Three ways to turn science into practice to reduce HIV among key populations

Written by Rose Wilcher, Director, Research Utilization, FHI 360, and Hally Mahler, Project Director, LINKAGES

This blog post was originally featured on FHI 360’s Degrees.

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Photo: Jessica Scranton, FHI 360

Next week, leading scientists and cutting-edge thinkers will gather at the International AIDS Society’s 9th IAS Conference on HIV Science in Paris to discuss the latest scientific discoveries in HIV prevention, care and treatment. These discoveries hold the potential to accelerate progress toward the global 90-90-90 targets set forth by the Joint United Nations Programme on HIV/AIDS (UNAIDS). And, they are especially important for key populations — including men who have sex with men, sex workers, transgender people and people who inject drugs — who shoulder a disproportionate burden of HIV. UNAIDS estimates that 45% percent of all new HIV infections among adults worldwide occur among these key populations and their sex partners. Reaching these groups with new technologies and approaches is essential to ending the epidemic.

The headway on display at IAS will, we hope, leave us feeling optimistic. However, science cannot have impact unless it is applied in policy and programs. We are working to translate evidence of what works into widespread practice for key populations through the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project, which is funded by the U.S. Agency for International Development (USAID) and the U.S. President’s Emergency Fund for AIDS Relief (PEPFAR). But progress is slower than it should be, largely because the issues that drive the spread of HIV in key population communities — unrelenting stigma, discrimination, violence and, in many cases, criminalization — also mean that these groups are often the last to benefit from scientific discoveries.

To ensure that new technologies and emerging evidence-based practices reach those who want and need them most, we should do three things.

We need more community-led demand for the latest evidence-based innovations. Even the most compelling evidence does not put itself into practice, especially for the benefit of the most marginalized. When members of key populations demand access to innovations that could make a difference in their lives, that is often the needed catalyst to move research to practice. Organizations led by key populations are chronically underfunded and undervalued, but their voice and engagement are critical to ensuring that evidence-based practices reach them in a way that is safe, appropriate and responsive to their needs.

For example, great strides have been made in recent years using pre-exposure prophylaxis (PrEP) as a new HIV prevention option, and it is sure to be a hot topic at the IAS conference. But, PrEP implementation, particularly for key populations, is complex and moving slowly. The International Treatment Preparedness Coalition (ITPC), a LINKAGES partner, recently convened a global think tank meeting with stakeholders representing the communities that are most affected by HIV to discuss how best to increase access to PrEP. “This was the first time that people from different communities from across the globe sat together in one room to discuss how to demand PrEP on their own terms,” said Solange Baptiste, executive director of ITPC. The discussions at that meeting are informing an upcoming global policy brief and an activist toolkit on PrEP that can accelerate implementation.

We must create an environment that enables the delivery and uptake of evidence-based interventions among those who need them most. Even when the latest prevention, care and treatment options and services are available, stigma, violence and discrimination from health care providers, family members, police, and partners hinder access to services. In many of the countries where LINKAGES works, including Botswana, Cameroon, the Dominican Republic, Kenya, Malawi and Suriname, we are systematically integrating violence prevention and response into HIV programming for key populations. We are working to mitigate stigma in health care facilities through the introduction of a text-message-based quality assurance tool that gathers information about key populations’ experiences of stigma and discrimination at health facilities and assesses overall client satisfaction with the care they received.

But, work to dismantle stigma and address violence against key populations, including through policy and legal reforms, always needs more attention. We will miss opportunities for the science to have maximum impact if the environment in which the science needs to be applied is not also progressing.

We need to accompany these efforts with the generation of more evidence through implementation science. Such investments will build collective knowledge about how to introduce proven interventions in real-world contexts, thereby speeding up the pace of replication and implementation at scale.

At the IAS conference, LINKAGES and colleagues from USAID, the U.S. Centers for Disease Control and Prevention (CDC) and amfAR will convene a satellite session that will present findings from implementation science studies focused on key populations that were conducted in Brazil, Peru, Senegal, South Africa and Thailand. Taken together, these studies contribute important new evidence about how to enhance uptake of and retention in services for key populations, across the HIV prevention, care and treatment cascade. They also illustrate how valuable implementation science is to ensuring that proven interventions achieve results through widespread implementation.

The evidence base on HIV and key populations has grown tremendously in the past several years, and more will come to the fore at the IAS conference. We will be participating with an eye toward how we can move the science into practice so that it benefits as many people as possible, as quickly as possible. The science holds much promise; we cannot let implementation lag.

Through Bullets and Bombs to Reach Health Care

Written by Cecilia Amaral, Global Health Corps Fellow, IntraHealth International, and Carol Bales, Senior Communications & Advocacy Officer, IntraHealth International

This blog post was originally featured on IntraHealth International’s VITAL blog.

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Photos: Alex Collins, Senior Program Officer, IntraHealth International

In conflict areas around the world, health workers like Patrick in South Sudan continue to risk their lives to do their jobs.

“There were guns, bullets, and bombs everywhere,” says Patrick Hakim, a clinical officer in South Sudan.

That was the scene around Juba last July after fighting broke out at the presidential compound between the Sudan People’s Liberation Army (SPLA) and the SPLA in Opposition (SPLA-IO) forces.

Amidst the country’s already horrific and brutal conflict, Patrick says those two weeks were characterized by widespread terror. Many borders, roads, and markets were closed. Patrick and his fellow health workers were afraid of leaving home, of being attacked or stopped at armed check points.

But he did. He went to work.

“I felt compelled to risk my life, get out of my house, and walk to Juba Teaching Hospital,” he says. “Because there were clients I had booked the previous week.”

Patrick is part of an IntraHealth International team supporting USAID’s LINKAGES project, which provides HIV testing, care, and treatment largely to foreign female sex workers—a key population in South Sudan’s fight against HIV. The team distributes condoms and antiretroviral drugs, which require regular follow-up and refilling of prescriptions.

So during the days of the July crisis, Patrick was still receiving calls for HIV services.

Patrick Hakim, LINKAGES Clinical Officer

He and his colleagues continued offering some HIV services to their clients and other South Sudanese. The team provided condoms to the female sex workers in Juba town through their peer leaders. And condoms, test kits, and antiretrovirals were made available at the Juba Teaching Hospital and Al-Saba Children’s Hospital, the other main hospital in Juba town.

But many of Patrick’s clients weren’t calling. They were scared, too. Many fled Juba and even South Sudan. Some hid in the bush. And some ran out of food and stopped taking their antiretroviral medications to avoid the side effects.

One client, a sex worker who travelled from Yei to Juba to refill her prescriptions every couple months, was determined to get her medication. She walked through bushes and villages to avoid the roads. The trip that usually took her four hours by bus took her almost four weeks. When she finally reached Juba Teaching Hospital, Patrick says, she had lost a lot of weight, was malnourished, and had a persistent cough. In fact, she could hardly breathe.

But she made it. Patrick can only guess how many others did not.

Disease Doesn’t Wait for War to End

Since civil war broke out in South Sudan in December 2013, tens of thousands of people have been killed and three million people have been displaced. The country has plunged into a humanitarian crisis that has been exacerbated by famine in the northern-central region. The crisis worsened in 2016, and 7.5 million people are in need of humanitarian assistance.

Now millions of people are vulnerable to disease and injury and unable to reach the health care they need. More are dying from vaccine-preventable and treatable diseases, such as measles and cholera—deaths that are directly linked to the lack of basic health services. Women lack skilled birth assistance and access to contraception, and people with HIV/AIDS or tuberculosis have been cut off from life-saving medications.

Only 43% of South Sudan’s health facilities are now functional. More than 100 have closed, and at least 29 have been looted or destroyed since the beginning of the civil war.

In February 2016, a Médecins Sans Frontières medical center in Jonglei state was caught in crossfire. A six-year-old boy was shot and died. Thirty-five other patients were injured. The center was looted of medical equipment and medicines.

In the days of the July crisis, when Patrick’s client was avoiding roads and hiding in the bush, shelling hit the maternity wing of an International Medical Corps hospital within a UN Protection of Civilians site in Juba. Fifty thousand people were suddenly without medical services and humanitarian aid.

Patrick had reason to be scared. Health workers, patients, and facilities are deliberate targets.

The waiting room of the LINKAGES drop-in center.

Last May, for example, soldiers at a checkpoint in Yei shot a doctor in the stomach while she was driving an ambulance late at night, returning from rushing a pregnant woman for emergency care. She died four days later from her injuries. In September, armed men threatened health officials at gunpoint while ransacking a health center in Lasu. In December, also in Lasu, SPLA-IO forces abducted three health workers during road clashes (they were later released).

And that’s not all. What’s happening in South Sudan exemplifies a continuing trend among conflict-ridden countries.

Impunity Must End

A new report by the Safeguarding Health in Conflict Coalition, Impunity Must End, documents attacks on health care in 23 countries in conflict around the world.

• In Syria, there were 108 attacks on health facilities and 91 health workers killed.
• In Afghanistan, there were 119 attacks on health facilities and health workers.
• In West Bank/Gaza, 162 medical technicians were injured by violence or interference with ambulances.

But documentation of such attacks remains spotty. The report’s numbers may greatly understate the actual extent and severity of these attacks.

And accountability remains almost non-existent. Despite the adoption of UN Security Council Resolution 2286 last year, which set out a roadmap to protect health in conflict, practically nothing has been done to enforce and implement it.

Impunity Must End makes concrete recommendations to end these atrocities, including regular reporting by countries to the UN on how they are preventing attacks, investigating those that occur, and holding perpetrators accountable. If member states fail to act, the UN Security Council—which met last week to discuss the resolution again—should initiate thorough investigations and establish accountability procedures. The UN Security Council must act.

It was Patrick’s childhood dream to become a health worker so that others wouldn’t suffer the hardships his family endured due to lack of access to health care. But he and his colleagues need to be safe to save lives. They should not have to be scared to go to work. And no one should have to be scared to seek out health care.

The impunity must end.

Read more about Patrick in this Picture It post.

IntraHealth is a founding member of the Safeguarding Health in Conflict Coalition. IntraHealth leads communications for the coalition and co-authored and edited the new Impunity Must End report. This blog post sites data from the report.

The ART center at the Juba Teaching Hospital, where LINKAGES clinical staff like Patrick provide HIV services on a weekly basis as support to the existing hospital staff.

The IDUIT offers practical guidance on implementing HIV programs for people who inject drugs

Written by Brun Gonzalez, Chair of Board of Directors of the International Network of People who Use Drugs (INPUD) and Judy Chang, INPUD Executive Director

Photos provided by: Brun Gonzalez

The Injecting Drug User Implementation Tool (IDUIT), jointly developed by INPUD and the United Nations Office on Drugs and Crime (UNODC), was released this April and is the fourth publication in a series of tools on implementing HIV programs with key populations. It offers practical guidance on implementing HIV programs for and with people who inject drugs (PWID) across the HIV care continuum and contains examples of best practices from around the world that can be used to support efforts to plan programs specific to the PWID community. The tool covers prevention, care, treatment, and support interventions and focuses on partnerships with or by PWID organizations.

The IDUIT is the product of a collaborative process between PWID, advocates, service providers, researchers, government officials, UN agencies, development partners, and nongovernmental organizations. The tool provides a strong platform for emphasizing the importance of community empowerment in reaching PWID with HIV services.

 

“The IDUIT is the result of a very positive and important collaboration between the United Nations and the international community of people who use drugs that reflects… high-level participation and engagement that answers the affirmation ‘nothing about us without us’ in a meaningful and constructive way,” said Brun Gonzalez.

A multidisciplinary group of people came together for a consultation meeting in Bangkok to elucidate optimal approaches for designing, developing, and implementing comprehensive services that meet the real needs of the PWID community. When developing the tool, it was also important to maintain a broad focus on issues that other key populations most at risk for HIV often face.

The sessions were attended by representatives from the UNODC, the Joint United Nations Programme on HIV/AIDS, the World Health Organization, civil society specialists, and members of the PWID community. Individuals working on health and harm reduction service provision, community organizing, and advocacy campaigns brought their unique experiences to the table to discuss best practices and efficient models based on community involvement and strengthening.

The convergence of “top-down” and “bottom-up” perspectives allowed for a rich, comprehensive process that brought together the best of both worlds to develop the IDUIT: the evidence-based, biomedical model and the pragmatic, rights-based model derived from what was referred to as “community wisdom” during the consultation.

It is essential to seek representation of and participation from the people who are immediately affected by the decisions being made when looking to improve harm reduction services and implementation tools. The IDUIT is one step in a long process of fine-tuning and updating the mechanisms set in place at an international level.

“I’ve been where they are”: a LINKAGES Malawi Photo Story

Click the image below to open the photo story of Caroline, a peer outreach worker reaching sex workers in Malawi.

Early Lessons from South Africa’s Rollout of Oral PrEP to Sex Workers

This blog has been reposted from Prepwatch.org; the original posting can be found here. Contributed by Neeraja Bhavaraju and Daniela Uribe from FSG, a member of the OPTIONS Consortium.

In June 2016, South Africa’s National Department of Health began making oral pre-exposure prophylaxis (PrEP) available to sex workers. This represented the first time that any PrEP product was made available outside of a research study or demonstration project in an African country. In the first six months, hundreds of women have started taking PrEP from a network of 11 sites across five provinces in South Africa.

Maria Sibanyoni, program manager of the sex worker program at Wits RHI, a research institute focusing on sexual and reproductive health, HIV and vaccine preventable diseases, shared some early insights on what she has learned about delivering PrEP. These are some of the first “real world” insights that we have about PrEP delivery, and they will be invaluable to the wider rollout of PrEP in South Africa and beyond.

Lesson #1: Meeting people where they are increases access and uptake

A multi-channel strategy supports PrEP uptake

“One of the approaches that we use to provide services is through fixed facilities. Sex workers are able to access these facilities anytime. The second approach is outreach. We go out with a package of services—medicines, equipment, and HIV test kits—and reach out to the sex workers in brothels. When we get to the brothels we request a room and set up a clinic to provide services in the brothel itself. The third approach is a mobile van. We are targeting those who are street-based, whether they are operating at the bush, on the highway, under the bridge, wherever, to reach those sex workers using a mobile van where we provide a comprehensive package of services. The fourth approach is using the peer educators, who form a link between the clinic and the sex workers because they do lots of referrals, they go out there, they mobilize, they also provide HIV testing services including finger pricking, give health talks, they talk about PrEP quite a lot, but also they make sure that they link the sex workers to our services so that they are able to access PrEP.”

Lesson #2: Those with high HIV-risk perception more frequently use and adhere to PrEP

Raising awareness among potential PrEP users about their own risk is a strategy to generate demand for PrEP and ensure higher levels of adherence.

“With sex workers, the ones who see themselves at risk are keen to take-up PrEP. However, those who are just worried will start coming up with excuses: ‘I can’t take a pill every day.’ They are worried for now but they are willing to take the risk. Those who see themselves being at risk know PrEP will help them. People know their lifestyle and who they engage with, they know the factors that are pushing them to request it.”

Area for further study
While it is clear that some women are “self-selecting” to use PrEP, we still don’t know whether those women who are “self-selecting” are those at highest risk for HIV transmission. Further study on this issue could mitigate concerns about the “worried-well” driving PrEP demand and will help inform plans for broader PrEP introduction.

Lesson #3: Creating a community of support increases adherence

From peer educators to friends, having a community to create accountability can make all the difference.

“We have looked at different strategies of adherence. We look at a buddy system – who are they bringing or identifying as their support person or support structure that will ensure that they take treatment on time and they come in for their check-ups. We also keep a register to ensure that those who do not honor their appointment are traced, telephonically and physically. We have peer educators who do the physical tracking. They go to the brothels to find the sex workers, even though they are mobile; the peer educators have been in the area and have a relationship with the community, and they will have feedback and information about where they are.”

Lesson #4: Engaging and supporting health care workers is essential

While PrEP represents a “breakthrough,” it also represents a significant new workload.

“PrEP is new, and as with anything that is new people will react differently. Some of the health care workers see PrEP as a breakthrough. But others see PrEP as an added responsibility that will increase their workload. A clinician used to see someone who was HIV negative and say “’stay negative and we will see you in 6 months or a year’s time.’ But with PrEP now we have to initiate you, call you after a week, call you after a month, call you after three months. So some might think ‘this is actually increasing my workload.’”

Photos by: Dawn Greensides, Wits Reproductive Health and HIV Institute

Key Population Heroes: Finding meaning and renewed purpose after my HIV diagnosis

Written by Christio Wijnhard, Project Coordinator for the LINKAGES Project at Foundation He+HIV, Suriname

Even though Clarence suspected that he might HIV-positive, the 24-year-old was shocked when he first learned his status. “I cried and I cried. I wanted to commit suicide. I thought it was the end for me.”

When Clarence first accepted his sexuality, he just began experimenting and never thought about practicing safe sex. But he lived in a small village where news traveled fast. When people started talking about two of his former sexual partners being HIV-positive, he realized the risks involved.

The young Surinamese man met a health navigator working for Foundation He+Hiv (FHH), a LINKAGES implementing partner. They had met before on social media, but the health navigator invited him for a one-on-one conversation at FHH.  The health navigator then determined that Clarence had been risky in his behavior and advised HIV testing. “At first I was reluctant to go for an HIV test. But, after thinking about it, I agreed.” Clarence’s health navigator motivated him to not be afraid and pointed out the importance of knowing his status for sure. Finally, on November 7, 2016, the health navigator accompanied him to a health care facility.

Clarence looks out the window.   Photo credit: Christio Wijnhard

 

The outcome was devastating at first. “I have two dogs, Bruce and Chulo, and I could see their chain in front of me because that was what I wanted to use to kill myself.” Clarence was embraced by his health navigator, who shared with him some surprising information that changed the way he would view his HIV-positive status.

 

“He told me he was also infected with the virus. At first I would not believe it because he was a normal-looking man on the outside.” Looking back, Clarence can honestly say that this moment changed his life. “Hearing and seeing someone that was also infected, but looked very healthy, took away the feeling of being alone and lonely. It took away my fear of dying.”

When the time came to start medication, Clarence had some difficulties. The side effects were too much to handle, and he even stopped taking his medication because of them. His health navigator and the specialist at the Academic Hospital had serious talks with him. The doctor even told him bluntly: “If you don’t take your medication, you will die. Is that what you want?” Finally, the health navigator decided to bring Clarence for a talk with the project coordinator.

The project coordinator asked Clarence about his dreams and his goals. Clarence shared that he was worried about his cousin.  “She is my favorite cousin. I love her very much but she is risky in her behavior, like I was.” Then, they started talking about the possibility of her being HIV-positive as well. When the project coordinator asked Clarence what he would do if his cousin was infected and did not take her medicine, Clarence replied, “I would tell her not to be stupid and take her medication of course!”

Clarence paused for a moment, before saying, “Okay, I get it!”

Today, Clarence is still working on accepting his status. Twice a month he attends MSM support group sessions, which focus on self-empowerment. He meets up once every few weeks with his health navigator. He also uses the psychosocial care services at FHH, and he joined the group for the annual retreat of key population members who are living with HIV.

“I feel super fantastic! Because of the coaching, I was able to define what I liked. I am very interested in photography and I would like to take dance classes, and I might pursue a career as a male model someday.” Clarence also told his health navigator that he no longer wanted to be accompanied by him when he needs to visit the health care facility. “I feel empowered enough to visit health care facilities on my own.” Clarence also started writing about his feelings in a dairy.

“I feel great, really. And I want to work on improving myself because I want to be a good example for other people dealing with acceptance of their HIV status. I want them to know that it is not easy but if I can make these changes and be happy and work towards a good life living with HIV, so can they! I want to be their inspiration.”

 

WE NEED TO TALK ABOUT “REGGIE”: THE IMPORTANCE OF INTEGRATING LGBTQ MESSAGING WITH HIV INFORMATION

Written by Georgia Arnold, executive director and founder of the MTV Staying Alive Foundation, and executive producer of the award-winning “edutainment’ campaign, MTV Shuga.

MTV Shuga is a 360 mass media campaign that uses the power of entertainment to generate positive sexual and reproductive health outcomes amongst young people. At the core of MTV Shuga is a TV drama, which follows the lives of a group of young friends as they encounter sexual, social, and educational challenges throughout their adolescent years. Following on from two seasons in Nairobi and another two set in Lagos, the fifth season has been produced in South Africa for the very first time.

The issue of HIV and AIDS among young people is as important today as it has ever been. Every day, 1,300 adolescents around the world are infected with HIV.

In the run-up to National Youth HIV & AIDS Awareness Day on April 10, we are reminded of the need to challenge the stigma surrounding HIV and AIDS and empower young people to take charge of their sexual and reproductive health.  One of the ways we can achieve this is by breaking down the taboos surrounding adolescent sexuality.

Across many countries in the world, the idea of sexual activity among young people carries strong negative connotations. Accurate and judgement-free conversations with young people about sexual behaviors or safe sex practices are few and far between, meaning that many teenagers are uninformed and misguided when it comes to sexual health.

Photo Credit: MTV Shuga

This is particularly true in the case of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community who, in the rare cases where information on sex and sexuality are provided, are often entirely ignored or are described as wrong.

Holding open, in-depth, and inclusive discussions about sexuality is imperative in our efforts to reduce HIV transmission and ensure that those living with HIV have access to care. Such conversations allow us to break down rigid norms attached to young people’s sexual behavior and sexual orientation.

This represents the first, and most important step, in ensuring that all young people feel able to access the necessary information and sexual health services available. After all, you can’t get information that protects you from HIV if you are afraid that your questions about your sexual behavior will be met with discrimination and disdain from your health care provider.

As part of our work on MTV Shuga, we aim to challenge harmful norms by fusing hard-hitting entertainment with important social, sexual health, and educational principles.  In our latest series set in South Africa, a new character Reggie – who is trying to understand his own sexual orientation – represents the medium through which LGBTQ messaging and HIV information can be successfully merged.

In Africa, where MTV Shuga is primarily broadcast, most countries have anti-homosexuality legislation and members of the LGBTQ community are often marginalized. Even in South Africa, where LGBTQ rights are legally enshrined, 55% of LGBTQ people live in fear of discrimination because of their sexual orientation. These data emphasize the need to talk about and create empathy for the “Reggies” of this world, but in a way that is carefully produced to maximize our potential impact.

This is a particularly complex endeavour as we broadcast in countries where LGBTQ storylines are not permissible. Although we cannot change existing laws, we can traverse state borders through our mass-media approach. Making use of digital platforms, such as YouTube, has allowed us to reach those living in places where LGBTQ stories are rarely told, and circumnavigate broadcasting regulations.

Young people face so many challenges throughout their formative years; the added burden of hidden sexual orientation has adverse implications for their health and well-being. We need to create safe spaces where all young people are free to explore who they are, including their sexual orientation, and get the information they need to live healthy and productive lives. While our approach may vary depending on the environment, the end-goal must always remain the same: to challenge harmful norms and affect a positive change in all young people’s sexual lives. Incorporating LGBTQ messaging in a sexual health context is an important way to realize this goal.

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For more information on the important work being carried out in the LGBTQ community in South Africa, ANOVA and OUT represent two leading organisations in this field. These groups promote the need to incorporate HIV information with LGBTQ messaging as a means of generating positive sexual health outcomes among South Africans.