1. The Global Context of SRH and HIV: Making seamless programmes and services a reality for PLHIV Designing comprehensive HIV and FP, RH programmes II Satellite 1: Sunday, July 18, 2010, 11:15 to 13:15, Mini Room 9 Presentation 3: Exploring integrated SRH and HIV models and programming examples from a variety of settings in countries/areas with concentrated HIV epidemics XVIII International AIDS Conference, Vienna, 2010 Amitrajit Saha, Anna Zakowicz, Dawn Averitt Bridge, Jill Gay, Robert Carr

2. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 2 Objective of the presentation To explore: Why we need to increase access to SRH services for most at-risk or key populations (KPs)* [sex workers, drug users and their partners, men who have sex with men (MSM), and PLHIV; and How we can do so… …in concentrated epidemic situations. *Key populations or KPs are populations who are key to the transmission dynamics and also key to the response to HIV. Key populations comprise, but are not limited to: sex workers (female, male and transgendered), injecting drug users and their partners, men who have sex with men and often bridge populations like migrant workers.

3. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 3 What we do know: evidence for SRH needs of FSW and HIV-positive women Cambodia (Delvaux, 2003) a very low proportion of sex workers using modern contraception except condoms, and that a high proportion had had at least one induced abortion. Bangladesh (Haq 2006), a study emphasising the links between health and human rights amongst sex workers, identified a need for family planning, sexually transmitted infection (STI) treatment and abortion rights. India (PATH 2007) a 4 state formative study found that sex workers demanded a range of SRH services, including access to family planning, birth spacing, abortion, ante-natal care and delivery services. USA (Averitt-Bridge 2008) – Women Living Positive survey showed a communication gap between providers and WLHIV.

4. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 4 Need to provide SRH and STI care Need to understand the gender and socio-cultural dynamics of IDUs: –Crucial role that romantic-sexual partners play in women injecting drug users’ initiation experience (Bryant, 2007). Need to address pregnancy and childbirth issues: –Malta study on the pregnancy outcomes of women using heroin (Savona- Ventura, 2004). –UK study to evaluate maternal and newborn outcome in pregnant drug-users (Thangappah, 2000). Need to address risk of other viral infections: –Risks for IDUs are compounded by their increased risk of hepatitis B and hepatitis C infections, and with the added behavioural risks of women IDUs selling sex to pay for drugs (Neaigus, 2007). Need to address providers’ stigma and discrimination: –There is evidence that women IDUs are often reluctant to seek healthcare due to stigma (Crokett, 2004). Need to use SRH service delivery as opportunity to help IDUs What we do know: evidence for SRH needs of IDU and their partners

5. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 5 Need to understand socio-cultural realities of MSM: A study in Bangladesh revealed that MSM frequently surrender to societal pressures to marry (Khan, 2005) [xiv]. Need to structure interventions around sexual behaviours rather than sexual identities: A Cambodian study with MSM found that risk of HIV was more correlated to sexual behaviour rather than identity. (Girault, 2004)[xvii]. Special needs of MSM who also use drugs: A study of Thai MSM who also use drugs showed that MSM had higher HIV rates and were younger; had more lifetime sex partners, more female partners, more female paid partners, and been paid for sex. Services for such population sub-groups should therefore take into account both sexual activity and substance abuse (Beyrer, 2005) [xviii]. Needs of young men: SRH services as they are currently structured are primarily geared towards married couples, and single men have little or no access. A India study showed, young men prefer to have separate men- friendly services modelled on targeted interventions for sex workers, which address their SRH awareness and service needs (PATH, 2007). What we do know: evidence for SRH needs of MSM and young men

6. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 6 Some examples of what works:

7. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 7 Integrated interventions for MSM, drug users and FSWs in the Caribbean Free clinics of Jamaica AIDS Support for Life provide safe spaces, HIV prevention and STI management, psycho-social support, livelihood training and literacy classes for SW, LGBT and MSM. They also provide clothing and food, and flexible hours and night clinics. The Caribbean Harm Reduction Coalition provides HIV/STI prevention and treatment services in Saint Lucia. They also provide shelter, meals, and DIC services to homeless MSM and crack users. Their ORWs also act as support for repeated checkups, and help the clients in understanding meds. Sexual health integrated programme for sex workers (SHIP) in Trinidad & Tobago run by FPATT and IPPF. Focus is to not only increase clinical services and SRH awareness among SWs, but also raise awareness about their rights and increase safer sex practices.

8. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 8 Demonstration project on integrating HIV and SRH services for FSW and PLHIV – India Involved government, private sector and not-for profit organizations from the design stage. Included community-based organizations, sex worker groups, HIV- positive groups. Interventions were district-specific – and addressed both community (FSW and HIV-positive people); and healthcare providers (government and private sector). District, state and national-level advocacy. Main limitation: duration of the demonstration projects were 2 years – not enough time for proper ‘impact’ evaluation.

9. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 9 What did we learn from the demonstration project? It was possible to make a change in access to SRH services. Over time, we saw increasing trends of FSW and HIV-positive women accessing SRH services including abortion and SRH services. Although pre- and post-intervention KAP questionnaire surveys among healthcare providers did not show much change in attitude; the stigma experience among FSW and HIV-positive people showed reduction – significant in case of FSW and HIV-positive men. Capacity-building interventions among healthcare providers work inasmuch the quality of their interaction with KPs improves – i.e., they at least know they cannot ‘show’ their prejudice in the public domain of their workplace.

10. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 10 What did we do differently? Our focus was on strengthening KP groups, individuals and their organizations. We spend time building capacities of HIV-positive groups in districts they were weak, and strengthening capacities of local organizations to support the KP groups. We continued to involve and engage with government and private healthcare providers despite their resistance to attending meetings/trainings, etc. We supported HIV-positive peoples’ networks and FSW groups to go beyond the SRH interventions.

11. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 11 Key steps: the ‘how to’ guide – community In concentrated epidemic situations: involve and obtain buy-in from key government departments and healthcare facilities – this is key. Involve FSW/MSM/IDU/HIV-positive people’s groups, CBOs and intervention projects from design stage – need to make sure representation is gender-conscious. Involve trained ‘key population consultants’ for background and baseline and endline data collection; for training local community facilitators, and for mentoring local organizations regularly. This is vital to success (besides strengthening community’s confidence and empowering them to ‘take steps beyond’ program purview). Organize direct interactions between community representatives and healthcare providers: this is vital to improve mutual knowledge and respect – and was a key to changes we saw at project end.

12. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 12 Key steps: the ‘how to’ guide – providers Providers, particularly doctors and nurses do not have time for long training sessions – tailor short but intense interactions focusing on SRH needs of HIV-positive people, universal precautions, and ‘soft-skills’ on ‘how to deal with key population groups’. Always have key population representatives during capacity-building sessions and involve them as ‘experts’ – this is vital. Always have focussed learning objectives and organize pre- and post- intervention review of what they have learnt. Involve team leaders, heads of departments or hospitals and district health authorities in these sessions. Involve doctors’, nurses’ and technicians’ unions/associations.

13. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 13 Key steps: the ‘how to’ guide – management Keep the project design flexible to address additional technical support needs of partners. Invest in strengthening technical and project management capacity of CBOs, HIV-positive networks and TI partners. Be strategic in identifying public and private provider partners. Expand HIV communication to include at least SRH and FP issues – develop relevant material and guides. Design interventions at local level involving KPs, PLHIV and other stakeholders, and link with local authorities to address administrative and logistic bottlenecks. Keep advocacy: local, province/state level and at national level – a priority. Utilize different media to reach out to a number of constituencies and use the media judiciously to achieve these objectives.

14. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 14 Summary and Conclusion Integrating SRH and HIV services to increase access services for MARP/KP groups in concentrated epidemic situations is possible. Centre-staging the requirements and needs of key populations, and involving them from design stage is key to sustainability and success. It is important to understand, identify and strategize for challenges that may be encountered. We should be clear that our objectives are setting up SRH and other integrated services to increase access for PLHIV and KPs – and not trying to change deeply held attitudes of providers, so the outcome of ‘interest’ is to ensure that they provide services without prejudice.

15. www.aids2010.org Satellite 1: Sunday, July 18, 2010 AIDS 2010 15 Acknowledgements: IAS and AIDS2010 Ron McInnis, Robert Carr, Anna Zakowicz, Jill Gay, Dawn Averitt Bridge The David and Lucile Packard Foundation The William and Flora Hewlett Foundation PATH Sex workers, MSM and PLHIV who provided information, support and unstinted cooperation. Amitrajit Saha MD Associate Director SRH, and Acting Director MCHN (India) PATH Street: A-9 Qutab Institutional Area, New Delhi 110 067 | Phone: +91 11 2653 0080 Email: asaha@path.org and amitrajitsaha@gmail.com Thank you