1. October 8, 2010 USAID Mini-University Clancy Broxton, MA, MPH Most At Risk Populations Advisor USAID Office of HIV/AIDS HIV Prevention for Most At- Risk Populations

2. Overview Discuss the definition of MARPs and why we should emphasize HIV prevention with MARPs ‘MARPs 101’: Review key interventions for most-at- risk populations ‘MARPs 102’: Discuss best practices in HIV prevention programming for MARPs Discuss emerging trends and innovations in HIV prevention for most at-risk populations

3. Who are the MARPs? Most at-risk populations (UNAIDS 2007): Drug using populations; Men who have sex with men (MSM); Persons engaged in sex work; Clients of persons engaged in sex work.

4. But if those are the MARPs, what about other vulnerable and high risk populations? Military and other uniformed services; Men and women engaging in transactional sex; Incarcerated populations; Mobile populations (e.g. migrant workers, trucker drivers); Street Youth; Persons who engage in alcohol-associated HIV sexual risk behaviors.

5. Not Distinct ‘Populations’ Sex Workers Men who have Sex with Men (MSM) Intravenous Drug Users (IDUs)

6. Why should we emphasize HIV prevention programming with MARPs?

7. Figure 2 Reason #1: MARPs account for the majority of HIV infections in most regions of the world Source: UNAIDS Epidemiological Update 2006 Source: UNAIDS

8. Country MSM Prevalence IDU Prevalence General Population Prevalence Brazil14.418-780.58 Kenya10.636-506.93 Zambia3342.517 Thailand24.611.521.55 Reason #2: MARPs have higher rates of HIV infection than the general population

9. Reason #3: MARPs have reduced access to healthcare and other public services

10. ‘MARPS 101’: MINIMUM PACKAGE OF SERVICES AND SUPPORTIVE INTERVENTIONS

11. Core components of MARP interventions:  Minimum package of HIV prevention services Supportive interventions for MARPs: o Measurement approaches o Enabling environment o Capacity building o Scaling Up o Monitoring and Evaluation HIV Prevention Programming for MARPs – A Strategic Approach

12. “Toolbox” for HIV Prevention with MARPs Referrals to non- clinical services Peer Education and Outreach Male and Female Condoms Measurement Approaches HIV Testing and Counseling Clean needle and syringe exchange Monitoring and Evaluation Scaling Up Lubricants Microbicides Capacity Building Medication Assisted Treatment Targeted Social/Behavior Change Communication STI Screening and Treatment Enabling Environment Skills Training

13. MINIMUM PACKAGE OF SERVICES FOR MARPs Kroeger, K and Patel, S, 2008 CLINICAL SERVICES STI Screening and Treatment HIV Counseling and Testing Needle and Syringe /MAT Programs HIV Care and Treatment SERVICES Targeted BCC, Risk Reduction Counseling, and Skills Training Condom and lubricant promotion/distribution NON-CLINICAL SERVICES Psychosocial and Legal Services FACILITIES Peer Outreach and Education CROSS- CUTTING ELEMENTS Dedicated ‘Friendly’ Clinics Mobile Outreach Services STI Screening Clinics/Facilities Primary Care Facilities HIV Care and Treatment Programs

14. Delivering an effective minimum package of services for MARPs Full, not partial implementation Ensure proper linkages between the different components ‘Friendly ‘services: –Non-stigmatizing –Confidential –Available and accessible

15. ‘MARPS 102’: BEST PRACTICES IN HIV PREVENTION PROGRAMMING FOR MARPS

16. ‘MARPs 102’: Comprehensive Services for MARPs Comprehensive Services: Psychosocial and Legal Services Substance abuse treatment Family Planning/RH Post-Exposure Prophylaxis (PEP) TB treatment Hepatitis treatment Male Circumcision Etc….. Comprehensive Package of Services Minimum Package of Services

17. ‘MARPs 102’: Package of Services for IDUs Core Interventions (WHO & PEPFAR): Community-based outreach; Needle and Syringe Programs (NSPs); Opioid substitution therapy (OST) and other drug dependence treatment; HIV counseling and testing (HCT); ART for IDUs living with HIV; Prevention and treatment of sexually transmitted infections (STIs); Condom programs for IDUs and their sexual partners; Targeted information, education and communication (IEC) for IDUs and their sexual partners; Vaccination, diagnosis and treatment of viral hepatitis Prevention, diagnosis and treatment of tuberculosis.

18. ‘MARPs 102’: Best Practices in Peer Education for MARPs  Includes product provision, behavior change messages, and linkages to services Other best practices: Provision of job aids/BCC Moderate supervision Peer groups with weekly meetings – social support Refresher trainings & Rotation of Messages Stipends for peer educators Badges/T-shirts/Identification  Involvement/ownership/ of peers

19. ‘MARPs 102’: Referral Tracking  Extremely important to establish effective referral systems Steps: 1.Establish referral linkages to ‘friendly’ providers 2.Track referrals using an agreed- upon system  Unique Identifier Code  Referral cards w/ follow-up 3.Enter information into a unified M&E system

20. ‘MARPs 102’: Unique Identifier Code Gray, R, Hoffman, L. (2008). Tracking coverage on the Silk Road: Time to Turn Theory into Practice. International Journal of Drug Policy, 19S, S15-S24.

21. CURRENT TRENDS AND INNOVATIONS IN HIV PREVENTION PROGRAMMING FOR MARPS

22. Trends in HIV Prevention Programming for MARPs- Behavioral Innovations Use of electronic media: Internet Websites Text Messaging Helplines: text/flash/phone lines YouTube videos

23. Trends in HIV Prevention Programming for MARPs- Behavioral Innovations Multiple Concurrent Partnerships & MARPs: Southern Africa – 53.7% of MSM reported both male and female sexual partners in past 6 months; 16.6% of MSM had bisexual concurrent relationships (Beyrer et al 2010) Only 12% of IDUs reporting penetrative intercourse with a primary partner reported always using condoms (Vanichseni et al 1993) Programmatic Conclusions: MSM programs: incorporate messages re dangers of concurrent partnerships IDU programs: include condom distribution and behavior change messages focused on sexual transmission

24. Trends in HIV Prevention Programming for MARPs- Biomedical Innovations Pre-Exposure Prophylaxis (PrEP) Chemophrophylactic use of an agent by HIV uninfected persons to avert infection. 11 trials ongoing (phases I-III) –Tenofovir disoproxyl fumarate (TDF) –TDF + FTC (emtricitabine) Potential to avert infections among MARPs as part of a combination approach

25. Biomedical Innovations – Male Circumcision for MARPs –Not proven effective for MSM –Can be targeted to high-risk men (clients of sex workers) –Useful at individual level –Unlikely to be cost- effective at pop’l level in conc epids

26. Trends in HIV Prevention Programming for MARPs – Non-Policy Structural Interventions Interventions to reduce vulnerabilities of MARPs leading to risk behaviors: Microfinance/Micro-Lending Economic Empowerment or Income Generation Activities Reducing gender-based violence Reducing stigma and discrimination

27. Thank You