1. Effective HIV & SRH Responses among Most at Risk Populations in Papua New Guinea Module 3: The Comprehensive Package of Programmes and Services for sex workers and their clients, MSM and transgender people

2. SESSION 2 A Comprehensive Package of Services for Sex Workers THE KEY ELEMENTS OF A COMPREHENSIVE RESPONSE

3.  The HIV and Sex Work Collection Key Elements Overview

4. Key Elements of a Comprehensive Response in Asia and the Pacific 1.community mobilization and organizational development of sex worker- led organizations and networks; 2.peer outreach, and education and drop-in services,; 3.promotion of and access to male and female condoms and water-based lubricants; 4.access to the full range of sexual and reproductive health (SRH) services to meet the needs of sex workers and their clients; 5.access to alcohol and drug-related harm reduction; 6.HIV voluntary testing and counselling; 7.access to HIV treatment, care and support; 8.preventing and addressing violence; 9.preventing and responding to stigma and discrimination; 10.economic empowerment programming; 11.advocacy and leadership building to reform laws, policies and law enforcement practices. Comprehensive Package of Services Key Elements

5. The Key Elements of a Comprehensive Response in Asia and the Pacific are aligned with the chapters of the SWIT Chapter 1 Community Empowerment: Key Element 1: community mobilization and organizational development of sex worker-led organizations and networks; Key Element 9: preventing and responding to stigma and discrimination; Key Element 10: economic empowerment programming; Key Element 11: advocacy and leadership building to reform laws, policies and law enforcement practices. Chapter 2 Addressing Violence against Sex Workers: Key Element 8: preventing and addressing violence. Chapter 3 Community-led services: Key Element 2: peer outreach, and education and drop-in services. Comprehensive Package of Services Key Elements

6. The Key Elements of a Comprehensive Response in Asia and the Pacific are aligned with the chapters of the SWIT Chapter 4 Condom and Lubricant Programming: Key Element 3: promotion of and access to male and female condoms and water-based lubricants. Chapter 5 Clinical and Support Services: Key Element 4: access to the full range of sexual and reproductive health (SRH) services; Key Element 5: access to alcohol and drug-related harm reduction; Key Element 6: HIV voluntary testing and counselling; Key Element 7: access to HIV treatment, care and support. Chapter 6 Programme Management and Organizational Capacity-Building Comprehensive Package of Services Key Elements

7. Group Activity Comprehensive Package Activity Comprehensive Package of Services Community Mobilisation KEY ELEMENT 1 Community mobilisation and organisational development of sex worker-led organisations and networks.

8. What is Community Mobilisation?  A process that is central to any community and social change effort that seeks to build support and participation of individuals, groups or institutions to work towards a common goal or vision  It is the development of community action around community issues. Comprehensive Package of Services Community Mobilisation

9. Why Community Mobilisation?  Attainment of rights  Knowing how to apply political pressure  Strengthening civil society and good governance  Empowerment and equity  Increasing community developmental capacity  Increasing social capital  Reducing HIV transmission, improving health & PLHIV support  Self-organisation and community capacity building. Comprehensive Package of Services Community Mobilisation

10. Source: SWIT Toolkit Elements of Community Empowerment Comprehensive Package of Services Community Mobilisation

11. Done for sex workersDone With & Led by sex workers Programmes sometimes focus on how sex workers can protect others from disease, and how society can be protected from sex workers. Often assume that knowledge and power reside with the programme staff and managers Programmes focus on sex workers’ collectively identified needs and develop appropriate solutions. Community discusses its needs before developing a programme, and sex workers are engaged in all stages of planning and implementation Involve sex workers in programme implementation commonly as volunteers, not as equal partners Involve sex workers as equal partners in programme implementation, more commonly as paid employees or as community outreach workers working with the community, not for external organisation Monitoring focuses on goods and services delivered and targets to be achieved. Monitoring focuses on quality of services and programmes, community engagement, community cohesion and community acceptance, as well as adequacy of service coverage Focus on building relationships within the health system with healthcare providers. Less emphasis is placed on building relationships among sex worker groups Focus on building relationships within sex worker communities as well as between sex workers and other organisations, service providers, human rights institutions and similar groups Comprehensive Package of Services Community Mobilisation Programme Approaches

12. Comprehensive Package of Services Community Mobilisation

13. The process of community mobilisation:  No fixed model  Often starts in response to an external force – injustice, discrimination, disaster, marginalisation  Requires passion, commitment and shared purpose  Timescale varies from community to community  Community strength usually develops gradually. Comprehensive Package of Services Community Mobilisation

14. Characteristics of mobilisation in key populations:  Usually grows out of marginalisation and injustice  Characterised by a struggle for rights and access to a fair go  Often involves a struggle against the mainstream & authority  Produces passionate advocates striving for justice  Characterised by a lack of trust in general community, government and services  Sometimes hard to shift from ‘angry advocate’ to ‘constructive collaborator’ as this often involves compromise. Comprehensive Package of Services Community Mobilisation

15. Sex workers self-organise to meaningfully participate in:  Choosing how they are represented and by whom  Choosing how they are engaged in the process  Choosing whether to participate  Having an equal voice in how partnerships are managed. Comprehensive Package of Services Community Mobilisation

16. Sex worker-led outreach programmes focus on:  The needs and experiences of sex workers themselves, not what programmers think sex workers need  The sex worker-led outreach process itself with emphasis on ways of protecting sex workers, rather than on process indicators (for example: counting the number of condoms distributed is part of a programme, but should not be seen as an end in itself)  Stimulating community empowerment and creating a collective identity among sex workers. Comprehensive Package of Services Community Mobilisation

17. Group Activity Comprehensive Package Activity KEY ELEMENT 2 Peer outreach, and education and drop-in services, including linking or providing services within sex worker specific programmes such as for sexually transmitted infections (STIs), voluntary testing and counselling (VTC) and family planning. Comprehensive Package of Services Peer Education, Outreach & Services

18. What is sex worker Peer Education?  Sex workers educating other sex workers How is Peer Education delivered?  Through Outreach  Through tailored print materials and mass-media  As part of other health service delivery. Comprehensive Package of Services Peer Education, Outreach & Services

19. What is Peer Outreach?  Peer-led engagement with sex workers where they are Where does Peer Outreach Occur?  At places sex workers meet for social and sexual connections  In clinical settings  Via the internet  At non sex work-based venues  Other Comprehensive Package of Services Peer Education, Outreach & Services

20. sex worker 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 sex work industry Comprehensive Package of Services Peer Education, Outreach & Services Why Peer Education And Outreach?

21. Peer Education Outreach Workers support behaviour change by: Providing correct information 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 sex workers who inject drugs Promoting the need for regular STI check-ups and prompt treatment of STIs Comprehensive Package of Services Peer Education, Outreach & Services

22. Encouraging HIV testing Encouraging knowledge sharing with peers to adopt safe sexual and drug use practices Promoting monitoring one’s health status for sex workers who are HIV positive Assisting in dealing with gender based violence Discussing and providing support related to sexuality Assisting peers in dealing with stigma and discrimination Comprehensive Package of Services Peer Education, Outreach & Services

23. Extended Peer Outreach may also: Provide voluntary rapid testing and double rapid testing in outreach settings Provide post-test counselling Promote, explain and record SRH clinic visits and VCT referrals Promote, explain and record alcohol and drug harm reduction services and provide referrals Accompany sex workers to clinical services and advocate for them as needed Ensure that the quality of clinical services is high and that there is no coercion at the facility Comprehensive Package of Services Peer Education, Outreach & Services

24. Group Activity Comprehensive Package Activity Comprehensive Package of Services Condoms and Lubricant KEY ELEMENT 3 Promotion of and access to male and female condoms and water-based lubricants, including strategies to ensure demand, access, utilisation and supply — particularly in sites where sex work takes place — community awareness and acceptance of condom use and empowering sex workers to negotiate condom use.

25. Condoms are the single most effective available technology to reduce the sexual transmission of HIV and other sexually transmitted infections Comprehensive Package of Services Condoms and Lubricant What and Why?

26.  Sex workers provided with consistent, high quality male and female condoms and water-based lubricants  Sex workers provided with education on correct and consistent condom use, including negotiation skills  An enabling environment for condom programming is created. Comprehensive Package of Services Condoms and Lubricant

27. Group Activity Comprehensive Package Activity Comprehensive Package of Services SRH Services KEY ELEMENT 4 Access to the full range of sexual and reproductive health services to meet the needs of sex workers and their clients. This includes diagnosis and treatment of STIs, the full range of contraceptive methods and counselling to prevent unintended pregnancies, access to antenatal, delivery and post-natal care, including access to antiretroviral drugs for mothers and to prevent vertical transmission.

28. What is STI diagnosis and treatment for sex workers:  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 and affordable for asymptomatic STIs Comprehensive Package of Services STI Diagnosis & Treatment

29. STI diagnosis and treatment is essential for sex workers as:  Presence of STIs increases the risk of an individual contracting and transmitting HIV. Treating STIs reduces HIV risk  Asymptomatic or symptomatic untreated STIs can lead to complications including infertility  Reaching sex workers through STI clinical testing and treatment increases opportunity to provide HIV education, condoms, lubricants and broader SRH services  Their Health is Their Wealth! Comprehensive Package of Services STI Diagnosis & Treatment

30. Contraceptive methods and counselling services 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 Comprehensive Package of Services Contraceptive Methods & Counselling

31. 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

32. From “Contraceptive Options for EWs and PLHIV Flipbook” Smart Girl Campaign Comprehensive Package of Services Contraceptive Methods & Counselling Condom Dual Protection and Dual Methods of Contraception

33. Comprehensive Package of Services Contraceptive Methods & Counselling Condom Dual Protection and Dual Methods of Contraception

34. 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  Male latex condoms are proven to protect against STIs including HIV. Comprehensive Package of Services Contraceptive Methods & Counselling

35. Comprehensive Package of Services Safe Abortion & Post Abortion Care Safe Abortion Services Where Legal Where legal, sex workers should have access to abortion and post-abortion care services to reduce related morbidity and mortality.  WHO Recommendations (2012):  Safe abortion services should be readily available and affordable  Strengthen policies and services  Develop evidenced based national standards and guidelines for safe abortion care  Training of 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.

36. Maternal Child Health is essential for sex workers Comprehensive Package of Services Antenatal, Delivery and Post-Natal Care To Protect Mother To Protect Baby

37. Comprehensive Package of Services Antenatal, Delivery and Post-Natal Care Safe Pregnancy  If a sex worker 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

38. What is PMTCT for sex workers:  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. Comprehensive Package of Services PMTCT

39. Comprehensive Package of Services Reproductive Tract and 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  Links to treatment services should be provided.

40. Comprehensive Package of Services Hormone Treatment for Transgender Sex Workers  Transgender people use hormonal therapy for its feminizing (oestrogen) or masculinizing (testosterone) effects  At present, no consensus on the safest and most effective dosing regimens for hormonal therapy for gender transition  High doses have potentially serious side-effects  A qualified practitioner should be consulted and continue to be engaged whilst considering and taking hormonal therapy.

41. Group Activity Comprehensive Package Activity KEY ELEMENT 5 Access to alcohol and drug-related harm reduction, including needle and syringe programmes and opioid substitution therapy. Comprehensive Package of Services Alcohol and Drug Harm Reduction

42. Some sex workers use drugs. Some injecting drug users sell sex. Therefore … All sex workers 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 Therapy. Comprehensive Package of Services Alcohol and Drug Harm Reduction

43. Group Activity Comprehensive Package Activity Comprehensive Package of Services HIV Testing and Counselling KEY ELEMENT 6 HIV voluntary testing and counselling.

44. What is HIV Testing & Counselling for sex workers?  Free, voluntary, confidential and readily accessible HIV Testing and Counselling with informed consent  Rapid testing where possible  Links to services  Meaningful knowledge of status HIV Testing & Counselling is essential for sex workers as:  Increased risk of contracting and transmitting HIV  Universal Access Right Comprehensive Package of Services HIV Testing and Counselling

45. Group Activity Comprehensive Package Activity KEY ELEMENT 7 Access to HIV treatment, care and support. Comprehensive Package of Services HIV Treatment, Care & Support

46. What is HIV Treatment, Care & Support for sex workers?  Available, affordable and consistent access to treatment, care and support for sex workers and their families HIV Treatment, Care & Support is essential for sex workers as:  Universal Access Right Comprehensive Package of Services HIV Treatment, Care & Support

47. Group Activity Comprehensive Package Activity Comprehensive Package of Services Prevent & Address Violence KEY ELEMENT 8 Preventing and addressing violence.

48. What is Preventing & Addressing Violence for sex workers?  Safe spaces for sex workers to share their experiences and protective strategies  Capacity building of sex workers to seek legal justice  Available, affordable and consistent access to health services. Preventing & Addressing Violence is essential for sex workers as:  Increased risk of violence  Association between violence and sexual health risk  Legal environment may impede access to health & law services  Human rights. Comprehensive Package of Services Prevent & Address Violence

49.  Modelling estimates a reduction of approximately 25% in HIV infections among sex workers may be achieved when physical or sexual violence is reduced (Kenya and Ukraine)  Addressing violence can make it easier for sex workers to access services and make their own choices about their long term health and welfare Comprehensive Package of Services Prevent & Address Violence

50. Group Activity Comprehensive Package Activity Comprehensive Package of Services Respond to Stigma & Discrimination KEY ELEMENT 9 Preventing and responding to stigma and discrimination, including in health care settings, through stigma reduction strategies, community legal education and access to legal services.

51. What is responding to stigma and discrimination for sex workers?  Community Mobilisation:  Build partnerships to ensure sex workers are able to self organise and self-identify as sex workers without fear of arrest, harassment and stigmatisation  Sex workers to take part in initiatives to address stigma and discrimination, confront violence and harassment, and create social support systems Comprehensive Package of Services Respond to Stigma & Discrimination

52. What is responding to stigma and discrimination for sex workers?  Structural interventions:  Address social exclusion, punitive laws, violence, stigma and discrimination  Support shift from disempowerment to empowerment  Build partnerships between sex worker organisations, police and health service providers to support an enabling environment Comprehensive Package of Services Respond to Stigma & Discrimination

53. Responding to stigma and discrimination is essential for sex workers as:  Stigma and discrimination are barriers to accessing HIV prevention, treatment and care and SRH services  Stigma in the form of devaluing, discounting and discrediting sex workers results in marginalisation and the inability to fully participate in community life or access health services. Comprehensive Package of Services Respond to Stigma & Discrimination

54.  93% of respondents from 8 Asia and Pacific countries reported stigma and discrimination, including self inflicted or imposed, affecting health seeking behaviors of SW  71% reported lack of sex worker friendly services, poor status of health care services and limited access discourages sex workers from seeking healthcare including uptake of treatment. Key IssuesResponses Stigma and discrimination 93% Criminalization of sex work 36% Mobility of sex workers 36% Accessibility & lack of a conducive environment in the delivery of healthcare services 71% Source: UNAIDS 2011 Barriers to Scaling Up Effective Interventions for sex workers: Comprehensive Package of Services Respond to Stigma & Discrimination

55. Group Activity Comprehensive Package Activity Comprehensive Package of Services Economic Empowerment KEY ELEMENT 10 Economic empowerment programming that expands choices for control over financial resources and generation of additional or alternative income.

56. What is Economic Empowerment for sex workers:  Initiatives to increase capacity and organisational development.  Sex Work Collectives  Micro-Credit and Income Generating Activities Economic Empowerment of sex workers is essential as:  Reduces vulnerability to coercion and in negotiation  Enables empowered decision in occupational choice  sex workers entitled to same rights as other informal workers:  Safe and fair working conditions  Skills training and education for life  Bank accounts and fair credit programmes  Potential to support their families and plan for their future. Comprehensive Package of Services Economic Empowerment

57. Group Activity Comprehensive Package Activity Comprehensive Package of Services Advocacy & Leadership Building KEY ELEMENT 11 Advocacy and leadership building to reform laws, policies and law enforcement practices that undermine rights and impede an effective response and to promote protective laws, policies and practices that support effective responses.

58. What is Advocacy & Leadership Building for sex workers?  Providing capacity building for sex workers and Organisations to confidently conduct well-informed advocacy that influences decision makers and promotes positive change  Advocacy is an important activity which must be integrated into sex worker HIV & SRH interventions. Comprehensive Package of Services Advocacy & Leadership Building Advocacy is an individual or collective effort to raise the voices of those unable to fully exercise their basic rights as a citizen of a country, because the enabling environment to do so is lacking or absent

59. Advocacy and leadership building:  Is essential for sex workers as it aims to:  Change laws and policies that criminalise sex work and administrative laws that are used to harass and abuse sex workers – reduction in violence  Change law enforcement practices that harass or abuse sex workers and deny human rights  Counters stigma and discrimination against sex workers and promotes sex work as work  Creates a more empowered and enabling environment for safe sex work and access to health and legal services. Comprehensive Package of Services Advocacy & Leadership Building