1. 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 Paris, France
#DoingTheRightThing
July 25, 2017

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

3. 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

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

5. 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)

6. 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.

7. Disaggregation

9. “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

10. 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 % 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)

12. 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

13. 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.

14. Systems for Monitoring Human Rights

15. 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

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

17. 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

18. 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

19. 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

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

21. 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

22. 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.

23. 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!

24. 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