1. This project is funded by the European Union. Is SRH/HIV Integration Serving the Needs of Key Populations? Experiences from India and beyond Sunita Grote, Programme Manager: SRHR, India HIV/AIDS Alliance, New Delhi, India Reaching Key Populations through SRH/HIV Integration: Opportunities for Impact 22 July 2012  15:45-17:45  GV Session Room 1

2. Context Increasing policy support for integration, linkages and ‘convergence’ – NACP4 development – Rapid Assessment process – KPs? What KPs? – Organisational direction Policy guidance until recently drawn from lessons from generalised epidemics and the ‘general population’ Anecdotal evidence across existing programmes of unmet SRHR needs among key populations Concerns about preserving and increasing the gains made

3. Unmet SRHR needs among Key Populations

4. Female sex workers Avahan, FGDs, 146 FSW from 5 districts in Andhra Pradesh 20% reported experiencing STI-related symptoms in last 3 months; 20% reported menstruation-related problems; Oral contraceptive pills most popular contraceptive – limited information on side effects, correct use etc; 30% reported unintended pregnancies Most resorted to abortion (10% self-induced at home) Majority reported post-abortion complications Government clinics least preferred (stigmatising and judgmental, confidentiality).

5. Women who inject drugs Chanura Kol baseline (3 sites in Manipur, 150 women, 18-49 years) Vulnerability (both injecting drug use and sexual transmission) – Role of gender norms – Concealing drug use to providers – Sex work Only 58% reported condom use every time over previous month; Only 36% of women reported having regular menstrual cycles; Unmet contraceptive need for limiting - 56% of married women; 52% reported a STI-related symptom during the last 3 months; 15% experienced forced sex ; 17% physical violence in last 3 months.

6. People living with HIV Koshish, baseline study, 803 PLHIV (15-49) across four states 78% aware of at least one contraceptive method; Comprehensive knowledge of HIV lacking among upto 1/2; Misconceptions HIV transmission among up to 1/3; ¼ reported STI-related symptoms in the previous 3 months; Only 12% -44% of women reported seeking maternal health advice during their last pregnancy; Awareness of SRH services among women(around 2/3); But low levels of use (highest - contraceptive info at 25%); Significant proportion perceived rights violations in service settings as common

7. Challenges – integrated programming for KPs

8. Global review of over 160 resources focusing on SRHR/HIV integration for key populations Objective: Assess how SRHR/HIV integration can not only improve the efficiency of programs but truly serve the needs of key populations Analysed successful approaches and lessons learned to inform future programme development, implementation and evaluation

9. 3 of the top 10 challenges 1.Inappropriate design of HIV/SRHR integration Insufficient regard for community recommendations o New services and providers vs ‘using what’s there’ o Full integration of all services is not required – but appropriateness and accessibility of existing services must be ensured o Lack of understanding of specific needs Insufficient investment and attention to community systems and strengthening Capacity and attitudes among service providers – impact on referrals 2.Missed obvious opportunities for HIV/SRHR integration Positive prevention and SRH as core components in prevention-care-support- treatment-continuum Post-test counseling low (1/3) -information or counseling about safer sex and safer injecting drug use not provided, if then often judgmental

10. 3.Lack of rights-based approaches and rights Stigma and discrimination Sexuality, sexual and reproductive rights Coerced sterilisation and abortions Attitudes and impact on service delivery and rights violations Criminalisation and other laws compromising SRHR Disease-focus vs SRH and rights more broadly Addressing sources of vulnerability, sexuality and gender

11. Making SRHR/HIV integration work for key populations

12. Key steps Lessons learned showed key steps to maximize effectiveness of SRHR/HIV integration for key populations: 1.Promote good practice principles for key populations  Centrality of community organisations and systems  Key populations’ individual rights – and as people, not just their risk/vulnerability  Greater involvement of communities at all stages  Not only the needs of key populations, but those around them 2.Plan and start HIV/SRHR integration by building on ‘what’s there’, gathering evidence and identifying key entry points  Type of HIV/SRHR integration that is effective/possible -community input  The diversity of HIV/SRHR needs within key populations 3.Ensure comprehensive HIV/SRHR integrated programming  Comprehensive definitions of HIV and SRHR that go beyond the ‘usual suspects’  Types, levels and inter-relatedness of vulnerability  Stigma and discrimination

13. Key steps (2) 4.Ensure effective and creative service delivery  Demand as well as flexible delivery and supply  Training and spaces are appropriately targeted, comprehensive and high quality 5.Ensure a strong ‘chain’ of HIV/SRHR integrated services, including through high quality and systematic referrals  Quality, confidentiality and ‘key population-friendliness’ of receiving services in referral s 6.Build community and health systems, including an enabling internal and external environment  Build a multi-level approach that includes, but goes beyond, joint services 7.Address the political, legislative and funding context of HIV/SRHR integration for key populations  Local/national advocacy on legislative, structural and policy barriers to sexual and reproductive rights of key populations

14. People who use drugs Particular challenges (Chanura Kol, Manipur): – Criminalisation and harassment by police – Homelessness and associated vulnerability – Concealing of drug use to service providers – Interactions of drugs, treatment, contraceptives and their impact on SRH, pleasure and health-seeking behaviour – Continuity and follow-up Good practices – Little consensus, though integration of SRHR -> harm reduction/HIV more common than vice versa – Very specific capacity building of service providers – Gender-transformative approaches (injecting & sexual beh) – Recognition and response to need of women and partners of users

15. Recommendations

16. Linkages and integration of SRHR and HIV are a desirable outcome in the long- run. Integration of services and systems that are not ready can compromise access and quality for KPs – Is it really the most effective way to increase access and realise rights? – It’s not that simple! The voice of the client: – Participation and community recommendations on what works best in different settings – Full integration of services is not required –which directionality will be effective when and where? Community-health systems continuum – Integration and linkages at various levels – Community systems strengthening as core component to scale up integration and linkages Addressing vulnerability and realising sexual and reproductive rights

17. Thank you! Sunita Grote India HIV/AIDS Alliance sgrote@aidsalliance.org Like Alliance India on Facebook: facebook.com/indiahivaidsalliance