Addressing violence in HIV programs for key populations: Opportunities for integration

In commemoration of the 16 Days of Activism Against Gender-Based Violence campaign, LINKAGES’ new infographic explores how HIV programs for key populations can address violence. The infographic highlights the global prevalence of HIV and violence among key populations, the impact of violence on HIV among key populations across the cascade, and six recommendations to integrate violence prevention and response into HIV programs for key populations. We hope it will be useful to those designing or implementing HIV programs for key populations as well as those who seek to advocate for greater integration between violence and HIV services.


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Everyone deserves to live free from violence: Assessing a model to increase access to holistic GBV-response services in Puerto Plata, Dominican Republic

Written by Robyn Dayton, Technical Advisor, LINKAGES, and Aubrey Weber, Technical Officer, Research Utilization, FHI 360


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Informational GBV materials are placed in the District Attorney’s office in Puerto Plata.

LINKAGES is partnering with the Center for the Promotion of Human Solidarity (CEPROSH), a local community-based organization (CBO), in the Dominican Republic to increase access to holistic post-gender-based violence (GBV) care, including HIV services, for members of key populations (KPs) – men who have sex with men (MSM), sex workers (SWs), and transgender women. Programs designed to decrease HIV incidence and improve the outcomes of people living with HIV (PLHIV), particularly those for KPs, must address GBV to be effective. For example, a recent study demonstrated that transgender sex workers in Santo Domingo are less likely to use condoms if they have experienced violence, thereby increasing their HIV risk. Studies from the Dominican Republic also demonstrate that violence from a sexual partner is associated with poor HIV treatment outcomes among female SWs. Evidence of the link between HIV prevalence rates and experiences of violence can also be seen among the general population – adult women in the Dominican Republic who have experienced violence are three times as likely to be living with HIV, and women in the Dominican Republic who are living with HIV are more likely to experience violence from their partners.

Given the low uptake of post-GBV care in the Dominican Republic, especially among members of KPs, and the missed opportunities to link victims of violence to services – particularly HIV services – the USAID– and PEPFAR– supported LINKAGES project, in partnership with CEPROSH, undertook an intervention in Puerto Plata, Dominican Republic to increase (1) availability of KP-friendly post-GBV services, (2) service integration for all victims of violence, and (3) post-GBV service-seeking among members of KPs. As part of the intervention, CEPROSH led the formation of a technical working group (TWG) of institutions that offer services to victims of violence, including the police, the public hospital, all local clinics for PLHIV, the district attorney’s office, and the Ministry of Women. The members of the TWG committed their institutions to providing KP-friendly services and CEPROSH trained staff from each institution. CEPROSH also led the development of materials that help identify violence, describe KP members’ rights, and list available services. These materials and outreach events were used to indicate which institutions are KP-friendly and raise awareness about and identify victims of violence. The goal of the intervention was to increase post-GBV service uptake, improving outcomes for victims of violence, including those related to HIV.

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Community leaders share the violence prevention and response services available to KPs.

To determine the impact of efforts to date, LINKAGES interviewed service providers and clients who received post-GBV care in Puerto Plata and reviewed CEPROSH programmatic data from November 2016 to August 2017. The assessment showed that the intervention achieved its desired short-term and intermediate results, demonstrating that a civil-society-led initiative can strengthen both public and private post-GBV services, make those services more inclusive, and increase their uptake by KP individuals. Pre- and post-test results from trainings demonstrate that after the trainings, attendees across sectors felt less stigma toward KPs and were less likely to blame victims for violence against them. At the same time, the intervention strengthened the overall system for violence response in Puerto Plata, with providers and clients reporting that providers across institutions now offer improved services to all victims of violence and that more members of the general population are also seeking post-GBV support. As noted by a respondent at the Ministry of Women, “Thanks to the information given by CEPROSH, the directory, and the brochure, more women are coming to get services here. Before, we might get seven girls a month. Now, we are getting six or seven daily. They have empowered themselves to come here and find assistance.”

Looking specifically at HIV services, the intervention increased access to post-exposure prophylaxis (PEP) and HIV testing, identified new HIV-positive individuals, improved antiretroviral adherence, and provided new opportunities for continuous engagement of both HIV-positive and -negative KP members. Through violence detection efforts and spontaneous disclosure, 435 people reported experiencing violence from November 2016 to August 2017. Twelve of these reports were of sexual violence in the past 72 hours, with 66 percent (8) receiving PEP. Of the 435 individuals reporting violence, 244 were members of KPs with an unknown HIV status. Forty-five percent (109) completed an HIV test as part of post-GBV care, with four new cases of HIV detected. While viral load was not specifically monitored in the assessment, doctors from HIV clinics noted that they have seen a change. One physician from the HIV clinic at the public hospital said, “Helping the clients to solve their violence situations is a direct help to their viral load, because if they are scared or suffering violence probably they won’t take their medications and their viral load will go up. We have seen in several cases, that after receiving violence response services, their adherence to the treatment has improved and therefore their viral load has declined. Their health and attitude significantly improves.”  Support groups have proven an effective way to continually engage with victims who are members of KPs. Fifty people attend the bimonthly support group meetings held at CEPROSH’s HIV clinic.

Finally, although participation in the intervention meant increased responsibilities for already overtaxed staff, service providers were enthusiastic about their new ability to address client needs and committed to offering new services. One CEPROSH staff person noted, “I have changed my way of speaking to clients and how I handle them. Before I just mentioned the issue of violence, now I’m able to help them address the issue. The attitude of the staff has changed significantly… When the activity began, some had a small notion of the GBV subject, but they said that there wasn’t any time to deal with that; now everyone feels committed.” Police respondents also indicated that trained officers took new pride in their work, “I’ve always been proud of being a police officer, but some of my partners who weren’t that proud, now they are.”

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Puerto Plata police officers attend a violence prevention and response training.

Most importantly, KP clients described a new willingness to attend services and corresponding improvements in their lives due to those services. As one sex worker who disclosed intimate partner violence said, “I understand a lot of things better. Before I was really closed inside myself. I believe that that man was everything for me; I was used to a man who was bad.  I was attached to that relationship but after the appointments with the psychologist I became stronger and understood that I deserved better. I left that relationship and feel better about myself. They lifted my self-esteem.”

These positive findings, as well as the identification of opportunities for improvement – such as the need for more messaging on the importance of reporting violence quickly to have access to PEP and other time-sensitive services – are helping to inform the expansion of the intervention beyond Puerto Plata.

The findings also demonstrate that integrated HIV and GBV programming benefits members of the general population as well as KPs. New strategies and laws are being contemplated and implemented to address the incredible burden of violence against women in countries like the Dominican Republic. Collaboration with implementers who focus on issues that intersect with violence against women, such as GBV against KPs and efforts to address the HIV epidemic, can be an important part of an effective response.

 

Enumerating key populations: setting denominators, targeting interventions, and measuring impact

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 November 30th, the USAID– and PEPFAR-supported LINKAGES project hosted the second webinar in a webinar series entitled Key Populations: Evidence in Action. This webinar included presentations on empirically-based population size estimation, mapping methodologies, and reaching key populations in areas without primary data collection.

Annette Verster, World Health Organization
Moderator

Navindra Persaud, FHI 360/LINKAGES Strategic Information
Welcome/Overview

Dimitri Prybylski, U.S. Centers for Disease Control and Prevention
Overview of empirical methods for population size estimation that may be linked to biobehavioral surveys

Didier Kamali, FHI 360/LINKAGES/Cote d’Ivoire
Progression approach: generating key population size estimation data to facilitate program implementation and target setting where data do not exist

Stefan Baral, Johns Hopkins Bloomberg School of Public Health
Small area estimation for key populations

Tobi Saidel, Partnership for Epidemic Analysis
The unknowns – understanding and reaching non venue-based key populations

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.

Violence Prevention and Response: An Integral Part of LINKAGES’ HIV Interventions with Key Populations

Written by Vanessa Mosenge, Gender-Based Violence Consultant, LINKAGES


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Representatives from the government, local NGOs, and CBOs pose for a group photo at a GBV stakeholder meeting in Yaoundé, Cameroon. Photograph by Christian Tanyi.

In Francophone Africa, as in many other contexts, key populations (KPs) experience violence and other human rights abuses, including harassment, exploitation, rejection, and denial of health, legal, and security/safety services. As violence increases HIV risk and poses serious barriers to KPs’ ability to access HIV services, the LINKAGES project has systematically worked to integrate violence prevention and response (VPR) into HIV programs for KPs.

Community-based organizations (CBOs) in Burundi, Cameroon, the Democratic Republic of the Congo (DRC), and Mali have shown great interest in addressing violence against KPs, including ensuring that service providers – health care workers, peer educators/outreach workers, and police officers – understand that violence is a real, priority issue for KPs and provide KP-friendly VPR services. As one KP member put it, “We want to get help like any other victim would and deserves, without things turning against us.”

Recognizing this need, a central component of LINKAGES’ VPR programming is building the skills of service providers – peer educators, outreach workers, and police officers – to ask about violence and provide first-line support to KP individuals who disclose violence, including linking them to essential health, psychosocial, and legal services. I have trained teams from Burundi, Cameroon, DRC, and Mali on VPR over the past three years, and one thing that has stood out to me is that many services providers start with the harmful belief (however untrue) that KPs make choices that expose themselves to violence and cannot blame anyone but themselves. During training activities – particularly panels where KPs share personal experiences – I’ve seen service providers introspectively assess how some of their behaviors hinder KPs’ access to services. In fact, I have seen doctors, lawyers, police officers, and government officials become more receptive and affirm that KPs also have a right to live free from violence and deserve services.

In addition to changing harmful beliefs, training service providers has helped them to become more informed about violence and its link with HIV, and service providers have begun to sensitize KPs on what violence is and what support is available through peer outreach, violence screening, psychosocial counselling, and support groups. For example, a peer leader in Cameroon shared, “Violence is prevalent; people don’t respect us; our clients and police do violate us. With this training, we know what to say to our peers; we tell our peers to talk about violence because it is very important to our health.” Service providers are also better able to create a safe environment and provide support to KP survivors. A health care worker in Cameroon further noted, “Training on GBV response helps us address stigma in relation to violence in the sense that we can help survivors know that violence is not their fault, and to speak up. We can also assure survivors of confidentiality and help them feel safe to disclose violence.” In fact, soon after LINKAGES VPR trainings take place, we observe a marked increase in the number of cases of violence reported and the number of KP members receiving support.

In-country capacity building has also helped service providers, government partners, and other stakeholders come together for a coordinated, multisector response to violence among KPs. LINKAGES’ engagement of service providers and other partners is important not only to ensure that KPs get all of the services they need and deserve, but also to garner political support for VPR work. In particular, the involvement of police is critical. Police are often cited as perpetrators of violence against KPs, leaving many KPs feeling as if they have no recourse when they experience violence. In Mali and DRC, we have successfully involved police and other law enforcement personnel in VPR trainings and activities, sensitizing them to the rights and needs of KPs, helping them to see their roles as allies and protectors when KPs experience violence, and helping to build trust between KP communities and the police.

One thing is common among KPs, irrespective of country and context — the desire to live in their community without fear of being abused and mistreated and, instead, to feel safe and protected. The LINKAGES VPR work fulfils the desire and right to live free from violence and contributes to effective KP programming that is responsive to the needs of KP community members.

Using a gender lens to increase impact of HIV programming for key populations: the LINKAGES Gender Strategy

Written by Giuliana Morales, Senior Technical Officer, Research Utilization, FHI 360, and Aubrey Weber, Technical Officer, Research Utilization, FHI 360


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LINKAGES, CHAMP, and CBOs participate in a small group discussion on strategies to improve the implementation of the minimum package of gender-based violence services for key populations in Bamenda, Douala, and Yaoundé, Cameroon. Photograph by Christian Tanyi.

Key populations (KPs) – including men who have sex with men (MSM), people who inject drugs (PWID), sex workers, and transgender (trans) people – often suffer from rigid and harmful gender norms. They underlie much of the stigma, discrimination, and violence faced by KP groups worldwide, inhibiting their ability to access HIV prevention, care, and treatment services. For example, in Kenya, women who inject drugs often face more stigma, discrimination, and violence than their male counterparts but may  be left out of PWID programming altogether due to the gendered expectation that PWID are male.gender strategy

While KP programming has rarely employed gender integration on a systematic level, gender integration has been shown to improve and sustain HIV outcomes. To address this missed opportunity, the USAID– and PEPFAR-funded LINKAGES project developed a Gender Strategy that describes the benefits of gender integration and provides specific actions and tools to integrate gender in HIV programming for KPs. Based on the mandate of the LINKAGES project and in accordance with PEPFAR guidance, LINKAGES focuses its gender integration efforts in three areas:

Designing and implementing activities that reach all members of KPs and challenge harmful gender norms at the root of stigma, discrimination, and violence against KPs

A gender analysis is the first step in the process of gender integration. As gender analyses have not been traditionally conducted with KPs, LINKAGES developed a Gender Analysis Toolkit, using learning from analyses conducted in Cameroon and Kenya. As the briefs from both countries show, a gender analysis can help programs answer important questions such as: Are all members of KPs being considered in your programming? What harmful gender-related beliefs may contribute to HIV risk, a lack of service uptake, stigma, discrimination, or violence against KPs? How do harms caused by gender norms link KPs and the issues they face to those of the broader population, and are there opportunities for combined efforts? The answers help in the design and implementation of gender accommodating and transformative HIV programming (the programming types most likely to result in lasting change).

Promoting the inclusion of trans people in KP programming

Trans women are 49 times more likely to be living with HIV than the general population, yet they have historically been ignored in HIV programming. Many of the reasons for this exclusion are gender-related; therefore, LINKAGES’ gender strategy emphasizes the need for increased understanding of and improved HIV programming for trans people. To support advocacy efforts for more trans-competent programming, LINKAGES developed Rights in Action: Transgender Health and HIV, a brief that includes information on the importance of working with trans people, the way that transphobia ultimately leads to HIV acquisition, and the many opportunities for intervention that address both current health needs and the underlying causes of the epidemic.

Preventing and responding to gender-based violence and other forms of violence against KPsresourcelist

Violence against KPs is widespread and can often be traced back to rigid beliefs about acceptable gender expression and sexual behavior for men and women. Global evidence shows that violence is both a cause and consequence of HIV: violence can increase HIV risk, decrease testing uptake and disclosure, and decrease adherence to antiretroviral treatment among KPs while living with HIV can increase KPs’ vulnerability to violence. To achieve lasting results in the fight against HIV, LINKAGES developed and is rolling out practical guidelines for integrating violence prevention and response into HIV programs. The LINKAGES Gender Strategy also provides information on international resources that can be accessed when violence occurs or safety threats intensify.

Addressing the HIV epidemic against KPs is necessary to achieving 90-90-90 goals, and incorporating a gender lens into KP programs will increase the impact of investments made in this vital programming area.

Making the case for asking key populations about violence: A success story from South Sudan

Written by Kim Dixon, Gender-Based Violence Consultant, LINKAGES


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LINKAGES’ South Sudan team shares their commitment to addressing GBV during the 16 Days of Activism Against Gender-Based Violence campaign.

Before joining the LINKAGES project, I spent most of my career developing, managing, and evaluating gender-based violence (GBV) prevention and response programs for women and girls in emergency, post-conflict, and development settings, as well as in the U.S. In my role as a GBV consultant for LINKAGES, I support country programs to develop and implement violence prevention and response (VPR) programs for key populations (KPs). I have learned directly from KPs themselves about the multiple layers of stigma, discrimination, and violence that prevent them from seeking and accessing services after they experience violence.

Because KPs’ behaviors are frequently viewed as not conforming to traditional gender norms and are often criminalized (e.g., sex work, homosexuality, drug use), they are afraid to seek help after experiencing violence due to fear of being arrested, shamed, or denied services. For these reasons, unless we become proactive in identifying KP individuals who experience violence, we are missing opportunities to link victims to important post-violence services, such as HIV post-exposure prophylaxis (PEP) and emergency contraception. The chance to address any barriers that interfere with adherence to ARVs among people living with HIV – such as not taking ARVs for fear of an abusive partner finding out their HIV status – is also missed. The failure to address violence among KPs ultimately limits our ability to achieve the 90-90-90 goals.

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Health care workers in South Sudan practice screening for violence during role plays.

This is why much of the VPR work in the context of LINKAGES focuses on building the capacity of project staff — including health care workers and outreach workers — to be proactive in identifying violence among KP individuals via violence screening. If we wait for KPs to disclose violence, we may not hear about it due to the barriers just mentioned. Instead, training providers to ask KP members about violence and building their skills to provide first-line support increases the likelihood that KP victims will get linked to important, time-sensitive post-violence clinical services and may increase uptake of and adherence to HIV care and treatment.

Success in South Sudan

Some LINKAGES countries that are implementing violence screening and response interventions are already showing good results. In South Sudan, health care workers were trained on core concepts related to sex and gender, harmful gender norms, and the connection between violence and HIV. They then developed skills for screening KP individuals for violence and providing first-line support to KP victims, including linking them to health, psychosocial, and legal services. Since the training, Jennifer Iden, GBV coordinator for LINKAGES South Sudan, and the rest of the team have successfully integrated VPR screening and response services into existing HIV prevention, care and treatment services. During the last quarter (July-September 2017), 608 female sex workers were screened for violence by health care workers during mobile clinics. Of those screened, 293 (48 percent) reported experiencing sexual violence in the past three months. In turn, 87 (30 percent) of those reporting sexual violence were eligible for PEP, which means that health care workers identified the sexual violence within 72 hours of the assault. Of the 87 women who were eligible for PEP, 87 (100%) received it and were able to reduce their risk of HIV infection.

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Health care workers are trained to screen KPs for violence.

The LINKAGES project in South Sudan is a success story that illustrates the direct link between violence screening and increasing KP victims’ access to critical HIV prevention services. I hope South Sudan’s success inspires others to integrate VPR activities into their HIV programming for key populations.