HIV/AIDS Programming for MSM in the Greater Mekong Region Nithya Mani, MPH February 19, 2009 Chennai, India

Presentation Overview Context of HIV/AIDS among MSM in the Greater Mekong Region Context of HIV/AIDS among MSM in the Greater Mekong Region USG strategy: hotspots and development of technical assistance-based model USG strategy: hotspots and development of technical assistance-based model Minimum Package of Services (MPS) for Prevention Minimum Package of Services (MPS) for Prevention Enabling Environment as a component of the Comprehensive Prevention Package Enabling Environment as a component of the Comprehensive Prevention Package

Significant Emerging MSM Epidemics in SE Asia Van Griensven, Frits; 2008

Who are MSM? Two dynamics: gender and sexual expression Two dynamics: gender and sexual expression MSM is an umbrella term MSM is an umbrella term Transgender (TG) Transgender (TG) Male Sex Worker (MSW) Male Sex Worker (MSW) Other MSM Other MSM Different sub-populations of MSM may need different approaches Different sub-populations of MSM may need different approaches

Technical-assistance based approach with focus on capacity building to ensure sustainability and facilitate integration of activities into routine systems Technical-assistance based approach with focus on capacity building to ensure sustainability and facilitate integration of activities into routine systems Four components: Four components: Develop replicable models for prevention and care Develop replicable models for prevention and care Improve the quality of prevention and care programs Improve the quality of prevention and care programs Increase the collection and use of strategic information Increase the collection and use of strategic information Share successful models and provide TA to other PEPFAR programs Share successful models and provide TA to other PEPFAR programs USG strategy

Geographic Focus Regional (regional MSM and PLHA networks and SI activities) Regional (regional MSM and PLHA networks and SI activities) Non-presence countries Non-presence countries - Burma - China - Laos - Papua New Guinea (PNG) - Thailand

Comprehensive Prevention Package PLHA Interventions Most-at-risk Populations MSM (including TG, MSW) IDU FSW Clients of FSWs Other vulnerable populations Minimum Package of Services Behavior change communication Condom distribution STI screening and treatment HIV counseling and testing Substitution therapy and safer injection practices for IDU Linkages to care and treatment Supportive interventions Strategic Information Capacity Building Community Mobilization Policy & Advocacy Stigma and Discrimination Income Generating Activities

Targeting MSM Identifying key hotspots Identifying key hotspots Peer informants and other input as part of program design Peer informants and other input as part of program design Formative behavioral research Formative behavioral research Understanding population and tailoring appropriate messages Understanding population and tailoring appropriate messages MSM, MSW, TG may require different messages and messengers MSM, MSW, TG may require different messages and messengers

Behavior Change Communication & Condom Distribution Peer outreach: critical Peer outreach: critical Innovative approaches (mid-media such as “edutainment”, website) Innovative approaches (mid-media such as “edutainment”, website) Targeted IEC materials Targeted IEC materials Drop in centers Drop in centers Peer activities, including skills development, training, and services available at drop in centers and on-site access to VCT and STI services Peer activities, including skills development, training, and services available at drop in centers and on-site access to VCT and STI services Targeted Condom Social Marketing Targeted Condom Social Marketing Ensuring access to condoms and lubricants is key, either by the program itself or through targeted condom outlets Ensuring access to condoms and lubricants is key, either by the program itself or through targeted condom outlets

Training Peer Leaders Community / grass-roots mobilization and ownership is essential Community / grass-roots mobilization and ownership is essential Systems with incentives where community volunteers can move up into part-time staff, later full-time staff and then leadership roles encourage continuity Systems with incentives where community volunteers can move up into part-time staff, later full-time staff and then leadership roles encourage continuity Important to target peers from sub-populations (MSW including TG SW as well as both feminized and masculine MSM) Important to target peers from sub-populations (MSW including TG SW as well as both feminized and masculine MSM)

Approaches to Delivering the MPS Model for MSM Community-based services Community-based services Drop-in Centers; one stop shop Drop-in Centers; one stop shop Mobile clinics Mobile clinics Services at community events Services at community events Referrals to VCT and STI services Referrals to VCT and STI services Government Government Private (can be subsidized with coupons, etc) Private (can be subsidized with coupons, etc) Follow up is critical Follow up is critical Need strong linkages to care and support services Need strong linkages to care and support services Desire for tailored programming for positive MSM Desire for tailored programming for positive MSM

Barriers to Clinical Services Stigma and discrimination by providers Stigma and discrimination by providers Need sensitization and MARP friendly services Need sensitization and MARP friendly services Lack of knowledge on MSM-specific STI screening (i.e rectal exam for asymptomatic infections) Lack of knowledge on MSM-specific STI screening (i.e rectal exam for asymptomatic infections) Lack of anonymity Lack of anonymity Names-based eligibility for services and reporting in some countries Names-based eligibility for services and reporting in some countries Cost: test and transportation Cost: test and transportation Loss to follow-up: must have rapid tests! Loss to follow-up: must have rapid tests! Need to link STI and VCT services Need to link STI and VCT services

Minimum Package of Services in the Past 12 Months, Bangkok, 2007 Source Data: Thai MoPH, BoE, 2007

Consistent Condom Use with Casual Partner & the MPS Source Data: Thai MoPH, BoE, 2007

Supportive Interventions for MARPs Strategic Information Strategic Information Capacity Building Capacity Building Community Mobilization Community Mobilization Policy Policy Stigma and Discrimination Stigma and Discrimination Income Generating Activities Income Generating Activities

Fostering an Enabling Environment Establishment of a Regional MSM Network: Purple Sky Network Establishment of a Regional MSM Network: Purple Sky Network USG and UN support USG and UN support Community and government involvement Community and government involvement Country level technical working groups Country level technical working groups Regional Technical Board Regional Technical Board Regional Coordination Secretariat Regional Coordination Secretariat Goal: To enhance and strengthen the capacity of the regional and in-country MSM working groups in developing and advocating for appropriate and effective programs, services and policies for reducing HIV and STI transmission among MSM in the Greater Mekong Sub-region. Goal: To enhance and strengthen the capacity of the regional and in-country MSM working groups in developing and advocating for appropriate and effective programs, services and policies for reducing HIV and STI transmission among MSM in the Greater Mekong Sub-region.

Successes of The Purple Sky Network An MSM HIV prevention component is now in every national/provincial AIDS plan in the region An MSM HIV prevention component is now in every national/provincial AIDS plan in the region Working groups including government organizations, CBOs and NGOs in all countries Working groups including government organizations, CBOs and NGOs in all countries Opportunity for sharing experience Opportunity for sharing experience Regional advocacy training Regional advocacy training Behavior change communication training Behavior change communication training Development and monitoring of a two-year vision Development and monitoring of a two-year vision Regional network capacity building plan (in progress) Regional network capacity building plan (in progress) Network newsletter and website (in progress) Network newsletter and website (in progress)

Challenges in the Creation of Purple Sky Network Lack of epidemiological data Lack of epidemiological data Different political structures and circumstances Different political structures and circumstances Securing government buy-in Securing government buy-in Varying levels of CBO and NGO engagement and human resource capacity Varying levels of CBO and NGO engagement and human resource capacity Linguistic barriers Linguistic barriers

Key Lessons Learned in Supportive Interventions Regional multi-level partnership approach can facilitate tangible national commitment by various stakeholders Regional multi-level partnership approach can facilitate tangible national commitment by various stakeholders Donor, government and non- government participation important in driving agenda Donor, government and non- government participation important in driving agenda Data is important but don’t wait for “enough” Data is important but don’t wait for “enough” Regional coordination mechanism is a key component in facilitating regional collaboration Regional coordination mechanism is a key component in facilitating regional collaboration Structured response can expedite mobilization of resources and actions Structured response can expedite mobilization of resources and actions

Challenges to Implementing the MPS Resource requirement to develop, evaluate, and disseminate replicable models Resource requirement to develop, evaluate, and disseminate replicable models Limited funding available to scale up prevention services for MSM Limited funding available to scale up prevention services for MSM Government and donor funding very limited Government and donor funding very limited GFATM HIV grants were limited in prevention, but increasing with Round 8 GFATM HIV grants were limited in prevention, but increasing with Round 8 Weak linkages between community and clinical services Weak linkages between community and clinical services

Acknowledgements Cameron Wolf, Senior Regional Technical Advisor, USAID/RDMA Cameron Wolf, Senior Regional Technical Advisor, USAID/RDMA Patchara Rumakom, Strategic Information Advisor, USAID/RDMA Patchara Rumakom, Strategic Information Advisor, USAID/RDMA Clif Cortez, HIV/AIDS Team Leader, USAID/RDMA Clif Cortez, HIV/AIDS Team Leader, USAID/RDMA