Social media influencers may be the key to reaching men who have sex with men with HIV interventions

Written by Matt Avery, Associate Director, Global Health, Population, & Nutrition, FHI 360

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Men who have sex with men (MSM) have a greater risk of HIV infection when compared to the general population and, in many regions, MSM account for the largest proportion of new HIV infections. Global programs designed to reach these individuals continue to depend on traditional, venue-based outreach and recruitment models, while MSM themselves are increasingly shifting to social media platforms to find social and sexual partners, access information about HIV, and, increasingly, receive services. The USAID- and PEPFAR-supported LINKAGES project in Thailand is piloting an online peer-driven intervention model to harness the power of social media influencers in reaching MSM virtual communities to identify high-risk individuals for HIV testing and referral to treatment.

LINKAGES’ partners are already implementing a form of peer-driven outreach in several cities in Thailand in which program clients are offered the opportunity to recruit members of their social and sexual networks to HIV testing in exchange for small incentives. When this model was introduced in Chiang Mai, initial results revealed that peer-driven recruitment could significantly contribute to overall programmatic reach and HIV testing uptake with comparatively high rates of HIV case-finding (Figure 1). What implementers did not anticipate was the emergence of “super-recruiters”—individual clients who successfully recruited 50 or more new MSM into the program (Figure 2). The most successful super-recruiters were moderators of highly active online platforms who were using their virtual networks to recruit large numbers of clients.

Based on the preliminary data, LINKAGES plans to replicate this model on a larger scale using targeted recruitment. More than 100 MSM-themed Facebook support groups are active in Thailand, some of which are organized around such specific activities as condomless sex or “party and play”—a term used to describe drug use coupled with sexual activity. Some of these Facebook groups are extremely popular with more than 20,000 registered members who represent a pool of underserved and potentially high-risk MSM.

LINKAGES recently partnered with Attitude Thailand, a leading MSM magazine, and Blued, a widely used social media application for MSM, to host a “VIP” party for key social media influencers, including moderators of some of the largest Facebook groups in Thailand. More than 150 influencers attended this event, where they received basic information about HIV among MSM in Thailand and counseling on the role they could play in helping to end the epidemic. Fifty Thai influencers agreed to work as online recruiters with LINKAGES, disseminating information and content about HIV prevention, testing, and treatment to their social media networks and referring their members for HIV testing through LINKAGES partners in exchange for small incentives.

Matt Avery presents during a multi-country sharing session at Connecting Asia HIV (Photo: Ben Eveslage).

To facilitate this process, LINKAGES Thailand has launched an online appointments application linked to key HIV testing providers known to provide MSM-competent services. Users can learn more about available services and view videos of the different centers, select a date and time to receive an HIV test, and provide contact information to allow health care facilities to follow up and confirm appointments. This tool can be integrated into any online platform and allows the project to track successful testing referrals from each participating platform and compare rates of testing uptake and case-finding. The tracking function also allows LINKAGES to monitor incentive payments for individual online recruiters, who can be paid via electronic bank transfer for complete confidentiality.

In his opening address, Glyn T. Davies, U.S. Ambassador to Thailand, shared his thoughts: “Social networking and social media are opening doors to inclusiveness like never before. The Internet allows for more voices to be heard, more perspectives to be shared, and more effective solutions to be reached. Social media platforms offer innovative new tools to help hasten an end to AIDS.”

In the coming months, LINKAGES Thailand will be translating these thoughts into practice and generating data that will broaden the evidence base of effective social media-based HIV interventions.

LINKAGES introduces online recruitment model to improve access to HIV services for MSM across Asia (Photo: Ben Eveslage).

THE RIGHT TRAINING CAN CHANGE MINDS, HEARTS, AND HIV SERVICES

Written by Kate Stratten, Senior Program Manager, IntraHealth International

This blog post was first featured on IntraHealth International’s VITAL blog. A version of this post originally appeared in The LINK: Issue 9.

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How we are treated by health workers can determine our future health decisions and behaviors.

Just think about the journey for those who live with HIV—from learning what HIV is and how it’s transmitted, to getting an HIV test, to, depending on the result, adopting lifelong changes in your everyday behaviors as part of your care and treatment.

At every point in this journey, the information a client receives—and how and from whom—will influence whether they decide to seek health care and remain on treatment.

We should never underestimate the power of a health worker who makes a client feel at ease, provides up-to-date information, ensures confidentiality, listens without judgment, confidently performs procedures, and carefully explains the benefits of taking medication correctly, returning for follow-up visits, and completing referrals.

LINKAGES, a global project funded by USAID and PEPFAR, is striving for this level of health care for groups of people who are most at risk of contracting HIV, such as sex workers, men who have sex with men, transgender people, and people who inject drugs.

To achieve this, project partner IntraHealth International has developed a training guide for health workers called Health4All: A Health Workers’ Training Guide for the Provision of Quality, Stigma-Free HIV Services for Key Populations.

Health4All is a compilation of some of the best, most up-to-date information and participatory exercises available. It also closely aligned with the WHO Guidelines on HIV Prevention, Diagnosis, Treatment, and Care for Key Populations. The training guide is made up of four modules:

1. The Rationale for Services for Key Populations
2. Heart and Minds: Quality Services for Key Populations
3. Appropriate Services for Key Populations
4. Action, Change, Commitment

It covers a four-day training for those who train other health workers and a three-day training for health workers; however, the material can be adapted for longer or shorter trainings. There are also opportunities for clients who are members of these key populations to join the trainings and interact with and learn alongside health workers.

Through a group of multilingual training experts and key population members, IntraHealth has translated and adapted the material and trained 291 trainers in Angola, Burundi, Cote d’Ivoire, Haiti, Honduras, Mozambique, and South Sudan, with more trainings to follow soon in Indonesia, Mali, and the Eastern Caribbean. For most participants, this training is their first opportunity to learn about key populations, understand the barriers to accessing services, and to reflect on their own feelings and attitudes about providing services to key populations.

I recently asked the group of master trainers for their observations during the trainings. What surprised most of them was health workers’ lack of awareness about gender and sexuality, and their limited knowledge of the unique health needs of key populations and of the urgency for key populations to access HIV services to curb the epidemic.

In one of the trainings, oral sex was discussed. Not only was this topic considered taboo, but one of the participants thought that oral sex is sex over the telephone.

Health workers have to understand people’s different sexual practices and lifestyles and develop the vocabulary and confidence to talk about them with all of their clients. Otherwise, clients will never feel comfortable discussing their high-risk behaviors and opportunities are lost to provide procedures such as anal exams for men and women, treatment for sexually transmitted infections, referrals for family planning, and pre-exposure prophylaxis.

Health4All offers a safe forum where health workers and key populations meet and talk about sexuality and key populations’ health needs—a dialogue that is appreciated by both groups. The importance of bringing these two groups together cannot be overemphasized. It is critical to empowering key populations, breaking down stereotypes, and reducing stigma.

However, it requires an experienced trainer to facilitate discussions (which can become very heated) and to move the group from debate to plans for action. One participant in a training of trainers in Mozambique demonstrates this:

“You know, I came here because I had to… but you must understand that this thing of men who have sex with men is really strange and it is not well accepted in our culture… and you know… we didn’t have this ‘problem’ here before.”

On the last day, this same participant said, “I would like to thank you for this wonderful training… I surely learned a lot about rights and HIV and how we can improve our health system, but what I’m really thankful for is that I learned to be a better human being and to respect our differences. This will change me for life.”

Despite difficulties and some uncomfortable moments during the training, all the trainers commented on the passion, determination, and optimism that participants have toward their work and their desire to improve the quality of HIV services for everyone, particularly key populations.

 

Test to treat: Enhanced peer outreach approach engages previously unidentified key populations at risk for HIV

Written by Tiffany Lillie, Senior Technical Advisor, LINKAGES

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The USAID– and PEPFAR-supported LINKAGES project aims to increase the number of key population (KP) members who are tested for HIV and who begin and remain in treatment after testing positive. To accomplish this, programs need to (1) expand HIV testing services, (2) effectively link people who test positive into care and treatment, and (3) re-engage HIV-positive individuals who have dropped out of care and link them back to treatment services.

To address the challenge of expanding outreach to KP members, USAID and FHI 360 developed the enhanced peer outreach approach (EPOA). The EPOA is led by peer outreach workers, who are trained to create and manage a “referral chain network.” This network has at least three levels. The first level is the peer outreach workers (usually KP members), who are trained to engage new KP members in HIV testing and to identify other KP members to serve as “peer mobilizers.” Peer mobilizers, the second level in the referral chain network, have undergone HIV testing (and, if HIV positive, are enrolled in treatment); they pass referral slips for HIV testing to members of their social or sexual networks. The third level of the referral chain are these peers referred by peer mobilizers to testing or antiretroviral treatment. If peers at this level get tested or visit a facility for treatment, both the peer mobilizer and peer outreach worker can receive a small incentive.

EPOA’s referral chain network

The EPOA empowers entire KP groups to be actively involved in improving HIV-related health outcomes for themselves and their communities. And by reaching deeper into social and sexual networks than is possible through traditional peer outreach, the EPOA is able to engage previously unidentified, high-risk, hard-to-reach KP members, particularly those who are not found at traditional locations (for example, bars and clubs, parks, and brothels).

To support countries in using the EPOA, LINKAGES developed the Enhanced Peer Outreach Approach (EPOA) Implementation Guide and will soon be releasing an accompanying training guide.

The EPOA is currently being scaled up by LINKAGES partners in several countries in Asia, Africa, and the Caribbean. Thus far, HIV case findings have shown improvements in all communities with one or more KP groups.  In Burundi, for example, 2,451 referral slips were distributed to female sex workers (FSWs) during a nine-week pilot. Out of 929 (37.9%) FSWs tested, 100 (11%) of them were found to be HIV positive and 90 (90%) of those were initiated into treatment. The average HIV-positive yield of 11% represents an increase over the 5% HIV-positive yield found in the three months prior to the introduction of the EPOA.

Henriette Manishimwe, project coordinator for the Society for Women Against AIDS in Africa-Burundi, shares her initial thoughts:

“The EPOA not only helped increase HIV testing yield, but also the demand for other services like sexually transmitted infection screening and treatment. It [has also provided] an opportunity to increase our index testing, because all positive FSWs who have young children got them tested.”

While data are preliminary, this demonstrates the potential effectiveness of the EPOA in identifying those who are HIV-positive and initiating them into treatment. Widespread implementation of the EPOA with high-risk populations holds promise as a strategy that could accelerate progress toward UNAIDS’ 90-90-90 targets.

Peer navigation connects key population members living with HIV to the health services they need to thrive

Written by Tiffany Lillie, Senior Technical Advisor, LINKAGES

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Photo: International AIDS Alliance

Peer navigation bridges the divide between members of key populations (KPs) who are living with HIV and the health systems in their communities that provide care and treatment services. Peer navigation is especially important given two main truths about today’s global HIV epidemic:

• The HIV epidemic is growing rapidly among KPs, who include men who have sex with men, sex workers, transgender people, and people who inject drugs.
• Antiretroviral therapy can have a dramatic, positive effect on the overall health outcomes of people living with HIV, yet KP individuals living with HIV face specific challenges both in accessing treatment and maintaining adherence.

Although programs vary, peer navigators are often HIV-positive, medication-adherent role models who are from KP communities. Because of peer navigators’ personal connection to the people they work with, they are best equipped to understand the needs of KP peers and can adequately convey how to access and use prevention, care, and treatment services for people living with HIV, their partners and loved ones, and their children.

Photo: Chris Morgan, Department for International Development

Marceline, a 38-year-old peer navigator in Cameroon, shares her thoughts on the work she does within KP communities:

“Being a peer navigator brings me a lot of joy and satisfaction because I not only follow current patients, but [I] also help patients who have abandoned treatment…. We really are helping save lives, a lot of lives. We become like family members because through our role we help reduce the number of deaths in the community. I am grateful that I was trained as a peer navigator to support others living with HIV.”

The Peer Navigation for Key Populations Implementation Guide was recently developed by the USAID and PEPFAR-supported LINKAGES project to help build a cadre of trained HIV-positive peers like Marceline to engage and retain KP members living with HIV in the health care system. This implementation guide evolved and was adapted from several initiatives that incorporate peers in HIV programming to improve health outcomes, including the HIV Prevention Trials Network 061 study, funded by the National Institutes for Health; the Key Populations Implementation Science study in South Africa, funded by USAID and implemented by FHI 360 and Johns Hopkins University; and Building Blocks to Peer Success, a toolkit for training HIV-positive peers developed by a consortium of partners and led by Boston University’s School of Public Health.

The ultimate goal is to have a trained group of peer navigators working as part of a team of providers who can reach and support KP communities around the world to ensure that those living with HIV can effectively and efficiently access the full range of clinical and psychosocial services available to them, and maintain healthy, positive lives. LINKAGES is currently implementing peer navigation in Botswana, Cote D’Ivoire, the Democratic Republic of the Congo, Jamaica, Kenya, and Malawi as a key strategy for improving KPs’ access to and retention in HIV care and treatment services.

Photo: Ian Taylor

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.