1. 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

2. 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 %)
National estimate of PLHIV: 9,500
433 new HIV cases in 2013
Estimated # of HIV+ women (15 – 49 years): ,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

3. National Coverage: PWID

4. 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

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

6. 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

7. 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

8. 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)

9. 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.

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

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