Supporting community action on AIDS in developing countries HIV Prevention with MSM, WSW and Transgender People Best practices, novel approaches and scaling up Supporting community action on AIDS in developing countries

All for one, one for all? Tendency to ‘lump together’ very disparate groups Shared issues – relationship to heteronormative masculinity, gender norms Denial, abuse of health and human rights widespread But even these take very different forms for different populations in different places Need to work on coming to understand each other Donors and funders need to allow space for this to be worked out Supporting community action on AIDS in developing countries

Novel approaches - WSW ‘Sex between women presents a low biological risk of HIV tx’ True, but there are lesbians and other WSW with HIV; also higher STI rates in some studies Drug use, sex work, gender-based violence are all modes of transmission It is not enough to say that needs of WSW ‘at risk’ are met through programs for FSW, PUD or by GBV interventions We need to start looking at how, if and when programs can meet the needs of WSW Supporting community action on AIDS in developing countries

Transgender persons Trans populations are many, many things – travesti, transsexual, transgender, traditional, transgressive One thing they are not is MSM Growing recognition of this in programming and also in advocacy spaces Needs are very different, as are the challenges Overwhelming impact of violence Supporting community action on AIDS in developing countries

MSM – ‘flavour of the month’ – again! We have a much better sense of what works and what doesn’t, with some notable successes, however… Rhetoric vs reality – lots of talk, limited coverage still in many places In some places, talk is of ‘sustaining safe sex culture’; in many others, we are still fighting for the space to create a safe sex culture Fear and blame are widespread Supporting community action on AIDS in developing countries

Best practice in HIV prevention Preventing HIV involves change – in individuals, families, communities Ability to change is not always fully in our own hands – influenced by context, laws, culture, policies Change needed at four levels Individual or family level Social, environmental and community level Structural or policy level Health and support services level Supporting community action on AIDS in developing countries

Best practice in HIV prevention In practical terms, this means comprehensive programs working to bring about change at all four levels, directed by or in collaboration with those most affected Need to address risk reduction, but also vulnerability reduction Be realistic about risk and pleasure – sex-positive approaches Supporting community action on AIDS in developing countries

Building Social Capital Critical concept in theories of change Skills, structures and beliefs we have to form social networks Bonding, bridging and linking Supporting community action on AIDS in developing countries

Building Social Capital enables prevention Vida Digna (Mexico) Focus on transgender needs and addressing transphobia Aimed to build strength and capacity, reduce vulnerability, rather than to ‘change behaviours’ Active participation of over 300 people; around 1000 police and 100 civil servants trained; 3 networks created and sustained, increased service access Supporting community action on AIDS in developing countries

Frontiers Prevention Project – capital building at scale Five country program on focussed prevention with key populations – primarily sex workers and msm ‘saturation’ sites with four sets of interventions Actively sought to build social capital Supporting community action on AIDS in developing countries

Service and Commodity provision for KPs Decrease in HIV Incidence amongst KPs Decrease in KP risky behaviour Decrease in KP STI Prevalence Decrease in HIV Incidence in site Empowerment for prevention for KPs Enabling Environment 2. FPP: Interventions to saturate sites Community interventions Individually focused health promotion Scaling up, targeting & improving services Advocacy, policy change & community awareness

Supporting community action on AIDS in developing countries 4. FPP quantitative results (1) Ecuador Condom use MSM 77.0% 75.3% 72.4% 84.9% 34.5% 21.7% 35.4% 53.1% 37.0% 54.9% 77.0% 33.6% 0% 20% 40% 60% 80% 100% ComparisionFPPComparisionFPP Baseline Follow-up Last partner male Condom last female Condom last male

Supporting community action on AIDS in developing countries Frontiers Prevention Project – capital building outcomes AP Community mobilisation to build leadership, solidarity and commitment – community advocacy groups, training, social network support Improved levels of reported social capital -social support, participation in support groups Among Kothi MSM, increased from 10% to 40.9% (n=925) Supporting community action on AIDS in developing countries

Just and lasting change: When Communities Own Their Futures The Blueprint Approach – fixed model which is replicated – ‘not appropriate when site-specific model is required, or when solutions need to be shaped by people’s voices’ Explosion approach – rapid mobilisation with a narrowly targeted intervention eg emergency vaccination during an outbreak Additive approach – adapting programs to local conditions, good for new models but not sustainable Biological approach – explores and experiments with one population unit to find a mix of strategies, then provides an enabling environment for growth and extension Taylor-Ide and Taylor 2002 In three of four FPP countries, MSM programs have changed, adapted and have been sustained – Cambodia, Morocco, India Supporting community action on AIDS in developing countries

Scaling up – four dimensions (Uvin) Quantitative – expansion to new audiences, new areas, new organisations Functional – addressing new technical areas Organisational – program diversification and growth Political – approach at community level broadens reach through policy and changes at macro/governmental level Supporting community action on AIDS in developing countries

Political scaling up - challenges and solutions Requires different skills set - ‘outward facing’ cf ‘community facing’ Policy space and permission Minority politics – division, drama and divas Stop-start funding Donor competition Supporting community action on AIDS in developing countries

Political scaling up - challenges and solutions Finding the space to develop shared agendas Agreeing on roles Being generous with each other, letting go of history Finding space for disagreement Recognise our allies, managing identity politics Mature political relationships Supporting community action on AIDS in developing countries

Investment in HIV prevention works! Policy analysis (2008) looked at divergent epidemics among gay men in three Australian states Luxury of extensive data Three critical differences 1.Sustained investment – allowed for program innovation and expansion 2.Partnership and shared political management between government and CBO 3.Involving and engaging PLHA – community dynamics Supporting community action on AIDS in developing countries

PLHA – partners in prevention Understanding relationships between HIV positive and HIV negative members of the same community are critical Importance of social capital, sexual ethics HIV+ MSM often experience direct and explicit rejection Need to address the dynamics of fear, stigma and rejection within our communities

Supporting community action on AIDS in developing countries PLHA – partners in prevention This means engaging with PLHA as sexually active subjects Acknowledge and validate positive sexuality ‘Shared’ or linked prevention responses should be a goal Requires a safe, non stigmatising environment

Supporting community action on AIDS in developing countries

New prevention technologies Will still require old social technologies to implement False dichotomy – ‘behavioural vs biomedical’ Condoms are a biomedical technology requiring behavioural and social change to implement Short of aerial spraying, so is everything else No magic bullet, no short cuts Supporting community action on AIDS in developing countries

Mainstreaming service provision Often necessary to establish specialist services to ensure immediate access Stand alone services have their drawbacks – unwanted visibility, access, stigma, envy All relevant services eg SRH, HIV should be accessible to all citizens Target service providers and populations, rather than services Supporting community action on AIDS in developing countries

Working in challenging environments Take our cues from those in the environment Recognise the risks and respect choices of those who will wear the consequences Work with media, religious leaders, academics – identify points of influence Engage human rights organisations and try to generalise rights issues Find points of connection and solidarity Supporting community action on AIDS in developing countries

Working in challenging environments Be open to windows of opportunity Sometimes, programming may open the way for greater space, sometimes we should focus on creating the space first Need to build a better understanding of the enablers of responses in difficult environments – more policy research Supporting community action on AIDS in developing countries

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