You are who you know: Social networks, super-mobilizers, and sex (Part III)

Written by LINKAGES’ Hally Mahler, Eric Stephan, Matthew Avery, and Virupax Ranebennur

A version of this blog post was originally presented at FHI 360’s Global Leadership Meeting 2017 and USAID’s Global Health Mini-University 2017.

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Photos courtesy of Thai Red Cross AIDS Research Center.

Read Part I and Part 2 of this three-part blog series here.

Motivated by the success we had in Chiang Mai, the LINKAGES team set out to find if similar social network approaches could be applied to men who have sex with men (MSM) in India – where 90 percent of MSM in Mumbai use virtual spaces to seek sexual partnerships.

Within the first three weeks of the pilot, mobilizers were able to reach 333 MSM who solicit sexual relationships through social apps, 93 of whom sought prevention, care, and treatment services including HIV testing. Almost all of these MSM individuals were university students that were not being reached through traditional, targeted intervention programs. As a result of the pilot’s success in utilizing social networks, the team observed an HIV yield increase from 1 percent to 4.1 percent, and a 9 percent syphilis yield. What did the data tell us? This group of young men were a previously unreachable priority population with a significantly high risk of HIV.

Expanding out of Asia

Currently, LINKAGES has expanded implementation efforts of the Enhanced Peer Mobilizer (EPM) model in five countries in Africa – Botswana, Burundi, Cote d’Ivoire, Democratic Republic of Congo, and Malawi. These new experiences have taught us lessons about how social networks work in different contexts.

In Botswana, LINKAGES is working exclusively with female sex workers (FSWs). In November 2016, we designed a pilot strategy based on the EPM model in an effort to reach FSWs online. Within the first four weeks, we tested 1,665 FSWs compared to the 951 FSWs reached in the previous quarter. An analysis of one district in Francistown revealed that 282 FSWs were brought in for HIV testing by only three super-mobilizers; 93 percent of those were first time users of LINKAGES’ HIV services. The HIV case finding increased from 13 percent at the start of the pilot to 31 percent. The deeper we got into the social networks, the more HIV-positive sex workers we found and linked to care.

LINKAGES discovered a similar trend in Burundi, where there was a large increase in case finding reported from all implementing partners, both in urban and rural areas. We then took the approach to MSM groups in Cote d’Ivoire and Malawi, and again in both cases we saw improvements in HIV case finding. The proof of concept is strong, but the challenge we now face is getting the approach to scale. LINKAGES achieved what is now called the Enhanced Peer Outreach Approach (EPOA) in Thailand and learned many lessons along the way that will inform our plans to scale up elsewhere.

What we have learned

• The Enhanced Peer Outreach Approach has the power to reach previously unreached – and sometimes unknown – networks of MSM and FSWs.
• From this early view, MSM and FSW networks may tend to look different. MSM networks usually have a single individual surrounded by many contacts, whereas FSW networks tend to present in waves and branches. The higher use of social media by MSM individuals may contribute to this.
• High levels of social media use by targeted key populations is beneficial for scale but not essential for success.
• HIV-positive mobilizers tend to bring in a higher percentage of HIV case finding.
• The longer the strings, the more HIV case finding for FSWs and some MSM groups – especially where social media is not used. We see higher yields come in around the third and fourth waves when we are reaching people not previously reached by the project.
• It is imperative to seek mobilizers with social networks outside of the groups we are already reaching through other methods. We had a few cases in which the coupons never left the community who were already being reached by traditional program interventions, thus resulting in no additional case finding.

Considerations for the future of the Enhanced Peer Outreach Approach

• Incentives have been important to the success of the program – be they direct payment or in-kind incentives. It is important for any incentives to be tailored to the country context in consultation with the KP groups that will be reached by the program.
• The use of mobilizers does not replace more traditional peer outreach workers! We still need outreach workers to maintain contact with new clients once they have been found. We are pursuing questions about how to keep mobilizers motivated, and how to further expand program promotion once personal social networks have been exhausted.
• Since the Enhanced Peer Outreach Approach brings in people who have never had contact with the program previously, it may be harder to effectively link them to care and treatment and continue to support them in the community.

You are who you know

There is still so much to be done, and we suspect that – when it comes to social networks, super-mobilizers, and sex – we have just reached the tip of the iceberg in our learning. What we do know is this: online social networks have dealt a substantial blow to the way a number of industries have worked for decades, including the news, television, job-hunting, shopping, and entertainment. These industries have been disrupted and recreated with online tools and spaces, and the same holds true for LINKAGES’ work. In Thailand and India, we saw people in online social spaces take on the task of referring their peers to HIV services themselves, in much the same way that young people now become salespeople or social media stars (i.e. “Instagram-famous”) due to their own personal branding.

As we saw in Botswana, even without a strong social media presence, key population communities around the world can harness their social power, through their own networks to become gatekeepers for HIV education, outreach, referrals, and even care and treatment. In an ever-changing online and off-line landscape, we believe this is a positive development. It will require us to continuously evolve, but innovation is both inevitable and necessary for progress. And, in the end, you truly are who you know, and who you know can make all the difference in bringing an end to HIV.

Social networks, vulnerability, and sex: Improving HIV case finding among key populations

Webinar hosted by the LINKAGES project as part of the Key Populations: Evidence in Action series.

To access the audio recording of the webinar, please click here.

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On October 5^th, the USAID– and PEPFAR-supported LINKAGES project hosted the first webinar in a new webinar series entitled Key Populations: Evidence in Action. This inaugural webinar included presentations on social network interventions to improve HIV case finding among female sex workers, men who have sex with men, and people who inject drugs.

Stephen Mills, FHI 360/LINKAGES/Thailand
Introduction and the purpose of social networking interventions in the HIV cascade

Kiira Gustafson, Population Services International/Myanmar
Innovative active HIV case finding in Myanmar for key populations: A focus on the most underprivileged and underserved groups

Olga Denisiuk, Alliance for Public Health/Ukraine
Optimized case finding as a strategy to improve the HIV care continuum for people who inject drugs

Wame Dikobe, FHI 360/LINKAGES/Botswana
How the enhanced peer outreach approach improved HIV yield among female sex workers and men who have sex with men in Botswana

This webinar series is intended to be a platform for (1) sharing state-of-the-art knowledge, emerging evidence, and promising practices for achieving greater impact on the HIV epidemic through programs for key populations; (2) addressing pressing questions and controversial issues from the perspective of key population experts and community members; and (3) fostering dialogue among a broad set of partners working in key-population-focused research, programming, and advocacy.

The webinars will cover a range of topics, including introduction and scale-up of HIV self-testing and pre-exposure prophylaxis for key populations; cascade monitoring and data use; information and communication technology-based interventions; effective strategies for addressing violence, stigma, and discrimination; differentiated models for delivering antiretroviral therapy; and community empowerment.

This webinar series is open to anyone interested in key populations, including program implementers, researchers, policy-makers, advocates, funders, and community members.

You are who you know: Social networks, super-mobilizers, and sex (Part II)

Written by LINKAGES’ Hally Mahler, Eric Stephan, Matthew Avery, and Virupax Ranebennur

A version of this blog post was originally presented at FHI 360’s Global Leadership Meeting 2017 and USAID’s Global Health Mini-University 2017.

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Read Part I of this three-part blog series here.

We have all heard how instrumental social networks can be in connecting people. But #10 – our nickname for the peer mobilizer mentioned in Part I – exceeded every expectation. Preliminary data analysis showed us that by the time most of our peer mobilizers had brought in 10 new contacts, #10 had brought in 71. At first, we were hesitant to believe it, but the numbers did not lie. And, #10 did not stop there – as recently as September 2017, he had successfully recruited a total of 240 clients to HIV testing, with an HIV-positive yield of nearly 15 percent.

#10 is what we like to call a super-mobilizer. As our program expanded within Chiang Mai and to other cities across Thailand, a trend of super-mobilizers began to appear.

What are super-mobilizers?

Most of the peer mobilizers turned super-mobilizers that work with LINKAGES to increase HIV testing uptake in Thailand are actually moderators or hosts of private social media-based groups on platforms like Facebook and Blued, a widely used social media application for MSM. However, super-mobilizers are not simply individuals with active social profiles who have many friends in online spaces. They are individuals who use social media platforms and tools for specific reasons and to reach specific audiences.

Social media is crucially important to key populations most at risk for HIV, as members of these populations face significant stigma and discrimination in the real world but can generally find safe online spaces such as chatrooms or Facebook groups. These groups are often centered around a specific theme or idea, so members typically share a common interest or activity, or frequent the same hotspots around town. Super-mobilizers like #10 took our peer recruitment program and introduced it to their trusted social media groups as a way to help the people in their online circles. By using this innovative approach to recruiting contacts and distributing coupons online, super-mobilizers helped LINKAGES Thailand tap into large networks of high-risk individuals that had previously been unreachable through other outreach methods.

Real progress through social networks

When we spoke with #10, we learned that he was initially an HIV testing client under LINKAGES who shared his personal testing experience on a private Facebook page he administers. He explained that the small cash incentive is a good “morale boost,” but far from the point.

“Every time I refer one of my friends to get tested, it means that I have helped my friend to have better health. I feel delighted!”

In Chiang Mai, peer mobilizers account for more new clients than traditional outreach workers. Clients recruited by peer mobilizers are also more likely to be newcomers to HIV prevention activities and more likely to accept HIV testing. Social media-based peer mobilization specifically has been so successful in Chiang Mai that LINKAGES began to replicate the model in other cities.

Now, the project purposively targets social media influencers in MSM communities who are willing to use their online platforms – closed Facebook groups, chatrooms, etc. – to increase awareness about HIV risks and encourage people to be proactive and get tested. Then, we set up an online appointment system in collaboration with our local testing partners, giving each “mobilizer” a unique, trackable token that they can share to connect people to the system.

Now, super-mobilizers can give their followers a direct link. It may seem simple, but that link allows individuals most at risk for HIV to choose a clinic, pick a time convenient for them, and schedule an appointment – all with guaranteed privacy – to take a small but impactful step in reaching an end to HIV.

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Stay tuned for Part III of “You are who you know: Social networks, super-mobilizers, and sex.” In this final installment of the series, find out where the LINKAGES team plans to expand the Enhanced Peer Outreach Approach (EPOA) in 2018, and learn about some of the potential challenges that lie ahead.

 

Call for papers: Optimizing the impact of key population programming across the HIV cascade

Written by Rose Wilcher, Director, Research Utilization, FHI 360

This blog post was originally featured on FHI 360’s R&E Search for Evidence.

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Key populations – including men who have sex with men, sex workers, transgender people, and people who inject drugs – shoulder a disproportionate burden of HIV. UNAIDS estimates that between 40 and 50 percent of all new HIV infections among adults worldwide occur in these key populations and among their sex partners. Reaching members of these communities with evidence-based interventions that improve their access to and uptake of services across the HIV prevention, care, and treatment cascade is essential to achieving the UNAIDS 90-90-90 goals. In this post, I highlight a new call for papers that will focus on new evidence and data-driven strategies for improving key population programming across the HIV cascade.

Serious challenges exist for key populations when trying to access HIV services. The issues that drive the spread of HIV in key population communities and hinder their access to care – experiences of stigma, discrimination, violence and, in many cases, criminalization – have been well documented. The need to overcome these challenges has led to advances in the monitoring of key populations’ uptake of services across the cascade to identify “leaks” in the system, as well as more sophisticated analysis and use of those data to identify solutions and strengthen programming. In addition, a number of key population-focused implementation science studies are under way across a range of geographies to evaluate the effectiveness of new innovations, outreach strategies, and delivery modalities in overcoming structural obstacles and improving service uptake and retention with different key population groups.

Announcement

An urgent need exists to take stock of this emerging evidence related to optimizing and monitoring service delivery for key populations. As key population programming is scaled up globally, it is critical that we maximize the public health impact of those efforts by bringing to bear the latest knowledge and evidence of what works to reach key populations and link them to the targeted prevention, treatment, and retention support they need.

Together with USAID, the U.S. CDC, and amfAR, FHI 360’s LINKAGES project has issued a global call for papers for a special supplement of the Journal of the International AIDS Society.

The special supplement will feature a compilation of high-quality research from a range of multidisciplinary efforts to advance key population science and practice. Submission topics may include, but are not limited to:

• Best practices in data use to refine and focus interventions and services at the country level to reduce HIV transmission and improve the impact of national HIV programs for key populations.
• Findings from implementation science studies that broaden our understanding of service delivery modalities that are effective at improving the reach of prevention services, the uptake of HIV testing, and retention in HIV care and treatment among key populations.
• Evaluations of new innovations to enhance reach and engagement of key populations at different points along the HIV cascade.
• Field-based policy and programmatic case studies of HIV prevention, care, and treatment efforts for key populations, especially those that are meaningfully engaging or led by key population community members.

Key dates

For questions about the supplement, please contact FHI 360’s Rose Wilcher. Note the following key dates regarding the submission and application timelines.

An invitation to submit an article is not a guarantee of publication. All editorial decisions regarding publication in the Journal will be based on the outcome of peer review.

Utilizing evidence and data-driven strategies for improving key population programming across the HIV cascade is critical to achieving the UNAIDS 90-90-90 goals. This special supplement of the Journal of the International AIDS Society will allow the HIV community to review emerging evidence related to optimizing and monitoring service delivery for key populations.

You are who you know: Social networks, super-mobilizers, and sex (Part I)

Written by LINKAGES’ Hally Mahler, Eric Stephan, Matthew Avery, and Virupax Ranebennur

A version of this blog post was originally presented at FHI 360’s Global Leadership Meeting 2017 and USAID’s Global Health Mini-University 2017.

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LINKAGES Director Hally Mahler presents at USAID’s Mini-University on September 14, 2017.

The USAID– and PEPFAR-funded LINKAGES project partners with communities, governments, and the private sector in 30 countries around the world. Our goal is to deliver HIV prevention, care, and treatment services and address essential cross-cutting issues such as the capacity building of key population (KP) led community organizations, stigma and discrimination, access to and delivery of dignified health care, and violence prevention and response. At the country and global levels, we also work with the World Health Organization, Global Fund, and others to strengthen data and cascades and improve the technical quality of key population programming.

LINKAGES’ team spends a lot of time asking, how can we implement just the right combination of interventions to make a big impact on the HIV epidemic – to achieve the “holy grail” of epidemic control?

We used to think that to fight HIV, it was up to our projects to mobilize outreach workers and maximize “reach” through our own legwork. But increasingly, and maybe obviously, what we are discovering is that the people who will bring an end to HIV and AIDS are not exactly “us” but the people in our social networks. They are our friends, our partners, and our support groups. Through social media technology, our networks become empowered.

MSM in Chiang Mai, Thailand

Chiang Mai is a popular city in northern Thailand with thriving KP communities. In recent years, Chiang Mai has made incredible progress in the fight to end HIV. However, rates of new HIV infections continue to be disproportionately high for MSM and transgender women and, in 2014, less than 20 percent of HIV-positive MSM in Thailand were aware of their status. Of those who were aware, only 1/3 were adhering to a treatment regimen.

In Thailand and most other countries around the world, these KP groups have a higher risk for HIV infection and they are less likely to receive preventative services or care and treatment if they are HIV-positive. This is especially troubling, as the AIDS Epidemic Model estimates that 53 percent of new HIV infections from 2015-2019 will result from male-male sex.

LINKAGES’ response

In 2015, we asked ourselves, how can we reach more MSM with HIV programming, and especially those who have not been reached before?

Since traditional methods have typically resulted in about 1/3 of reached clients electing to receive an HIV test, LINKAGES began to think outside the box. How can we improve uptake of testing and HIV case findings in these communities? We decided to shift the responsibility for recruiting new clients onto the program clients themselves. This was inspired by respondent-driven sampling methodology used in research, where study participants are given coupons to pass onto their friends and others in their social circles; those making successful referrals are awarded a small cash incentive.

With respondent-driven sampling, we are usually interested in a representative sample. However, our assumption here was that people who are highly vulnerable to HIV themselves usually “run” or associate with other vulnerable people. These are also the groups least likely to be reached by our usual program activities. To reach these communities, the LINKAGES Thailand team started using eCascade, a smartphone app that collects data in real time and guides outreach workers with questions to ask potential clients and steps to take to link individuals to care. We added a component to eCascade prompting outreach workers to offer their clients coupons that they could use to recruit new individuals into the program: “We’re so glad to have this talk with you. If you take 3 of these coded coupons and give them to your friends, and a friend brings the coupon back to me to have a talk and referral to testing, then you will earn 100 baht for having brought us a new client.”

Clients who agreed to distribute these coupons became peer mobilizers and we named our strategy the “Enhanced Peer Mobilizer” (EPM) model.  Like with respondent-driven sampling, when coupons come back to us with a new client, and then that new client distributes coupons to bring in the next wave of friends, we can use the unique coupon codes to create a visualization of social network nodes.

The development of “super-recruiters”

This type of social network analysis used to take days, but with more modern tools we are now able to visualize social network recruitment in real time. These networks give us a wealth of knowledge. They can tell us in which social networks HIV-positive MSM and transgender women are found, which networks have more first-time testers, and who the most valuable and successful recruiters are.

Why do we want to know all of this? Once we identify which networks produce priority clients, our community partners – including Caremat, which manages a large cadre of known HIV-positive clients who receive ongoing care and support – can then “pivot” to work intensively with those individuals to maximize recruitment and HIV testing successes.

When we first launched these efforts back in 2015, we started to notice an interesting pattern of networking in Chiang Mai. When we visualized our early social networks, we saw, right in the middle of the social networks display, a huge round cluster surrounding one particular peer mobilizer. With two months of work completed under our EPM model, our best peer mobilizers had brought in 10 new contacts each. But one individual had brought in 71 clients alone, and he was just getting started.

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Stay tuned for Part II of “You are who you know: Social networks, super-mobilizers, and sex.”

“Nothing about us without us:” South-to-South learning is a key ingredient for success in HIV programs

Written by Aubrey Weber, Technical Officer, Research Utilization, FHI 360

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Today marks the 14^th International Day for South‒South Cooperation. This day celebrates advances made by regions and countries in the global South and highlights efforts to continue work on technical collaboration and support among developing countries. It also shines a light on the role of partnerships among developing countries in transitioning to sustainable programs.

Although much knowledge and expertise have been transferred from the global South to the global South (S2S) and numerous guides have been produced about mentoring in general, few tools exist on how to best conduct S2S mentoring.

What is S2S mentoring?

S2S mentoring is a form of peer learning where both mentor and mentee are located in the global South and have direct experience operating in low- and middle-income countries. S2S mentoring among key-population-led organizations (KPOs) is a highly effective method in building key populations’ (KPs) capacity to lead efforts that improve their lives and overall health. Approaches are tailored to the needs of KPs and are therefore are more likely to be nonstigmatizing and applicable to KPs’ needs and lived experiences. S2S mentoring works because it values global diversity and global South expertise, it is cost-effective, and the knowledge transferred is often more relevant than North‒South mentoring. As LINKAGES’ senior technical advisor Meg DiCarlo sees it, the benefits for KP mentors and mentees go even further.

“S2S exchanges are particularly valuable for organizations working with key populations — that is, sex workers of all genders, men who have sex with men, people who inject drugs, and transgender people — because the exchanges can help increase these marginalized communities’ agency and thus empower them.”

LINKAGES’ response

In 2016, the LINKAGES project designed a toolkit for existing mentors from KPOs in the global South to enhance the quality of mentoring they provide to other KPOs in the global South. Specifically, the toolkit explains what S2S mentoring is, discusses mentors’ role in S2S mentoring, describes different S2S mentoring approaches and how to choose among them, and reviews the technical skills needed to mentor effectively. It also provides best practices in enabling local KPOs that are already engaged in mentoring to more effectively manage, conduct, and monitor mentoring activities. Brian White, LINKAGES’ senior technical advisor for community strengthening, sees the toolkit as a guide for building strong, mutually beneficial partnerships and support systems.

“The S2S mentoring toolkit provides a framework through which our communities can share their knowledge and expertise with each other, allowing them to focus on exchanging valuable skills, best practices, challenges and lessons learned. The mentoring builds relationships and further strengthens networks and sustainable organizations.”

For KP-specific HIV programming, S2S is especially critical. A prevailing theme in LINKAGES’ line of work, “nothing about us without us” emphasizes KPs’ critical role in identifying, developing, and implementing solutions that will most directly affect their well-being; their ability to access HIV prevention, care, and treatment services; and their livelihood.

LINKAGES country leaders participate in a twinning exercise during a managers meeting in June 2017. Twinning is an important step in S2S mentoring (Photos: Ben Eveslage).

From peer educators to HIV testing counselors: how female sex workers are assisting their communities in Angola

Written by Celma Pedro, ​Technical Officer, Positive Living, Management Sciences for Health

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ASCAM FSW peer educators and HIV testing counselors join together for a focus group facilitated by Angola’s Ministry of Health during the PEPFAR-GF joint cascade assessment.

Delfina da Costa worked eight years as a peer educator for female sex workers (FSWs) in her community in Angola, educating those at high risk for exposure to HIV. She frequented hot spots around town to share informative messages in a safe environment on how to stay healthy and prevent contracting or spreading HIV. She forged strong, trusting relationships with the women she helped, but Delfina wanted to do more. In October 2015, she was trained to be an HIV testing counselor.

“I always followed HIV testing on the side lines, watching carefully how it was performed on the women I referred. I always wanted to test. Now I can.”

Delfina da Costa works as an HIV testing counselor for FSWs in Angola.

Delfina administers HIV rapid tests at hot spots, screens FSWs for sexually transmitted infections, and consults with health care professionals about the specific needs of her clients. She also links HIV-positive FSWs to peer navigators and care support services. If a FSW does not want to meet with a peer navigator, Delfina supports the patient herself from the onset of treatment.

Delfina’s transition from peer educator to HIV testing counselor marked the beginning of professional development and advancement for peer educators working with key populations (KPs) in Angola. Her experience is unique, as members of KPs have not typically held positions of leadership or authority in the past, and KP-led HIV organizations are scarce. Until recently, giving KP peer educators the opportunity to train as HIV counselors was frowned upon by many civil society organizations (CSOs) in the country.

Since 2015, LINKAGES has partnered with Associação de Solidariedade Cristã Ajuda Mútua (ASCAM), a local nonprofit CSO in Luanda, Angola, and the first in country with an entirely KP-led management team. ASCAM began as an emergency support service during wartime; today, the organization works almost exclusively in HIV education. Together, LINKAGES and ASCAM recruit individuals from KP communities—primarily FSWs—to be peer educators. After serving in this position for at least one year, peer educators can train to become HIV testing counselors within their local communities. HIV testing counselor training is a two-week course with theoretical and health facility practicum requirements, conducted in partnership with the Angolan government.

Professional development for KP individuals in HIV prevention, care, and treatment services has come a long way in recent years. “When we started working in Angola in 2015, the only CSO that had key population peer educators was ASCAM,” says Ana Diaz, LINKAGES Angola program manager, “but the HIV testing counselors were not key population members. KP members had never been given the opportunity to train as counselors, but now they can.”

A group of newly trained community HIV testing counselors celebrate becoming certified by the Angolan government and LINKAGES.

Establishing more prominent roles for KP community leaders in the HIV prevention, testing, care, and treatment of individuals like themselves builds trust between health provider and patient, and strengthens referral uptake of KPs to HIV service providers.

The success of these trainings in reaching previously unidentified KP individuals has made other partner organizations aware of the benefits in providing opportunities for KP peer educators. LINKAGES has trained 23 KP HIV testing counselors to date, 16 of whom are FSWs. Becoming a counselor is a big step in establishing a career in health care. Having a training certificate from the government can open many doors to other projects that may even go beyond HIV prevention, care, and treatment services.

For Delfina and other HIV educators in Luanda, empowering FSWs within CSOs is an ongoing effort to promote more accurately representative leadership.

Fatima Zua, a FSW peer educator with ASCAM, says: “When we work to empower women [key population members], everyone wins. I feel they understand our needs because they were in our position before.”