1. Reaching out, Stepping up: Working with Vulnerable Populations in a Difficult Context Melbourne - July 23 rd, 2014 Dr. Cherif Soliman FHI 360 - Egypt

2. HIV/AIDS Situation in Egypt General Population : about 87 million (CAPMAS Egypt) UNAIDS estimates: – 6,500 PLHIV (4,300 – 10,000) – Estimates for MARPs (2011): 100,000 IDUs 48,000 MSM 24,000 FSWs – HIV Prevalence : less than 0.1% “Low prevalence does not mean low risk”

3. Challenges: Captaining Curling team = Skip & Sweepers

4. Challenges: Collaboration NGOs, Civil Societies Government Outreach, Limited servicesARVs, Viral load, Hospitalization Different key players are not always included

5. Challenges: Sustainability No income generating activities to ensure sustainability “My Pyramid, My Project”

6. IIIIII Challenges: Coordination Duplication and Competition

7. Weak Monitor and Evaluation system at both governmental and CSOs levels Research and Ethics principles are not always followed up Challenges: Data & Documentation

8. HIV Bio-BSS among MARPs (FHI 360/2006-2010) Groups20062010 Street boys Cairo0.0%0.5% Street girls Cairo0.0%0.5% FSW Cairo0.8%0.0% MSM Cairo*-5.7% (2.6 -10.1%) MSM Alex* 6.2% (1.7-14.4) 5.9% (3.0 -10.2%) MSM Luxor*-0.0% Male IDUs Cairo* 0.6% (0.1-1.8) 6.8% (3.9 -10.8%) Male IDUs Alex* -6.5% (3.3 -10.3%) * RDS population estimates

9. FSWs in Cairo (Bio BSS 2010) n=200n=73 Reported Condom Use during Last Sex n=200 Under 20 years of age10.5% Ever had sex before 16 years22.5% Currently married45.5% Injecting drugs in past 12 months6.0%

10. MSM in Cairo and Alexandria (Bio BSS 2010) Reported Condom Use during Last Sex Cairo n=260 Alexandria n=262 Ever had sex with a female39.8%59.2% Currently married3.4%4.7% Injecting drugs in past 12 months2.3%4.9% Forced sex with a male partner in past 6 months12.7%14.6% n = 87 n = 83

11. Male IDUs in Cairo and Alexandria (Bio BSS 2010) Cairo n=275 Alexandria n=285 Currently married48.7%29.3% Shared needles with one or more partners in past month22.9%40.5% Ever had sex with a male14.3%7.7% n= 182 n=175 n=29 n=32 n=93 n=61 Reported Condom Use during Last Sex

12. Transmission through Mosquito Bites FSWs: 20.8% Male IDUs: 35.3% MSM: 35.9 % Ever Tested for HIV FSWs: 3.4% Male IDUs: 9.5% MSM: 22.1% HIV/AIDS Misconceptions among MARPs in Cairo

13. Peer Education VCT Clinic Provision Syringes Condoms IEC Counseling Addiction HIV Rehab. ARVs Social Legal Medical Religious STI General Home care HIV Support Groups Approaches for Services Provided to MARPs FHI 360 Comprehensive Care Center (CCC) Referral Outreach

14. Approaches for Services Provided to MARPs Direct Referral Direct Street Referral No CCC Outreach

15. Building a Good Will (Benefit for All) Potential Complications Transmission Dynamics at the Population Level

16. Adapted Harm Reduction Approach that consider local context Overlap of Risk Behaviors Combination of safe sex and safe injection Security Concerns New needle & syringe instead of needle exchange High Stigma towards MSM and FSWs IDUs are the entry Point to outreach Other stigmatized populations Gradual implementation Different outreach techniques Provision of services for all MARPs & related communities Anonymous, confidential and free of charge

17. Difficulty in Dealing with MARPs For All – Stigma and discrimination – Lack of trust – Security issues Females – Not motivated to participate – Low status limit ability to negotiate safer sex, obtain information and receive health care Male IDUs – Lack of concentration (High on drugs) – More concern toward Hepatitis Infection FSWs – Weak networks – Very low self-esteem – Pimps are the principal recruiters

18. Location of the CCCs Connection Path between Rich and Poor Districts

19. Standardized, high quality and stigma-free services for MARPs and related communities 23 Members (Dec 2013 till June 2014) 13 CSOs/Projects 4 UN agencies 2 Funding agencies: Drosos Foundation – Ford Foundation NAP FHI 360 Beneficiary Resource Person

20. NAHR Objectives Establish NAHR as coordinating body for all harm reduction projects in Egypt Strengthen the capacity and improve access to quality services for MARPs and PLHA Reduce stigma and discrimination among MARPs and PLHA through advocacy

21. Outreached (n = 3859) Visited the CCCs (n=3215) Received Full VCT (n= 2902) Number of Condoms Distributed (n= 17927) NAHR Beneficiaries reported by 6 CSOs (Jan 2013 – May 2014)

22. NAHR Beneficiaries (n=3215) (Jan 2013 – May 2014) 2.7% were detected HIV+ve 11 Support Groups (143 sessions – 90 beneficiaries) MSM 39% IDUs 51% Others 8%

23. Religious Leaders are the Best Supporters

24. 1.Equal Rights, Care and Support for all human beings 2.Build a Good Will (Benefit for all) 3.Reduce vulnerability (do not push MARPs for confrontation) 4.Empower MARPs to deal with their needs 5.Build social capital among members 6.Partnerships and collaboration (Synergy); CSOs, Gov. etc. 7.Provide continuous capacity building for high quality of services 8. Identify creative ideas to attract females Elements for Success

25. 9. Create an enabling environment (supportive groups including religious leaders) 10. Adapt Harm Reduction approaches that: - Consider local context - Deal with different risky behaviors - Provide services to partners and family members as well 11. Develop a strong M&E system; transparency in sharing information 12. Ensure participation, commitments and ownership of all members (including MARPs and peers)

26. Thank You