Quality Monitoring System (SMS2) Continual engagement to support behavior and attitude change – pinpointing challenges for performance improvement & training (Health4All) SMS messages sent to patients, peers, and HCWs with info on health services Service Users KPs Service Providers Healthcare workers LINKAGES is addressing stigma and discrimination in healthcare settings through its innovative Service Quality Monitoring System (SMS2). With SMS2, peer outreach workers send text messages to people who have attended health services, asking a few simple questions about their satisfaction with the care they received. The granular data generated by the system can be segmented by KP group and allow the pinpointing of specific facilities where KPs report experiencing low satisfaction with service quality. These data are then used to inform performance improvement strategies in the facilities where they are needed. Outreach Workers/PE

Resources for Implementing Comprehensive HIV and STI Programs for Key Populations: Community Leadership in Responses

Country has any Training Programme on Non-Discrimination We Must Do Better Country has Done Training on Human Rights for PLHIV and KPs in Past 2 Years UNAIDS, 2017

PEPFAR Stigma and Discrimination Task Force Expert Consultation Nov 2 – 3, 2016 We are continuing to work together to compile and share best practices within PEPFAR and with our Global partners.

Summary There have been significant advances in measurement, stigma monitoring tools, methods and violence response systems – Time to Scale Better feedback between KPs and care providers leads to Accountability & continuous quality improvement Full Community Engagement and Leadership– leads to better impact across the cascade and better programs. Partnership, mutual respect and trust must be instilled between KP community members, CBOs, healthcare providers, allies and champions, and key decision makers Making the Impossible Possible -- The Time is Now!

Acknowledgements Alison Cheng, USAID Tisha Wheeler, USAID Kent Klindera, USAID Noah Metheny, The Global Fund Stefan Baral, Johns Hopkins University Tonia Poteat, Johns Hopkins University Julie Pulerwitz, Population Council/SOAR Barbara Friedland, Population Council/SOAR Laura Nyblade, Health Policy+ Diego Solares, GH Pro Chris Akolo, FHI360/LINKAGES Hally Mahler, FHI360/LINKAGES Ben Eveslage, FHI360/LINKAGES