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

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

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

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

What is S2S mentoring?

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

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

LINKAGES’ response

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LINKAGES puts key population HIV programming on the map at IAS 2017

Written by Tiffany Lillie, LINKAGES Senior Technical Advisor; Hally Mahler, LINKAGES Director; and Chris Akolo, Director of Global Health, Population, & Nutrition, FHI 360

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Hally Mahler leads one of two satellite sessions hosted by LINKAGES at IAS 2017.

LINKAGES had a significant presence at the 9^th International AIDS Society (IAS) Conference on HIV Science (IAS 2017), held July 23-26 in Paris. The project hosted two satellite sessions on key populations (KPs), an oral abstract on peer navigation in Cameroon, and 12 poster exhibitions from Angola, Botswana, Burundi, Kenya, and Thailand. During the conference, LINKAGES also participated in multiple stigma and discrimination sessions hosted by IAS and the “Me and My Healthcare Provider Initiative,” a global campaign focused on the broader needs of KPs affected by HIV that celebrates the many doctors, nurses, receptionists, pharmacists, and other frontline health providers who deliver quality HIV prevention and care to their KP patients every day.

UNAIDS offered these global statistics: “In 2016, more than two-thirds (70 percent) of people living with HIV now know their HIV status. Of the people who know their status, 77 percent were accessing treatment, and of the people accessing treatment, 82 percent were virally suppressed.”

Giuseppe Cristino (LINKAGES Angola) presents a poster on HIV risk assessment.

While the numbers are promising, UNAIDS also noted that those most at risk for HIV – namely KPs – are still being left behind, and integrated health services will be necessary moving forward to reach 90-90-90 targets. This idea was a key takeaway from IAS 2017, with increased attention being placed on the need to deliver quality and responsive HIV services to KPs – including men who have sex with men, people who inject drugs, sex workers, and transgender people.

Chris Akolo addresses a group of KP health workers during a special session.

Globally, 44 percent of new HIV infections are among KP members and their sexual partners. In sub-Saharan Africa (SSA), that figure remains at 25 percent. In regions outside of SSA, a staggering 80 percent of new HIV infections are among these groups. So, what innovative service delivery models were showcased at IAS 2017 to improve HIV programming for KPs worldwide? The LINKAGES team notes seven key takeaways:

1. Pre-exposure prophylaxis (PrEP), the use of anti-HIV medication to keep HIV-negative people from being infected, is being scaled up at a tremendous rate around the world. In the United States, Europe, Africa, and certain parts of Asia, PrEP on demand is increasingly popular. In order to prevent HIV from spreading, health organizations must take bold action to move forward with PrEP.
2. Undetectable = Untransmissible. The evidence is clear. A large study was conducted in Australia, Brazil, and Thailand that examined transmission risk among HIV serodiscordant MSM couples. After years of follow-up, not a single linked HIV transmission within any of the participating couples was found. This groundbreaking research supports the hypothesis that undetectable viral load prevents HIV transmission in MSM. MSM-specific programs are beginning to use this data to help encourage HIV treatment with sex-positive messaging.
3. Innovations in information and communications technology (ICT) are forging ahead quickly, particularly with online appointment systems that allow at-risk populations to maintain confidentiality while seeking HIV testing or treatment services. Initial success with LINKAGES’ own SMS², a mobile system that allows peer outreach workers to send text messages to KPs to ask about HIV service satisfaction, proves that ICT is an essential component of HIV programs.
4. HIV self-testing is here and ready for prime time. Several studies, including LINKAGES Thailand work, have revealed that people like to have a variety of choices in how they access self-testing. Presentations on mail order, central pickup locations, and peer-mediated testing were given at IAS 2017.
5. Stigma and discrimination are real barriers to achieving an HIV and AIDS-free generation, but there are no easy answers. Stefan Baral, Associate Professor of Epidemiology at Johns Hopkins Bloomberg School of Public Health, presented research on this topic. After an intensive training package in stigma reduction for KP clients and health providers, clients became more willing to seek health services but their experiences of discrimination within the health system did not diminish.
6. Differentiated care and service delivery is promising for HIV programming for KPs. Providing options to individuals grants them autonomy and allows them to choose how and when they access services. IAS released a supplement on differentiated care and HIV, which prominently features KPs.
7. Finally, demonstration projects are no longer necessary. The previously mentioned innovations, channels, and topics of discussion at IAS 2017 have proven successful in improving health outcomes. What comes next? Health organizations and other key stakeholders must take these innovations in HIV science and bring them to scale where they are needed most.

Lusia Ang, Stella Chege, and Neo Monnapula were recognized as HIV health provider champions. Photo courtesy of IAS 2017.

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