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1. 2 Identification of Human Trafficking Victims by Health Professionals – Suzanne T Poppema, MD ARHP Conference September 21, 2013 1.

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Presentation on theme: "1. 2 Identification of Human Trafficking Victims by Health Professionals – Suzanne T Poppema, MD ARHP Conference September 21, 2013 1."— Presentation transcript:

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2 2 Identification of Human Trafficking Victims by Health Professionals – Suzanne T Poppema, MD ARHP Conference September 21, 2013 1

3 Looking Beneath the Surface: Role of Health Care Providers in Identifying and Helping Victims of Human Trafficking NATIONAL SYMPOSIUM ON THE HEALTH NEEDS OF HUMAN TRAFFICKING VICTIMS POST-SYMPOSIUM BRIEF Erin Williamson, M.P.A., M.S.W., Nicole M. Dutch, B.A., and Heather J. Clawson, Ph.D. ACF(Admin for Children & Families) » Office of Refugee Resettlement » Anti-Trafficking in PersonsOffice of Refugee Resettlement US DHHS’ Campaign to Rescue and Restore Human Trafficking Victims

4 Presentation Overview Understanding human trafficking Identifying human trafficking victims Health problems of trafficking victims Special considerations when working with trafficking victims Support for victims through Trafficking Victims Protection Act of 2000 (the TVPA)

5 Human Trafficking: What Is It? Human trafficking is a form of modern-day slavery Victims of trafficking exploited for commercial sex or labor purposes Traffickers use force, fraud or coercion to achieve exploitation After drug dealing, human trafficking is tied with the illegal arms trade as the second largest criminal industry in the world, and it is the fastest growing.

6 Human Trafficking: What Is It? Sex Trafficking: Commercial sex act induced by force, fraud or coercion, or in which person performing the act is under age 18. –Victims can be found working in massage parlors, brothels, strip clubs, escort services Labor Trafficking: Using force, fraud or coercion to recruit, harbor, transport, obtain or employ a person for labor or services in involuntary servitude, peonage, debt bondage or slavery –Victims can be found in domestic situations as nannies or maids, sweatshop factories, janitorial jobs, construction sites, farm work, restaurants Crime of trafficking occurs with the exploitation of the victim. The physical movement of the victim is not a requisite. The TVPA protects both U.S. citizens and non-citizens.

7 Human Trafficking: How Are Victims Trafficked? Force, fraud and coercion are methods used by traffickers to press victims into lives of servitude, abuse –Force: Rape, beatings, constraint, confinement –Fraud: Includes false and deceptive offers of employment, marriage, better life –Coercion: Threats of serious harm to, or physical restraint of, any person; any scheme, plan or pattern intended to cause victims to believe that failure to perform an act would result in restraint against them; or the abuse or threatened abuse of the legal process.

8 Human Trafficking: Who Are Victims? Approximately 800,000 to 900,000 victims annually trafficked across international borders. Between 18,000 and 20,000 victims trafficked into United States annually. More than half of victims trafficked into United States are thought to be children; victims are probably about equally women and men. Victims can be trafficked into the U.S. from anywhere. Victims have come from, among other places, Africa, Asia, India, Latin America, Eastern Europe, Russia and Canada.

9 Many victims in the U.S. do not speak English and are unable to communicate with service providers, police, or others who might be able to help them. Often kept isolated and activities restricted to prevent them from seeking help. May be watched, escorted or guarded by traffickers Traffickers may “coach” victims to answer questions with cover story about being wife, student or tourist. Victims comply and don’t seek help because of fear Within the U.S., both citizens and non-citizens fall prey to traffickers. Purpose for coming to United States and immigration status no longer issue when determined to be victim of trafficking. Human Trafficking: Who Are Victims?

10 Trafficking Victims: Understanding Mindset Frequently victims: Do not speak English and are unfamiliar with the U.S. culture Confined to room or small space to work, eat, sleep Fear, distrust health providers, government, police –Fear of being deported Unaware what is being done to them is a crime –Do not consider themselves victims –Blame themselves for their situations May develop loyalties, positive feelings toward trafficker as coping mechanism –May try to protect trafficker from authorities Sometimes victims do not know where they are, because traffickers frequently move them to escape detection Fear for safety of family in home country

11 11 10 Trafficked women Trafficked People Sex Workers Victims of Violence, Torture Immigrants Exploited Workers Understanding the Health Needs of Trafficking Survivors Zimmerman et al, LSHTM 2003

12 Identifying Victims of Human Trafficking Frontline health providers play important role identifying and helping trafficking victims While trafficking is largely hidden social problem, many victims are in plain sight if you know what to look for Very few places where someone from outside has opportunity to interact with victim

13 Identifying Victims of Human Trafficking Is potential victim accompanied by another person who seems controlling? Does person accompanying potential victim insist on giving information to health providers? Can you see or detect any physical abuse? Does potential victim seem submissive or fearful? Does potential victim have difficulty communicating because of language or cultural barriers? Does potential victim have any identification? Is potential victim suffering from common health problems experienced by trafficking victims?

14 14 Case Studies A woman kept in domestic servitude in the United States for several years was rescued when a neighbor, noticing that she had a large tumor, offered to take the woman to the emergency room/health clinic. Because the health providers asked the right questions they realized the woman was a victim of human trafficking. As a result, they helped the woman escape her situation. 13

15 15 Case Study A construction worker named Philip visits a community health centre seeking treatment for a chest infection. While treating him, the doctor and nurse notice serious bruises on his chest and forearms. They ask him if he was in an accident at his work at a construction site. He says no, he just tripped and fell. They leave the topic alone for the moment, but a few details Philip lets slip about his life make them begin to wonder. After the doctor treats his bruises and gives him a prescription for his chest infection, Philip says he’s worried he may not be able to afford the medication, because he hasn’t been paid yet for his work—and then he tells them the real story about his “accident”: It turns out that his employer beat him the day before when the coughing caused by his chest infection forced him to stop work early. Copyright © 2011 Province of British Columbia. 14

16 16 Case Study 2 They find out that he has been living where he works, at the construction site, for more than two months, and that he does not have proper equipment: no helmet or steel-toed boots. After the doctor treats his bruises and gives him a prescription for his chest infection, Philip says he’s worried he may not be able to afford the medication because Copyright © 2011 Province of British Columbia. 15

17 17 Case Study 2 he hasn’t been paid yet for his work—and then he tells them the real story about his “accident”: It turns out that his employer beat him the day before when the coughing caused by his chest infection forced him to stop work early. Copyright © 2011 Province of British Columbia. 16

18 Health Issues Associated with Victims of Human Trafficking Victims suffer from host of physical and psychological problems stemming from: –Inhumane living conditions –Poor sanitation –Inadequate nutrition –Poor personal hygiene –Brutal physical and emotional abuse –Dangerous workplace conditions –General lack of quality medical care

19 Health Issues Associated with Victims of Human Trafficking Preventive health care virtually non-existent Health problems typically not treated in early stages –Tend to fester until they become critical, life-endangering situations Health care frequently administered at least initially by unqualified “doctor” hired by trafficker with little regard for well-being of “patients” – even less regard for disease, infection or contamination control

20 Health Issues Associated with Victims of Human Trafficking Sexually transmitted diseases, HIV/AIDS, pelvic pain, rectal trauma and urinary difficulties Unwanted pregnancy, resulting from rape or prostitution Infertility from chronic untreated sexually transmitted infections or botched or unsafe abortions Infections or mutilations caused by unsanitary and dangerous medical procedures performed by unqualified individuals Chronic back, hearing, cardiovascular or respiratory problems from endless days toiling in dangerous agriculture, sweatshop or construction conditions Weak eyes and other eye problems from working in dimly lit sweatshops

21 Health Issues Associated with Victims of Human Trafficking Malnourishment and serious dental problems –These are especially acute with child trafficking victims who often suffer from retarded growth and poorly formed or rotted teeth Infectious diseases like tuberculosis Undetected or untreated diseases, such as diabetes or cancer Bruises, scars and other signs of physical abuse and torture –Sex-industry victims often beaten in areas that will not damage their outward appearance, like lower back

22 Health Issues Associated with Victims of Human Trafficking Substance abuse problems or addictions Psychological trauma from daily mental abuse and torture, including depression, stress-related disorders, disorientation, confusion, phobias and panic attacks Feelings of helplessness, shame, humiliation, shock, denial or disbelief Cultural shock from finding themselves in strange country

23 Communicating with Victims of Human Trafficking Before questioning potential trafficking victim, isolate individual from person accompanying her/him without raising suspicions –Individual accompanying patient may be trafficker posing as spouse, other family member or employer –Say that ER/health clinic policy is to examine patient alone Enlist trusted translator/interpreter who also understands victim’s cultural needs –If patient is child, important to enlist help of social services specialist skilled in interviewing child trafficking or abuse victims

24 Communicating with Victims of Human Trafficking For victim’s safety, strict confidentiality is paramount –Ask questions in safe, confidential and trusting environment –Limit number of staff members coming in contact with suspected trafficking victim Importance of indirectly and sensitively probing to determine if person is trafficking victim –May deny being trafficking victim, so best not to ask direct questions –Phrase “trafficking victim” will have no meaning

25 Communicating with Victims of Human Trafficking: Questions Can you leave your work or job situation if you want? When you are not working, can you come and go as you please? Have you been threatened with harm if you try to quit? Has anyone threatened your family? What are your working or living conditions like? Where do you sleep and eat? Do you have to ask permission to eat, sleep or go to the bathroom? Is there a lock on your door or windows so you cannot get out?

26 Communicating with Victims of Human Trafficking: Messages Gaining victim’s trust important first step in providing assistance Sample messages to convey: –We are here to help you. –Our first priority is your safety. – If you are a victim of trafficking and you cooperate, you will not be deported. –We will give you the medical care that you need. –We can find you a safe place to stay. –We can help get you what you need. –We want to make sure what happened to you doesn’t happen to anyone else. –You are entitled to assistance. We can help you get assistance. –If you are a victim of trafficking, you can receive help to rebuild your life safely in this country.

27 Victims of Trafficking and Their Needs There are four general areas of victim needs: Immediate assistance –Housing, food, medical, safety and security, language interpretation and legal services Mental health assistance –Counseling Income assistance –Cash, living assistance Legal status –T visa, immigration, certification

28 Getting Victims of Human Trafficking the Help They Need If you think you have come in contact with victim of human trafficking, call National Human Trafficking Resource Center, 1.888.3737.888. This hotline will help you: –Determine if you have encountered victims of human trafficking –Identify local community resources to help victims –Coordinate with local social service organizations to help protect and serve victims so they begin process of restoring their lives For more information on human trafficking visit Call local police if victim at risk of imminent harm 1.888.3737.888

29 29 New Virtual Organization 29


31 MULTIPURPOSE PREVENTION TECHNOLOGIES (MPTS) FOR SEXUAL AND REPRODUCTIVE HEALTH Bethany Young Holt, PhD MPH Executive Director, CAMI Reproductive Health 2013 21 September 2013 – Denver, CO

32 Session Objectives This session is designed to help you do the following:  Define multipurpose prevention technologies (MPTs)  Describe existing MPTs in use globally  Describe the range of MPT delivery systems in development  Describe the challenges and timeline for MPTs development  Provide your input on MPTs that are in development

33 Global Need… HIV & STIs  In 2010, 1.8 million people died of AIDS… in 2009 an estimated 2.6 million become infected with HIV. 1  Young, married women are the fastest growing group of HIV+ people worldwide. 2  Worldwide, women are 5 times more likely to get sexually transmitted infections than men. 3  Each day, about 500,000 young people, mostly women, contract an STI. 3 4

34 Global Need… family planning  Each day, close to 800 women in developing countries die from complications related to pregnancy and childbirth. 5  An additional 15 to 20 million women suffer debilitating consequences of pregnancy. 6 Maternal Mortality Ratio, 2010  222 million women have an unmet need for modern contraception. 7  There are approximately 80 million unintended pregnancies in the developing world 7  Resulting in 40 million abortions, 30 million unplanned births, 10 million miscarriages. 7 8

35 In the United States  Nearly half of all pregnancies among American women are unintended, and four in ten of these end in abortion. 9  An estimated 750,000 women aged 15- 19 in US become pregnant annually, of which over 80% are unintended. 10,11  STIs are the most commonly reported communicable diseases in the US. 12  Of the 18.9 million new cases of STIs each year in the US, 9.1 million (48%) occur among 15-24 year olds. 12 13 14

36 What are Multipurpose Prevention Technologies (MPTs)? A single product or strategy, configured for at least two SRH prevention indications: Unintended pregnancy HIV Other STIs WHY MPTs?  Greater efficiency in terms of cost, access and delivery of SRH prevention products  Capitalize on the demand in populations using one product type to achieve uptake and use of a second “product”

37 MPTs: Historical Precedents H 2 O + flourideGrains + folic acidThe pill + iron

38 Why do women need MPTs?  Healthy timing & spacing of intended pregnancies  Protection against HIV  Protection against other STIs

39 MPT products currently available = Male and female condoms are the only currently available methods for prevention of multiple SRH risks

40 MPTs in the Pipeline Drug Combinations Bacterial Therapeutics Nanoparticles Drug/Device Combinations Multipurpose Vaccines

41 Successful products means listening to what women want… Product Prioritization and Gap analysis Ideal MPT Products Supported Technology Filter X1 3 Candidate MPTs Anti-retrovirals &non ARVs Other anti-infectives Contraceptives (hormonal/non-hormonal

42 INDICATION Mechanism of Action Formulation Dosage and Administration Complexity of developing MPTs 10 MPT IVR10 Single Indication IVR31 HIV Entry Inhibitors 3 On-Demand MPT12 On-Demand HIV Only11 Enzyme Inhibitors 2 Barrier MPT2 Injectable HIV Only7 Other HIV Inhibitors 23 HC products2 Lacto-based Products29 non-HC products

43 MPT Product Profile: Working Group Recommendations MPT PRODUCTS HIV/STI Prevention Contraception

44 Priorities for 1 st Generation MPTs Used around time of intercourse For women who have intermittent sex or want more direct control over their protection User-initiated, does not require daily action Should increase adherence and effectiveness Sustained release “On Demand”

45 On-Demand Products: Gels, NFDs 1 st proof-of-concept vaginal microbicide Coitally-dependent Confirmation trial underway for 2014 MIV-150 + Zinc Acetate + LNG in NFD Prevents pregnancy, HIV, HSV- 2, HPV Up to 24-hrs protection MZL Combo NFD (Pop Council) Tenofovir Gel (CONRAD)

46 On-Demand Products: Devices + Active Agents “One size fits most” silicone diaphragm Intended for OTC pregnancy prevention 5-yr shelf life, re-use up to 3 yrs SILCS barrier = delivery device Non-hormonal MPT protection: pregnancy, HIV, HSV2 up to 24 hrs + TFV Gel (CONRAD) SILCS (PATH, CONRAD, NICHD)

47 Sustained Release Devices: Combination Intravaginal Rings MIV-150 + Zinc Acetate + LNG Demonstrated single- API success Pregnancy, HIV, HSV2 DPV + LNG Testing underway, clinical studies 2013 Pregnancy, HIV TFV + LNG Testing underway, clinical studies 2013 HIV, HSV2 60-day Dapivirine + LNG (IPM) 90-day TFV + LNG (CONRAD) 30-day MZL Combo (Population Council)

48 MPT Target Product Profiles (TPPs) MPT Product Priority and Gap Analysis Priority Indications (Regional Differences): Pregnancy + HIV HIV + STI Pregnancy + STI Dosage Forms: “Suite of Products” Sustained release (IVR), LA Injectable, On-Demand Drugs: ARV for HIV, HC for pregnancy, STI specific drugs (GAP!) Non-ARV/non-HC options are longer term (GAP!) Other Product Attributes: Stability, shelf life, safety and efficacy targets, COST, scale- up, user preferences, adherence potential, market demand…

49 Single & Multipurpose Vaccines Today  Single purpose vaccines (e.g. HPV)  Multipurpose vaccines that include HBV (e.g. Twinrix) Future  Multipurpose STI vaccines (HSV, HIV, Gonorrhea, Chlamydia, Trichomonos, other STIs)  Reversible immunocontraceptives (e.g. anti-sperm)  What would your patients want in a multipurpose vaccine?

50 MPT Product Development Timeline NWJ Group, LLC PRE-CLINICALCLINICAL Q1Q2Q3Q4Q5Q6Q7 Q8 Y3 Y4Y5 Y6Y7

51 The Initiative for Multipurpose Prevention Technologies

52 Barriers to progress on MPTs

53 Initiative for Multipurpose Prevention Technologies (IMPT) Secretariat: part of the Public Health Institute Scientific Agenda Acceptability and Access Communications and Advocacy SRH Policy and Advocacy Orgs AVAC, ARHP, Guttmacher Institute Biotechnology Companies & Orgs Auritec, Mapp Biopharmaceutical, Medicines360, Osel, ReProtect, Teva, WomanCare Global Universities China, India, Kenya, Nigeria, South Africa, UK, USA National & Int’l Funding Agencies BMGF, ICMR, IPPF, USAID, USFDA, US National Institutes of Health, WHO, Wellcome Trust Research & Public Health Orgs California Family Health Council, CONRAD, IPM, Jhpiego, PATH, IPPF, Population Council, Public Health Institute, RTI International Funding Coordination

54 MPT: Conclusions and the Future So Far… MPT Products can potentially address major unmet medical needs for women globally Key advantages over current strategies The IMPT has defined product attributes for an MPT TPP Product specific MPT development is ongoing with partners The IMPT has defined MPT pipeline priorities and gaps Helps set the R&D agenda for the future Next… Informing/interacting with regulatory agencies and local country stakeholders will be crucial going forward Understanding market/commercialization issues for MPT is crucial to GO/NO GO decision making Consensus agreement on product priorities is crucial to achieve coordinated investment among funding organizations in MPT

55 Multipurpose Vaccines for Sexual and Reproductive Health Your Insights can help ensure acceptable and successful MPT development Make MPTs a reality!


57 Enter Question Text (a) HSV (genital herpes) + HIV (AIDS) (b) HSV + HIV + HPV (genital warts/cervical cancer) (c) HSV + HPV Which of the following vaccine combinations do you believe would be most useful for your clients? Q1

58 Enter Question Text (a) 30 – 49% (b) 50 – 69% (c) 70 – 89% (d) 90% + What do you believe is the minimum acceptable efficacy rate (for all the pathogens targeted) of a MPT vaccine? Q2

59 Enter Question Text (a) Injection (by provider) (b) Mucosal (needle-free and self- administered) Which type of vaccine administration do you believe your clients prefer? Q3

60 Enter Question Text (a) $50 – $99 (b) $100 – $149 (c) $150 – $199 (d) $200 – $249 (e) $250 – $300 How much do you believe most of your clients would be willing to pay for the entire series of an injectable MPT vaccine? Q4

61 Enter Question Text (a) Yes (b) No (c) No difference Would adding a reversible contraceptive vaccine to a multipurpose STI vaccine lead to an overall increase in uptake by your clients? Q5

62 Would adding a reversible contraceptive vaccine to a multipurpose STI vaccine lead to an overall increase in uptake by your clients? Q5 (a) Yes (b) No (c) No difference

63 The time for MPTs is now

64 Acknowledgements Thanks to the following individuals for their contributions to this effort:  Joseph Romano (NWJ Group)  Judy Manning (USAID)  Wayne Shields (ARHP)  Kathryn Stewart (CAMI)  Susan Rosenthal (Columbia U)  Diane Royal (CAMI)  Kevin Whaley (Mapp Biopharmaceutical)  Greg Zimmet (Indian U) … and the following organizations for their critical support:  Association for Reproductive Health Professionals  Bill & Melinda Gates Foundation  Mary Wohlford Foundation  Microbicide Trials Network  National Institutes of Health  Public Health Institute  US Agency for International Development  Wellcome Trust Learn more!

65 Support for this project is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the HealthTech Cooperative Agreement #AID-OAA-A-11-00051, managed by PATH. The contents are the responsibility of CAMI/PHI and its partners and do not necessarily reflect the views of USAID or the US Government. Thank you!

66 References Global Need: HIV & STIs 1.UNAIDS. Global Report: UNAIDS Summary of the AIDS Epidemic, 2010. 2.PATH, UNFPA. Female Condom: A Powerful Tool for Protection. Seattle: UNFPA, PATH; 2006. 3.UNFPA. Reproductive Health: Breaking the Cycle of Sexually Transmitted Infections, 2009. 4.UNAIDS. 2010: A Global View of HIV Infection. Global Need: Family Planning 5.WHO. May 2012. Fact Sheet No. 348: Maternal Mortality. Media Centre. 6.Ashford L. Hidden Suffering: Disabilities From Pregnancy and Childbirth in Less Developed Countries. Population Reference Bureau, 2002. 7.Singh S. and Darroch J.E. Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012. New York, NY: Guttmacher Institute and United Nations Population Fund (UNFPA), 2012. 8.WHO. 2010: Maternal Mortality Ratio. In the United States 9.Finer L.B. and Zolna M.R. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception, 2011: doi: 10.1016/j.contraception.2011.07.013. 10.Kost K., et al. U.S. Teenage pregnancies, births and abortions: National and state trends and trends by race and ethnicity. Guttmacher Institute, 2010. 11.Finer L.B. et al. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 2006: 38(2):90–96. 12.Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance, 2009. Atlanta, GA: U.S. Department of Health and Human Services, 2010. 13.Kost K. Unintended Pregnancy Rates at the State Level: Estimates for 2002, 2004, 2006 and 2008, New York: Guttmacher Institute, 2013. 14.Craft C. Sacramento County one of state's hotbeds for sexually transmitted diseases. Sacramento Bee, July 9, 2013.

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69 DISCLOSURES Dr. Teal has served on Scientific Advisory Boards for Actavis, Inc and Bayer Healthcare Ms. Romer has no potential financial conflicts of interest

70 LEARNING OBJECTIVES Develop strategies to make LARC placement the default clinic visit outcome Identify unique features of adolescents that impact the contraceptive initiation visit Integrate experiences of other session participants to improve your own service delivery model

71 WHAT IS BC4U? Adolescent-specific Title X clinic with: Dedicated schedulers/web appts Evening and same-day appts Offers same-day IUDs, implants and all other FDA approved methods Free Confidential All IUDs and implants: 100% OFF!!!

72 STARTING UP Hiring committed staff who shared the vision Training schedulers, MAs, all support staff Supply chain Supplies and equipment Promotion and outreach

73 WHAT DOES IT MEAN TO MAKE LARC INITIATION THE “DEFAULT OUTCOME” Assume the device goes in TODAY Minimize contraindications to ONLY what is solidly supported by evidence No funny feelings in left toe Always have provider available to place any device May need to change work schedules, change providers, change templates Address biases Have devices available Just do it!


75 Mean ± SD or % 21.3 ± 2.3Age (years)20.6 ± 2.7 Race/ethnicity 6.6%Black5.1% 29.7%Hispanic14.5% 26.4%White63.4% 33.6%Other/Mixed/ Not reported 17.0% 7.4 ± 0.8Uterine depth (cm)7.0 ± 0.8 73.4%LNG-IUS79.9% 1,182 INITIAL IUD ATTEMPTS n = 485 parousn = 697 nullips 4.2% 96.4% 95.8% 3.6% N.S. 1.1% Ancillary measures N=1182 Teal SB, et al Contraception. 2012; 86:291. 1,182 Initial IUD insertion attempts


77 ADOLESCENCE The process of cognitive, psychosocial and moral growth and development that transforms dependent children into independent self-sufficient members of society CHANGE

78 WHAT MAKES PROVIDERS DREAD INTERACTIONS WITH ADOLESCENTS? Narcissistic, self- absorbed Disrespectful Giggling Bravado Personal invulnerability Flip-flopping TMI Impulsive behavior Intensity of behavior Discomfort with adolescent sexuality Difficult to interview: 20 questions

79 WHAT MAKES ADOLESCENTS DREAD INTERACTIONS WITH PROVIDERS? Being judged Disrespectful of her decisions Minimization of seriousness of her life Threat to burgeoning autonomy Gulf between our worlds Natural alignment with parent

80 PUTTING IT ALL TOGETHER Let her try what she thinks she wants Respect her social networks as information sources Work within her framework


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