1. Keeping up with the epidemic Programme success leaves us with new challenges: An evaluation of programmes for injecting sex workers

2. Background Some 90% of people living with HIV in our district are drug injectors We have harm reduction programmes that we believe are effectively preventing transmission among IDU The biggest risk for onwards transmission to non-injectors is from female IDU who sell sex We therefore aim to provide safe sex services for women who both inject and sell sex

3. Programme logic Our programme aims to reach women who both sell sex and inject drugs. Entry points are finding injectors among sex workers as well as identifying female IDU who sell sex Outreach workers will distribute condoms to them, give skills training to promote condom negotiation and use, and refer to STI services. We will train doctors and support clinics providing quality STI services. Female injectors who sell sex will increase their use of condoms and STI screening and treatment. The risk of STI and HIV transmission will fall

4. Data analysis plan Look at programme monitoring data to see if programme is being delivered Programme and BSS data tell us if we are reaching the target population Programme and BSS data tell us if the target population is using the services BSS data tells us if the programme has an effect  Does behaviour changes over time?  Do people with programme contact have different behaviour than people who have no programme contact? Biological surveillance data will show no rise in HIV

5. Outreach workers are getting condoms to both sex workers and IDU

6. And they seem to be doing an especially good job of reaching the women who both inject drugs and sell sex

7. Condom use with clients has more than doubled among women who inject drugs and sell sex

8. Skills training helps sex workers use condoms consistently, but even those with no skills training report high condom use

9. Contact with outreach workers appears to have a bigger impact on STI screening behaviour

10. And the outreach is more effective for injecting sex workers than for non-injectors

11. So how are we doing ？ We are distributing condoms Outreach workers are reaching injecting sex workers, who say they receive condoms Those reached by outreach are more likely to use condoms and go for STI screening, and the difference is greatest among injecting sex workers …our programmes seem to be working

12. But… What are all those well-trained doctors doing ？

13. There’s room for improvement, but our programe seems to be contributing to limiting onward transmission from injectors who sell sex to clients Does that mean we’ve reached our programme goal ？

14. Yes! HIV among sex workers is not rising Well maybe not. Are we missing an ongoing epidemic in IDU? Methadone programme introduced

15. The proportion of female injectors who sell sex is falling …but the proportion of IDU who are women is on the rise

16. What must we do now? Sustain programmes to promote safe sex and condom use, especially for women who inject drugs Re-evaluate STI programming, and strengthen if necessary Analyse needle exchange and methadone data; urgently strengthen programmes to decrease transmission among injectors