1. Use of Referral Vouchers to Measure Increased Demand of HIV Testing and Counseling among Key Populations in Kyrgyzstan Djamila Alisheva, alisheva@psi.kg Population Services International /Central Asia, http://www.psi.org/central-asia 2 July 2013

2. The USAID Dialogue on HIV and TB Project is a five-year, USAID funded project to improve health behaviors among key populations. A consortium of INGO and NGO partners led by PSI provides a targeted outreach package of services tailored to each population. This includes HIV education on reduction of risky behaviors and referrals to government-provided HIV testing and counseling (HTC).  Target populations included in this analysis: Sex workers (SW); People Who Inject Drugs (PWID); Men who have Sex with Men (MSM).  17,390 unique individuals in Kyrgyzstan project target sites were reached with HIV prevention and referral from 2010 to 2012. Background

3. Main Entry Points for Key Populations into the Program Targeted Outreach Package of Services Case Management Referral Network Trainings: -Service Providers in the Referral Network - Social Workers in case management - NGO outreach models - Community Leaders - Journalists - Pharmacies - M&E Tools Trainings: -Service Providers in the Referral Network - Social Workers in case management - NGO outreach models - Community Leaders - Journalists - Pharmacies - M&E Tools Referral Services: -HTC -ARV treatment -STI testing and treatment -TB testing and treatment -Drug Detoxification & Treatment -MAT -Trust Points -Friendly Cabinets -Family Planning -Social services -Legal services -Support groups Referral Services: -HTC -ARV treatment -STI testing and treatment -TB testing and treatment -Drug Detoxification & Treatment -MAT -Trust Points -Friendly Cabinets -Family Planning -Social services -Legal services -Support groups Case Management: -Motivational Interviewing -Risk Assessment -Personal Action Plan -Referrals to health and social services -IEC materials -IPC activities -Condom distribution -MARP specific services -ARV and TB treatment adherence support Case Management: -Motivational Interviewing -Risk Assessment -Personal Action Plan -Referrals to health and social services -IEC materials -IPC activities -Condom distribution -MARP specific services -ARV and TB treatment adherence support TOPS Core Package: -IEC materials -IPC activities -Motivational Interviewing -Condom & lubricant distribution -Referrals to health and social services -Population specific services TOPS Core Package: -IEC materials -IPC activities -Motivational Interviewing -Condom & lubricant distribution -Referrals to health and social services -Population specific services USAID Dialogue on HIV and TB Project Collaboration: Partner Consortium, Regional Oversight Committee, Country Working Groups, Round Tables

4.  The referral voucher is an M&E tool used to measure the effectiveness of NGOs’ efforts in building demand for government-provided HTC services among key populations.  Voucher Referral System is endorsed by the Kyrgyzstan Ministry of Health: Issue of MoH Order “On improvement of measures on HIV and TB co-infection prevention in KR and assistance in the strengthening of the Referral system created for the most vulnerable groups”. Referral Voucher System (1)

5.  MoUs were signed among NGOs and government health facilities for ongoing support and collaboration. Facility providers participated in trainings under the project in use of referral system, stigma reduction and communication skills when working with key populations. Referral Voucher System (2)

6. PAGE 6  Outreach workers provide HIV education to improve health behaviors among key populations and referrals to government-provided HTC services.  Depending on the key population and needs of the individual, additional referrals are made to other governmental services: TB testing, family planning, dermatologist, psychologist, legal, etc.  In cases where the target individual fears going to a service facility alone, the outreach worker escorts the individual. Referrals and Linkages

7. Referral Voucher

8. Referral Voucher (back side)

9.  Providers – When a client presents voucher at the service point, the provider signs and collects the confirmed voucher for the project to pick up.  UIC – All clients use a Unique Identifier Code (UIC) to provide an anonymous way of monitoring services received and frequency of contact with unique individuals. The Voucher as a M&E Tool (1)

10.  Voucher – The UIC is written on both sections of the voucher to monitor both referrals issued and to confirm services received.  MIS – The project uses an Access-based Management Information System (MIS) where UIC data is entered when voucher is issued and again when redeemed. The Voucher as a M&E Tool (2)

11.  17,390 unique individuals (11,281 PWID; 4529 SW; 1580 MSM) were reached in the first three years of the USAID Dialogue on HIV and TB Project (2010 -2012).  3060 individuals were referred and received HTC services using referral vouchers. Individuals receiving HTC without the voucher are not included in voucher results. Results (1) page 11

12.  Although coverage refers to unique individuals, duplicate UICs are filtered out in MIS reports; service referrals are not filtered for duplication.  An individual UIC can be filtered in the MIS to see frequency of a referral service received during the life of the project.  Uptake of HTC among the three key populations using the referral voucher system increased significantly. Results (2) page 12

13. HTC Uptake Using Referral Vouchers (MARPs)

14. HTC Uptake Using Referral Vouchers (PWID)

15. HTC Uptake Using Referral Vouchers (SW)

16. HTC Uptake Using Referral Vouchers (MSM)

17. Lessons learnt (1) page 17  Success of the voucher system relies on governmental support and strong partnerships between government facilities and NGOs.  While the voucher itself has no financial value, uptake of services using the voucher allows the individual to overcome many obstacles: absence of passport/registration; escort and paid transportation as needed.

18. Lessons learnt (2) page 18  Stigma and discrimination, especially self stigma of populations fearing disclosure of unsafe behaviors when accessing HTC services, was reduced. Clients informally report friendlier interaction with providers when the voucher is presented.  A referral voucher can be used to measure a program’s contribution to increased demand for HTC, providing evidence to the government of civil society contribution towards reaching national health goals.

19. Questions ? Contact: Djamila Alisheva, Population Services International /Central Asia Email: alisheva@psi.kg 1 1 2 0 1 9 T H S T R E E T, N W | S U I T E 6 0 0 W A S H I N G T O N, D C 2 0 0 3 6 P S I. O R G | T W I T T E R : @ P S I H E A LT H Y L I V E S | B L O G : P S I H E A LT H Y L I V E S. C O M PSI