Presentation on theme: "High Transmission Areas: Key Populations"— Presentation transcript:
1High Transmission Areas: Key Populations Additional Content to the National Sexually Transmitted Infections Care and Treatment Course for Health Care WorkersHigh Transmission Areas:Key Populations
2High Transmission Areas: Key Populations “No one is born hating another person because of the colour of his skin, or his background, or his religion. People must learn to hate, and if they can learn to hate, they can be taught to love, for love comes more naturally to the human heart than its opposite.” ― Nelson Mandela, Long Walk to Freedom
3High Transmission Area Programme (1) Created by NDoH as a means to control HIV through implementation of targeted interventions for key populationsVision of program focuses on:reducing HIV/STI/TB incidence among key populationsslowing HIV transmission in general populationimproving health outcomes of all key populations
4High Transmission Area Programme (2) Interventions: increased HIV prevention, care, treatment and support servicesServices include:HCT, STI, and TB screening and treatmentSexual and reproductive health screening and family planningProviding condoms and lubricantRisk reduction counselling, education
5High Transmission Area Programme (3) Strong focus on peer educationIntegrated approach – combined HIV/STI/TB – because of interacting causes of HIV/STI/TB risk and vulnerabilityStructural, biological, psychosocial and behavioural dimensionsBest way to create change and see improvements in the health of key populations
6Who are Key Populations in the Context of HIV/AIDS? ASK participants the question on the slide and allow time for them to respond before clicking through to the next slide.
7Key Populations Defined (1) Populations at higher risk of HIV exposure – more likely to be exposed to HIV or to transmit itIncludes both vulnerable populations and most at risk populationsEngagement of key populations is critical to a successful HIV responseSource: HEALTH SECTOR HIV PREVENTION STRATEGY FINAL DRAFT (1 October 2013)
8Key Populations Defined (2) Vulnerable:People who are particularly vulnerable to HIV infection in certain contexts, such as:adolescentsorphansstreet childrenpeople in closed settings (e.g. correctional centres)people with disabilities andmigrant and mobile workersMost-at-risk:men who have sex with mentransgender peoplepeople who inject drugssex workersoffenders in prison settingsCarry disproportionate burden of HIV and STIsSource: WHO 2014
9Key Populations NSP 2012-2016 Young girls Infants and children under age 15Sex workers and their clientsMen having Sex with MenMobile and migrant populationsClientele of taverns and shebeensOffenders in correctional facilitiesPeople living in unstable communitiesMen between ages 12-49Sero-discordant couplesHIV-infected pregnant womenTB/HIV co-infected patients
10Key Populations: Groups In this training, we will focus on the following key populations and issues specific to STIs:Sex workersMen who have sex with men (MSM)PrisonersRemind participants that all individuals who engage in sex are at risk of STIs. However, this module will provide additional content related to the special needs of several specific key populations, as they relate to STIs.
11What Makes These Populations Vulnerable? Sexual violenceDrug & substance abuseDecreased ability to negotiate safe sex practicesIncreased risk of violencePoor living conditionsUnique needs are ignoredStigma and discriminationLimited access to medical careLegal, political, religious and socio-cultural resistanceHostility and intolerance from the communityServices are deniedNote that this slide is animated.ASK participants the question in the slide title and allow time for them to respond before clicking through to show the answers.
12Values, Attitudes and Beliefs Our values, attitudes and beliefs are one of the most defining things about each of us. Think about your most important value. On a blank piece of paper, answer the following:Describe your most important values that make you who you are.Identify 3-5 beliefs that you find important.Who has influenced your values and beliefs and why?Why did you become a healthcare worker?CONDUCT activity as described on the slide.ALLOW 5 minutes for people to complete the questions.ASK for volunteers to give answers for each of the points listed on the slide.FACILITATE a brief discussion about values and beliefs and how that affects how we treat other people.HIGHLIGHT the role of the healthcare worker as a person who was trained to help others, regardless of who they are.SUMMARISE discussion by telling participants to be mindful of personal value systems as we continue today.Source: Adapted from Sex Workers: an introductory manual for health care workers in South Africa. Desmond Tutu HIV Foundation.
13When do values or beliefs become discrimination? DiscussionWhen do values or beliefs become discrimination?ASK participants question.FACILITATE brief discussion.Some Possible Answers:Denying treatmentTreating people differently based on some reason (for example, using two pairs of gloves when working with an MSM)Harming someone because of their sexual orientationPreferential treatment towards some more than others based on sexual orientation or other reasonsSUMMARISE discussion by saying that discrimination occurs when we let our values or beliefs impact the way we treat someone.
14HIV Prevalence Among MSM vs. All Adults EXPLAIN that the global prevalence of HIV in MSM compared with regional adult prevalence reported by UNAIDS, 2010We obtained prevalence estimates of HIV reported in MSM by country from reports published after 2007 from studies done during or after Prevalence in all adults was from UNAIDSWe include prevalence reported from biobehavioural surveillance without methods, sample size, or number positive in the prevalence map but not regional prevalence estimates. Error bars are 95% CIs.Rising HIV epidemic among MSM in many regions across the worldSource: Beyrer, C., Baral, S. D., Griensven, F. et al, . (2012). Global epidemiology of HIV infection in men who have sex with men. Lancet, 380(9839),
15MSM Risks Occur in the Context of Mature and Widespread HIV Epidemics Among Heterosexuals Slide Courtesy of Dr Stefan Baral
16Sex Work PrevalenceSlide Courtesy of Dr Stefan Baral
17Approximate Number of Sex Workers in South Africa (1) Female sex workers5% Male7 0004% Transgender6 000NATIONAL TOTAL% of adult female population(0,9%)Source: South African National AIDS Council, “Estimating the Size of the Sex Worker Population in South Africa, 2013” – Sex Workers Education & Advocacy Taskforce (SWEAT). Page 4, intermediate estimates.
18Approximate Number of Sex Workers in South Africa (2) Provincial distribution for intermediate estimateSource: South African National AIDS Council, “Estimating the Size of the Sex Worker Population in South Africa, 2013” – Sex Workers Education & Advocacy Taskforce (SWEAT). Page 4, intermediate estimates.
19Systematic Review of HIV Prevalence among Female Sex Workers Source: Baral, S et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet Infectious Diseases
20HIV among Offenders in South Africa South Africa has the highest number of offenders in southern Africa: 413 /HIV prevalence among offenders in South Africa:YearHIV PrevalenceSample Size22.8%HIV testing available to all sentenced offenders on average per year200619.8%8 649 (only participated)200241%Modelled projectionAsk participants why they think offenders would be at greater risk for STIs and a potentially vulnerable population?Discuss risk of MSM activity within correctional settings and risk of violence if reported. Thus, underlying the need for STI screening, condom provision and PEP availability and safety of individuals who do report rape/abuse.Source: Key Populations, Key Solutions: A Gap Analysis and Recommendations for Key Populations in South Africa, and Recommendations for the Ntaional Strategic Plan for HIB/AIDS, STIs, and TB (2012 – 2016), October 2011, pp
21DiscussionKey populations are estimated to contribute about one quarter of new HIV infections in South Africa*:How do you feel about this statistic?Why are key populations in our communities more at risk of HIV and STIs?How do my values or beliefs affect my opinion about this?How might my values or beliefs affect the way I deliver care to my clients who I suspect of being a key population?*Source: Getting to zero: HIV in eastern and southern Africa Regional Report. UNAIDS 2013This slide is animated. Ask each question and discuss before moving to the next question.FACILITATE a brief discussion. Note: Probe for personal opinions and how that affects care.EXPLAIN that populations key populations are more vulnerable to HIV infection due to a variety of factors:more frequent exposure to the virus,involvement in risky behaviours,potentially weak family and social support systems,Marginalization,lack of resources, andinadequate access to health-care services or poor treatment at health facilities discouraging them to return and stay engaged in careEXPLAIN that providers who hold stigma toward certain groups or behaviours may not wish to treat patients with those characteristics, or may not provide them with the same level of care they provide to other patients. Patients who feel that a health care provider holds negative attitudes toward them or people like themselves may avoid seeking care.SUMMARISE discussion by saying that sometimes value systems or beliefs can challenge our ability to provide the best quality of care to our clients. When we treat people differently or poorly for any reason, it may inhibit them from returning to clinic, even if they need clinical care. It is important that we treat all of our clients with the same dignity and respect, regardless of sexual orientation or circumstances. We are all human and we all deserve to be treated equally, as protected in the constitution.
22South Africa’s Constitution Protects Key Populations Section 9: the right to equality before the law and freedom from discrimination. Prohibited grounds of discrimination include race, gender, sex, pregnancy, marital status, ethnic or social origin, colour, sexual orientation, age, disability, religion, conscience, belief, culture, language and birth.Section 10: the right to human dignity.EXPLAIN that while sex work is currently illegal in South Africa, the South African government is currently in the process of potentially reforming the law and it may change in time. There is no laws that restrict healthcare workers from providing clinical care to sex workers, MSM or any other key population and the constitution still mandates freedom from discrimination.
23What are Some Interventions that May Benefit Key Populations? DiscussionWhat are Some Interventions that May Benefit Key Populations?ASK participants question.FACILITATE brief discussion as a means of transitioning and introducing the topic of interventions for key populations.
24Recommended Interventions for Key Populations Behavioural interventionsBiomedical interventionsStructural interventionsAdditional care and supportWhat are some examples of each of these types of interventions?Note that this slide is animated.ASK participants to give examples of each type of intervention before moving on to the next few slides.
251. Behavioural Interventions Peer education and outreachSexual health screening, risk reduction counselling and skills buildingPromotion, demonstration and distribution of condoms and lubricantsScreening and referral for drug and alcohol abusePromote utilisation of HIV, STI and TB screening and treatment
26Information, Education and Communication Awareness raising, information and education about HIV, STIs, viral hepatitis, and TB with all key populationsEspecially important in closed settings like correctional centresPeer education programmes, developed and implemented by trained key populationsFellow sex workersFellow offenders
27Counselling for Condoms (1) Provision and counselling towards consistent condom useAccess to lubrication especially for people practicing anal sexFemale and male condom demonstrationsCondom negotiation skills for sex workers:Taking client’s money prior to sexual encounter so clients cannot refuse to pay if condom is usedTaking client to known sex work venue where rules of the venue require use of a condomNegotiating with client to engage in non-penetrative sex, like oral sexIf safe, refusal to engage in sex without a condom
28Counselling for Condoms (2) Widespread condom accessibilityCondom negotiation skills for other key populationsPartner notification and partner treatment emphasis!Make condoms easily and discreetly accessible to offenders at various locations without having to request them & without them being seen by othersHCWs should distribute condoms and lubrication to offenders and have condom campaigns
29Male Condoms EXPLAIN steps in using male condoms: Use a new condom for each sex act.The condom should be put on with rolled side out after the penis is fully erect, and just before penetration.Pull foreskin back (if uncircumcised) and unroll condom all the way to base of penis.After ejaculation, hold bottom rim of condom in place, and withdraw penis while it is still hard.Once the penis is soft, the condom should be removed carefully without spilling the semen, wrap in paper or tissue and discard into dustbin. Do not put in a toilet.Do not use oil-based lubricant such as Vaseline or mineral oil, as they destroy the integrity of the condom. Use only water-based lubricants.Use condom only once.
30Female Condoms EXPLAIN steps in using female condoms: Open package carefully. Make sure the condom is well lubricated inside.Choose a comfortable position – squat, raise one leg, sit or lie down.Squeeze the inner ring at the closed end and gently insert the inner ring into the vagina.Place the index finger inside condom, and push the inner ring up as far as it will go. Make sure the outer ring is outside the vagina and the condom is not twisted.Be sure that the penis enters inside the condom and stays inside it during intercourse.To remove, twist outer ring and pull gently. Discard into dustbin.Try to use a new condom with each sex act.Do not use the male and female condom at the same time.
31MSM: Men who have Sex with Men A public health term used to define a risk group by its behaviourDifferent than identity: includes men who are homosexual, gay, bisexual and heterosexualMen usually do not identify themselves as ‘MSM’Sexual behaviours, orientation and identity may change over time for various reasonsIdentity and terms used to describe oneself may change
32Situational Role in Behaviour Some men have male-to-male sex due to the situation they are in and may not have homosexual orientationSingle-sex institutions:MilitaryCorrectional CentresBoarding schoolsWork in remote areasOther situations:Sex for moneyForced sexChildhood exploration of sex with male peers
33Male to Male Sexual Behaviour Overview Male-Male sexSimilar to male-female sexInvolves feelings and emotions as well as physical pleasureHow do MSM have sex?No fixed roles (insertive, receptive)Sexual tastes and likes can change over time
34Male-Male Sexual Behaviours (1) KissingTouchingOral sexAlso known as ‘fellatio,’ ‘blow job’The most common type of male-male sex, performed by more than 90% of MSM in some studiesEasily ‘performed,’ unobtrusive, easy to stop if interruptedIncludes licking the testicles and scrotumVery low risk for HIV infection, but can transmit STIs to the genitalia, oropharynx or face
35Male-Male Sexual Behaviours (2) Anal sexPracticed by both men and womenNot all MSM enjoy it or engage in itThe perianal skin, anal canal and rectum are rich in nerve tissue and can produce pleasurable feelings when stimulatedMassaging of the prostate during anal sex:Creates pleasurable sensationsHeightens orgasmIncreased risk of HIV and STI transmission if no condom and lubrication used
36Counselling on Anal Sex Practices Important with MSM clients and in correctional centre settingsPractice with fingers or sex toysGradually increase size of toys to train musclesUse of different positions and techniquesBacking onto penisSitting on penisBearing down (abdominal pressure)Deep breathing
37Penile-Anal Penetration Use plenty of water-based lubrication and condomsSelf-lubrication does not occurWater-based lubricantReduces trauma during penetrationDecreases ‘openings’ for infections, including HIVOil-based lubricants damage condoms - should be avoidedCleanlinessMen may be uncomfortable due to fear of faecal matterGentle cleaning with mild soap and water on the outside is sufficient
38Anal Play Use of toys (vibrators, dildos) to stimulate rectum Rub perineumInsert into anusObjects should not be shared to avoid pathogen spreadPeople should use their own toys or wash well before exchangingIf necessary, condoms can be used on shared toys
39Oral-Anal Sex Mouth-anal stimulation Sometimes called rimming or anilingusCan be foreplay to anal penetrationCan transmit STI or other infections (Hepatitis A, diarrheal diseases)Barriers can be employed to reduce pathogen riskPlastic wrapDental dams
40Safer Sexual Practices When providing counselling to patients about safer sexual practices, the following non-penetrative alternatives may be givenMasturbationThigh-sexBody rubbing, “dry humping,” massage
43Anorectal Region: Health Issues (1) Optimal anal health is important for MSM and transgender people who practice anal sexPerianal skin is tough but prone to damage from:Faecal soilingPersistent moistureToilet tissue abrasionAbrasion from scratching‘Dry’ anal sexForced, unlubricatedIrritating treatmentsOver the counter pastes, creamsSeek help before self-treatment
44Anorectal Region: Health Issues (2) Typical SymptomsPainLumpsUlcersRashesDischargeBleedingDifficulty defecatingTenesmusSensation of needing to pass stool accompanied by pain, cramping, strainingDetectionSTIs can be difficult to detectAsymptomaticMisinterpreted symptoms
45Anorectal Health Care: Perianal Cleansing Gently wash with water before/after anal sexMay reduce amount of bacteria that could be spreadMay also remove some of the body’s natural protection against infectionUse water only-- without soap or detergent-- can reduce the loss of this natural protectionIf decide to use soap: advise use of normal soap and water, not strong soap
46Anorectal Health Care: Barriers Condoms help prevent spread of STIs (including HIV) when worn prior to and during anal contactMale condomsFemale condoms, also termed receptive condomOral–anal contactSafest when non-permeable membrane usedCan use plastic food wrapActs as a barrier between the mouth or fingers and the anusADVISE that with the use of female condoms the internal ring should be removed for use during anal sex
47Anorectal Health Care: Lubrication Should be used during anal penetrative sex to prevent mucosal tearingAnus does not produce own lubricationUse water-based lubricant onlyOil-based lubricants can cause irritation and increase the risk of breakage of latex condomsIf lubrication not available, saliva can be usedAvoid spermicides
48Anorectal Examination Ask patient to roll to left side, facing away from you (‘left lateral position’)Hips and knees flexed towards stomachAsk patient to retract right buttock with right handInspect the perianal region & natal cleftLook for warts, ulcers, rashes, hemorrhoids, bleeding, discharge, fissures
49Digital Rectal Examination (1) Ensure patient is comfortableUse plenty of water-based lubricantUse slow circular motions as you advanceValsalva manoeuvre will relax anal sphinctersAs patient does this, slowly advance your middle finger in the anus as far as possibleCan take up to 1 minuteGauge their comfort
50Digital Rectal Examination (2) Note sphincter tone and any masses or disproportionate tenderness
51Digital Rectal Examination (3) ProstateGlandPalpate the prostateNote shape,consistency, regularity,and any tendernessProstate examination –should be performedin all men over 60Examine for symptomsof urinary obstruction(e.g. prostatitis, benign prostate hypertrophy)PROSTATE GLANDEXPLAIN that enlargement, tenderness or any masses can indicate infection of the prostate and/or prostate cancer.
52Digital Rectal Examination (4) Slowly withdraw your fingerMake note of any blood on examination fingerPerform testing on stool and rectal specimens if indicated
53Completion of Examination and Visit Remove & dispose of glovesProvide tissue for patient to wipe him/herselfAsk patient to dress & sit by desk againWash hands with soap and waterContinue sexual health consultationCollect specimens for diagnostic testsEmpiric treatmentPrevention counselling, condoms and lubricationCounselling and provision of partner notification slipsFollow-up
542. Biomedical Interventions HIV counselling and testing (HCT)HIV care and treatment (including ART)STI and TB screening and treatmentSexual and reproductive health servicesCondoms and lubricantsPost-exposure prophylaxisVoluntary male medical circumcision (VMMC)Biomedical interventions for PWIDEXPLAIN the last bullet further:PWID = people who inject drugsInterventions include:Needle and syringe exchange programmesDrug dependency treatmentDrug overdose prevention and treatment
55HIV Testing Coverage Among Key Populations, Regional Median, 2011 EMPHASISE that we need to do a better job with HCT uptake among key populations!Though HIV is concentrated among key populations, less than half of them know their HIV statusSource: Prepared by based on UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012
56ART Decreases hospitalisations Increases survival Slows replication of HIV (reduces viral load) and stops immune deteriorationImproves immune system function and prevents opportunistic infectionsAlters/reverses course of existing opportunistic infectionsDecreases hospitalisationsIncreases survivalImproves quality of lifeRestores hopeReduces HIV transmissionBenefits both adults and childrenEXPLAIN further about the benefits to using antiretroviral therapy:It helps to stabilise the immune system, reversing the progressive destruction of immune function and increasing the CD4 cell count.Because the development of opportunistic infections is associated with severe damage to the immune system and very low CD4 cell counts, these infections should be prevented with antiretroviral therapy. If the infections are already present, their course may be shortened or made less severe with antiretroviral therapy.Antiretroviral therapy has reduced hospitalizations for treatment of HIV-related infections and the death rate from AIDS has been dramatically reduced.The quality of life of HIV-infected individuals has improved with therapy, and their hope is restored.Antiretroviral therapy has been associated with major reductions in mother-to-child transmission in the developed world, and, by lowering the amount of virus in the blood, it is expected that other forms of HIV transmission may be reduced as well. Antiretroviral therapy has been shown to benefit both adults and children.The availability of therapy may be an incentive for voluntary HIV counselling and testing, which increases identification of HIV-infected individuals, allowing them to access health care and preventing further transmission.
57REDUCES HIV transmission by 96%. ART is essential to HIV prevention. ART and HIV PreventionART is a game changerWhen people take their medicine in the correctlyREDUCES HIV transmission by 96%. ART is essential to HIV prevention.
58DiscussionWhat are some challenges related to ART as prevention within key populations?ASK participants question.FACILITATE brief discussion.Some Possible Answers:DiscriminationClinic hours and distance challengingAdherence does not fit with lifestyle or creates stigma/risk of violenceEtc.SUMMARISE discussion by saying that multiple challenges can create barriers. Encourage a follow-up discussion related to solutions. The next slide demonstrates some of these.
59ART in Key PopulationsProvision of services responsive to needs and requests of clients (for example, evening and weekends)Community settings or decentralized services through mobile units to take service delivery to clients themselvesFamily-centredPatient-held records for mobile populationsNutritional supplements for offenders in the prison settingEqual access to ART provided to all offenders to ensure continuity of care at all stages, from arrest to releaseRespectful and non-judgmental staff attitudes
60Note that treatment of STIs still follows the NDOH algorithms – does NOT differ for key populations
61TB Screening (1)Screening is essential in prison populations and sex workersAccess to GeneXpert for timely diagnosis, especially for MDR-TBIntensified active case-findingCase finding tracked back to families for new offenders entering prison settingsPeriodic and systematic screening of entire prison populationsIPT
62TB Screening (2)Segregate offenders in prison setting until they are no longer infectiousEducate on coughing etiquette and respiratory hygieneContinue treatment during all stages of detention, from arrest to release in prisonsProvide PICT for persons with HIVAnnually screen healthcare workers and other staff working in prisons and clinics
63TB Screening Questions Have you had a cough for two weeks (or ANY duration if HIV-positive)Do you have a fever?Do you have drenching night sweats OR weight loss?Have you lost your appetite?
64Screening for STIsAll patients ages should be screened for STIs regardless of clinical presentationAsk the following 3 questions:Do you have any genital discharge?Do you have any genital ulcers?Has/have your partner(s) been treated for an STI in the last 8 weeks?
65STI Clinical Services: Sexual History Taking Can be learned with trainingBecomes easier with practiceMost patients are willing to answer detailed questions about their sexual behaviour if provider is comfortable and professional in approaching sexual historyImportant in all settings including prisons
66General Guidelines for Taking a Sexual History (1) Normalise sexual history as part of routine care for all patientsEnsure privacy and confidentialityDo not start patient visit with sexual history: discuss easier issues firstUse an open and non-judgmental attitude, good communication skills
67General Guidelines for Taking a Sexual History (2) Explain the reasons for taking a sexual historyAsk less-threatening questions firstGenital symptoms, last sexual episodesMake no assumptions! Ask all patients about same-sex and opposite-sex partnersFocus on sexual behaviour rather than orientation
68Privacy and Confidentiality The sexual history should be done in a private roomAuditory privacyOnly the provider and patient presentRequest family members and others to leave the roomCONFIDENTIALITYMedical information should not be released to anyone without the patient’s permissionReassure patient about the confidentiality of his/her medical information before taking the sexual history
69Communicating with the Patient Encourage patient communicationVerbal prompts: Yes, OK, Thank you…Reflecting and repeating what the patient saidNon-verbal prompts:Face the patientLook the patient in the eyeNod the headDo not label or categorise (MSM, gay, sex worker, etc.)Patient may choose to label himself or herselfUse words that the patient can understandExplain medical termsUse slang words if comfortable with them and used appropriately
70Prepare the Patient for the Sexual History Tell them that you are going to ask sensitive questionsGive them the option of not answeringReassure them the information is confidentialExplain why you are asking these questionsExplain that thisis part of theexamination for all patientsDIRECT attention to pictures on the slide.EXPLAIN that they should ask some specific questions:Do you have any sores or discharge from your penis, vagina mouth or anus?Does it hurt to pass urine?If female: Do you have pain in your lower abdomen?ANDHave you had contact with someone else’s genitals?
71Sample Script to Prepare the Patient Example: “I’m going to ask you questions about your sexual behaviour. These are questions I ask all my patients. This information will help me to treat you and give you the correct advice on how to protect your health. Everything you tell me is confidential and will not be released to anyone else without your permission. If there are questions that make you uncomfortable or you do not want to answer, just tell me…”
72Types of QuestionsAsk open-ended questions to get details of sexual behaviourWho, What, Where, HowAsk the patient to clarifyIn general do not ask ‘why’ questionsUsually not necessary to know why in regard to sexual behaviourAsking why implies the behaviour was bad and sounds like a parent scolding a childOne “Why” question that is OK:“Why did you not use a condom?”
73Sexual History: Sample Questions Can you tell me a little about your sex (romantic) life?When was the last time you had sex?Do you ever have sex with men?Do you ever have sex with women?Do you ever have sex for money or favours?When you have sex with men, what kind of sex do you have?Do you ever have oral sex? Do you ever have anal sex?When was the last time you had anal sex and did not use a condom?What got in the way of using a condom that time?What prevents you from always using a condom?
74STI Clinical ServicesSymptomatic screening of STIs including cervical and ano-rectal infectionsSyndromic case managementRegular screening for asymptomatic infections using lab testsType of ScreeningRecommended ActionSyphilis screeningIn MSM offer periodic serological testing for asymptomatic syphilis infectionOffer regular screening to sex workersGonorrhoea and chlamydia screeningIn MSM offer periodic testing for asymptomatic and rectal N. gonorrhoeae and/or C. trachomatis infectionPeriodic presumptive Treatment in sex workersIn areas where STIs>15% prevalence of N. gonorrhoeae and/or C. trachomatis infection with counselling and informed consentThis slide is sensitising HCWs that although the syndromic management approach is typically practiced within the general population, there are times when routine laboratory screening for asymptomatic STIs may be helpful. This is most useful in high risk populations, such as with key populations.
75STI Drug Resistance (2)Consider treatment failure with clients, especially MSM - at increased risk of resistanceAggressively treat suspected resistance cases according to the guidelinesTake swabs from all exposed anatomical sites which includes urethra, vagina, pharynx and ano-rectum in suspected resistance casesLook specifically for isolated Nisseria GonorrhoeaPartner notification slips and counselling on importance of partner treatment especially important!
76Sexual and Reproductive Health Services (1) Pregnancy testingFamily planning counselling and servicesProvision of contraception – dual methodsEmergency contraception within 5 days/120 hoursTOP and post-TOP servicesSafe pregnancy: ANC, HIV and STI prevention and testing, nutrition and safe deliveryEspecially important in female offenders prior to releaseFamily planning counselling for sex workersSexual historyMenstrual hygienePromote family planning methodsAssess need and counsel on family planning choices
77Sexual and Reproductive Health Services (2) Treatment of reproductive tract infectionsReproductive tract cancer screening (cervical, breast, anorectal and prostatic)Care for unintended pregnancies (post abortion care)Partner notification slips and counselling on importance of partner treatmentEMTCT services in prisons for HIV-positive pregnant women, with ensured continuity
783. Structural Interventions Services to mitigate sexual violenceSensitisation of healthcare workers, police, correctional staffCapacity building of Key Population support groups and individualsImplementation of existing policies that safeguard health rights of Key Populations
79Gender Based Violence/Sexual Assault Support Services (1) Complete history and physical exam to determine appropriate careEmergency contraception for women presenting within 5 days of sexual assaultHIV post-exposure prophylaxis for women presenting within 72 hours of assaultSTI post-exposure prophylaxis
80Gender Based Violence/Sexual Assault Support Services (2) Psychological support and careCrisis centresOther community resourcesVulnerable prisoners, such as people with different sexual orientation, young offenders and women should be held separately from adult or male offendersAppropriate measures to report and address instances of violence in prison settings
814. Additional Care and Support Psycho-social supportFamily and social servicesSubstance abuse services
82Key Populations Require a Tailored Counselling Approach Due to risk factors like increased stigma and gender based violence, counselling should be tailored to specific needs of each key population e.g.:PopulationCounselling NeedsPrisonerscondom negotiationHIV and TB counselling and testingSex workersgender based violence, negotiating safer sexprevention interventions (e.g. condoms, HCT, early treatment and TB screening)MSMsafe sex practicesearly treatment
83Crisis CounsellingWhat are some strategies you have used to counsel clients who have experienced gender based violence or sexual assault?
84Steps in Crisis Counselling Intervene immediatelyDetermine facts of crisisFocus on short-term goalsFoster hope and positive expectationsProvide supportFocus on problem solvingEXPLAIN that healthcare workers play a critical role in crisis counselling.REVIEW steps using additional points as necessary:Intervene immediatelyIndividuals cannot tolerate stress of a crisis for too longHe/she may become self-destructive if not given immediate helpDetermine facts of crisisEmbark promptly on helping client understand their crisisReview previous strengths and weaknessesReveal precipitating events before crisisFocus on short-term goalsHelp the client reach some sort of limited goalThis helps provide a sense of relief and control over the situationFoster hope and positive expectationsCounsellor should expect the client’s crisis to be resolved in some way at some timeThis expectation must be instilled in the client who works with the counsellor to solve the problemProvide supportOne of the reasons a problem develops into a crisis is lack of adequate social supportThe counsellor needs to provide support and also assist the client expand his/her support system as soon as possibleProvide attention to person in crisisFocus on problem solving:Determine main problemBrainstorm solutionsImplement realistic plan of action
85Mental HealthKey populations are vulnerable to mental health problems because of:PovertyMarginalizationDiscriminationViolenceScreen and provide treatment for depression, alcohol-use disorders, self harm, suicidal ideation, & other emotional or medically unexplained conditions
86Group ActivityIf a client feels she/he is being judged for lifestyle choices, what will happen?How can I ensure that my clients don’t feel judged?What is my role as a HCW in protecting the rights of key populations?What will I do to improve my clinical practices with key populations?How will I personally contribute to improving the quality of life of key populations in my community?Note: This slide is animated.ASK each person to pull out a piece of paper.READ the first question on the slide.ALLOW 2 minutes to answer it. Have each person write their response on their paper.ADVANCE the next question and repeat until all questions are done.ASK them then to turn to their neighbour and disclose their responses.ASK for a few volunteers to say their responses aloud to the entire group.
87For to be free is not merely to cast off one's chains, but to live in a way that respects and enhances the freedom of others. - Nelson Mandela
88References (1)D. Lewis, C. Sriruttan, Etienne E. Muller, et al. Phenotypic and genetic characterization of the first two cases of extended-spectrum-cephalosporin-resistant Neisseria gonorrhoeae infection in South Africa and association with cefixime treatment failure. J Antimicrob Chemother. doi: /jac/dkt034Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: recommendations for a public health approach. World Health Organization, 2011.Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions. World Health Organization, 2013.
89References (2)HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of interventions policy brief. UNODC, ILO, UNDP, WHO, UNAIDS. Accessed January 2014.HIV in Prisons: A WHO guide to the essentials in prison health. WHOSex Workers: an introductory manual for health care workers in South Africa. Desmond Tutu HIV Foundation.HIV Transmission Area Program Guidelines. NDOH, Republic of South Africa.Operational Guidelines for HIV, STIs and TB Programmes for Key Populations in South Africa. Version 0.5.3, Sept NDOH, Republic of South Africa.