Click the image below to open the photo story of the women of LINKAGES Nepal.
Speed, scale, and quality: How LINKAGES implemented evidence-based key population programming in 19 countries in its first 12 months
When the USAID– and PEPFAR-supported LINKAGES project first started in June 2014, we expected a handful of countries to buy in to the global mechanism dedicated to meeting the HIV prevention, care, and treatment needs of key populations (KPs). However, almost immediately, the demand exceeded our expectations. USAID missions in seven countries bought in to LINKAGES in the first six months, and in just over a year, LINKAGES was working in 19 countries! The exponential growth of the program across Africa, Latin America and the Caribbean, and Southeast Asia required us to re-evaluate how we could successfully deliver high-quality KP programming across such a large swath of countries, with more being added by the day. We did not want to have disjointed country programs of varying quality. We wanted each program to be delivered efficiently and tailored to local context, but grounded in the critical, evidence-based elements of KP programming. As a global mechanism, we had a unique opportunity and an obligation to support countries to scale up quality KP programming that would achieve results.
Our answer was the program acceleration (acceleration) initiative, which was launched in December 2015. The goal of this initiative is to accelerate and strengthen service delivery for KPs at scale by providing training, capacity development, mentoring, and knowledge exchange to in-country LINKAGES staff, local implementing partners, and staff from ministries of health. One of the first steps we took under the acceleration initiative was to develop a common core KP program and guide to serve as the initiative’s foundation. The common core includes information on seven key program areas based on global guidance:
- Engage key populations in population size estimation, mapping, and program planning
- Key population empowerment and engagement in programs
- Structural interventions
- Peer outreach
- Clinical services
- Program management
- Monitoring and data use
Next, we trained a core group of expert technical assistance providers and country implementers on the common core program and set up frequent, rapid, and targeted technical assistance to support countries in implementing high-quality KP programming.
It has been almost two years since the acceleration initiative was established. Implemented in 17 countries to date, the initiative has been successfully supporting local staff and partners to deliver a comprehensive package of health services at speed, scale (within and across countries), and according to standards (a common core program).
We have documented the achievements and lessons from acceleration in two new resources. For more on how to rapidly deliver and scale up quality KP programming, see Accelerating the Implementation and Scale-up of Comprehensive Programs for HIV Prevention, Diagnosis, Treatment, and Care for Key Populations and Acceleration Country Success Stories.
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.
Everyone deserves to live free from violence: Assessing a model to increase access to holistic GBV-response services in Puerto Plata, Dominican Republic
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.
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.”
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.
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.
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
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.
Written by Chris Akolo, Technical Director, LINKAGES
Today marks the 19th World AIDS Day – a global call for unity in working toward epidemic control, support for people living with HIV, and commemoration of the more than 35 million people who have died of HIV- or AIDS-related illness since the virus was first identified in 1984.
I began work as an HIV physician in 1999 and have spent the past 18 years implementing HIV prevention, care, and treatment programs in resource-limited settings. For the past three years, I’ve served as technical director of the USAID– and PEPFAR-funded LINKAGES project, the largest global project dedicated to addressing the epidemic among key populations (KPs) including men who have sex with men, people who inject drugs, sex workers, and transgender people.
Since we first set out in 2014, the LINKAGES project has been through three major phases: (1) start-up; (2) rapid acceleration; and (3) stabilization at scale. We are now forging ahead in this third phase, providing support and technical assistance to improve HIV programming for KPs in 30 countries across Africa, Asia, and the Caribbean. Using a common core Key Population Implementation Guide, which is oriented around the HIV cascade, our support in these countries consists of a range of activities designed to identify, reach, and help KP members learn their HIV status and enable those who are HIV-positive to access care and remain adherent to treatment. Getting to this phase has not been easy, and I have learned a lot along the way. On this World AIDS Day, I share some of the most important lessons I’ve learned during my time with the project:
- Key population members themselves must be at the forefront of programming. We are most successful when KP members are directly involved in the design and implementation of services. In all of the countries where we work, we engage KPs as peer educators and outreach workers to identify others in their communities and connect them to HIV testing and other related services. We employ them as peer navigators to support others living with HIV to access and adhere to treatment. And, we undertake institutional capacity building with KP-led community-based organizations for long-term sustainability.
- Data for decision-making is key. LINKAGES has developed robust strategic information systems with custom indicators that allow us to understand – in a timely manner and with great specificity – where we are having success and where we need to adjust our programmatic approaches at different points along the cascade. We have built the capacity of country teams and implementing partners in data analysis, interpretation and use, and instituted frequent data review meetings at country level. This culture of data use has allowed us to fine-tune our programming to each country context and accelerate progress toward aggressive program targets.
- We must constantly innovate. Sometimes the data tell us we are falling short and, when that happens, we must be quick to try new solutions. For example, when we were having trouble reaching HIV testing and case finding targets in a few countries, we introduced the Enhanced Peer Outreach Approach (EPOA) to engage previously unidentified and particularly high risk KP members with HIV prevention and testing. We saw immediate improvements with this approach, which is now being scaled up in other LINKAGES countries.
- We must modernize key population programming. As new biomedical interventions are introduced – like HIV self-testing and pre-exposure prophylaxis (PrEP) – we work to ensure that KPs have access to them. LINKAGES is introducing HIV self-testing in three countries and implementing PrEP demonstration projects in two others, with plans underway to expand to three more. We also employ cutting-edge information and communications technology (ICT) solutions in our programming – leveraging social media, conducting “virtual mapping” to enumerate online spaces commonly used by KPs, introducing online appointment booking, and partnering with ICT companies like Grindr to expand our reach and impact.
- We cannot underestimate the context of violence, stigma, and discrimination in which we work. Our efforts to improve uptake of HIV testing services and link those who are positive to treatment will have limited success if we are not also addressing the structural determinants of KPs’ vulnerability to HIV. LINKAGES is dedicated to integrating violence prevention and response in our programming. Nineteen countries have implemented at least one violence prevention and response activity, with two more set to begin implementation by the end of this year. These activities have already identified more than 1,200 cases of violence, brought new KPs to HIV services, increased the provision of post-exposure prophylaxis and emergency contraception to victims of sexual violence, changed attitudes among police and other common perpetrators of violence, and helped victims of violence understand and demand their rights. In order to address stigma within health care settings, we have developed a training package with health care providers in more than 10 countries on providing KP-competent services. LINKAGES has also developed SMS2, a text message-based system for monitoring and providing real-time feedback on the quality of health services provided to KPs.
As we look to a fast-approaching new year, we will carry forward these lessons from the past and renew our call to place key populations at the forefront of global efforts to reach epidemic control and achieve UNAID’s 90-90-90 targets by 2020.