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 9th 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.”

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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.

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

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.

Commission on the Status of Women & Transgender Women

Written by Beyonce Karungi, Executive Director, Transgender Equality Uganda

The Commission on the Status of Women (CSW) is the largest international gathering of governments and civil society dedicated to developing an agenda that promotes progress for women and girls. Each year, the UN brings together women and girls from all over the world to discuss issues that affect women from all spheres of life. Despite the sense of total inclusion, transgender women and girls are often underrepresented in this crucial space. Consequently, the transgender community faces a challenge in raising and addressing the issues specific to them.

The CSW recently emphasized inclusion of transgender people in its sustainable development goals. The discussion surrounding trans inclusion was unprecedented and a major credit to the UN organizers. Hopefully, this discussion continues to provide an ongoing dialogue that will work toward the improvement of the status of all women – including trans women – around the world.

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Beyonce Karungi presenting at a sex worker panel during CSW

I was one of the few transgender women present at the latest CSW. While there, I participated in many forums including development of the UN Women’s Strategic Plan development (2018-2021) at the UN headquarters. We lobbied UN women to include the transgender community in the strategic plan by connecting us with country offices and registering us to participate not only in trans-specific events but also in the main CSW discussions that typically include all women and girls.

At CSW, I also participated in a sex worker session focused on the conditions faced by this key population. Internationally, policy discourse has shifted in many ways to defend sex work as real work. Still, efforts to criminalize clients are unaligned with what sex workers need in order to be able to thrive as workers.

I was also involved in the Lesbian Bisexual Transgender Intersex (LBTI) women’s session. LBTI women are not explicitly mentioned as a vulnerable group in many spaces. This cultural stance and attitude is in large part internalized by LBTI people, which creates a strong obstacle to self-identification. The stigma surrounding LBTI women makes them a socially invisible community within general society. The result is that, with a few exceptions, the most vocal leadership of LBTI women’s rights has traditionally been men.

CSW participants discussed many issues, including peace and security for women and human rights defenders, sexual and reproductive health and rights, maternal health, gender-based violence, and family planning. Transgender women and girls continue to be excluded from the economic, political, and social sectors, which limits their access to education, health services, and employment.

While one of the main goals of the CSW is to empower all women and girls, transgender women remain unfairly marginalized.

The CSW needs to ensure that transgender people are represented and that data collection is supported so we can begin to advance the livelihood and well-being of transgender women everywhere. It is within the power of the CSW to include all women in discussions on women’s status in the world, and doing so will increase the awareness and importance of transgender inclusion, health, and rights.

International Day to End Violence Against Sex Workers

The Global Network of Sex Work Projects (NSWP) exists to uphold the voice of sex workers globally and connect regional networks advocating for the rights of female, male, and transgender sex workers. NSWP represents 264 sex-worker-led organizations in 79 countries.

Globally, sex workers of all genders face physical, psychological, and sexual violence. Gender-based violence against sex workers has particularly acute repercussions, given that in many countries, sex workers do not have equal protection under the law and therefore are unable to seek due justice. Perpetrators of violence against sex workers are often:

  • Members of the general population (including state actors) who pose as clients in order to target sex workers
  • People who facilitate sex work and abuse their power—for example, managers, brothel keepers, receptionists, maids, drivers, landlords, and hotels keepers
  • State actors, including police and health care providers.
  • Anti-sex-work organizations that seek to “rehabilitate” sex workers and work with the police to “raid and rescue” sex workers and their children

Issues faced by sex workers vary from region to region depending on laws and social and cultural contexts. One common issue faced by all sex workers is their vulnerability to and experience of violence.

Violence against sex workers in Kenya drew international attention when Philip Onyancha confessed to murdering 17 sex workers in the town of Thika in 2010. Bar Hostess Empowerment and Support Program (BHESP) led demonstrations to highlight the violence and to demand justice. More recently, the Kenya Sex Workers Alliance drew attention to the murders of sex workers in Nakuru County, while NSWP drew attention to the mass arrest and mandatory testing of Kenyan sex worker in Kisii County in 2015.

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Key populations fight erasure during High Level Meetings on Ending AIDS in New York. Photo Credit: MSMGF

Transgender Europe (TGEU) tracks violence against transgender people in Europe. According to TGEU a majority of the transgender people murdered in Europe in 2016 were sex workers. This year, NSWP highlighted the high levels of violence faced by transgender sex workers in Turkey. NSWP called for urgent action to uphold the human rights of male, female, and transgender sex workers in their country. However, transgender sex workers in Turkey still face on-going violence with little or no protection from the law. On 12 August 2016, Hande Kader was murdered, which drew international attention to the extreme violence faced by transgender people in Turkey.

Sex workers also experience stigma and discrimination when their voices are disregarded or when they are silenced as they speak about the realities of their lives to the media, programmers, and policymakers. People often assume to know what is in the best interests of sex workers, without meaningfully consulting sex workers themselves. When sex workers are silenced or disregarded in the development of policies and programmes that directly affect their lives, it leads to policies and practices that are harmful to sex workers and is a form of violence against marginalized populations. For example, this year at the United Nations High Level Meeting on Ending AIDS, member states adopted a political declaration that did not meaningfully include key populations, including sex workers, men who have sex with men, transgender people, LGBT people, and people in prisons. NSWP wrote a joint statement documenting the devastating effects of this exclusion.

NSWP calls on those who fight gender-based violence to support the global sex workers movement on the 17 December, the International Day to End Violence Against Sex Workers.

Let’s acknowledge that gender-based violence also affects transgender people and other key populations

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

Last year, a friend and colleague, Beyonce Karungi, wrote about what it is like to be a transgender woman in Uganda. She talked about being rejected by family members and about being beaten up and burned with cigarettes for being transgender. She described being harassed by police who wanted to make her a “proper man.” She recounted being raped at gunpoint by a client when she was a sex worker, because she insisted that he use a condom. Beyonce wrote that “… from the standpoint of a transgender woman like myself — our human rights and unique challenges are not addressed and not given the attention they deserve.”

Beyonce’s story is not uncommon. Experiences of violence are widespread among key populations: sex workers, men who have sex with men, transgender people and people who inject drugs. Here are just a few examples:

 This violence can often be traced back to homophobia, transphobia and other rigid beliefs about acceptable behavior for men and women. For example, perpetrators of violence against men who have sex with men often claim that they are attempting to “cure” men who are perceived to have rejected their masculinity. Likewise, transgender people experience violence from those who believe they have not fulfilled expectations associated with the sex they were assigned at birth.

Trans women are particularly vulnerable to violence from those who believe that experiencing violence is part of what it means to be a woman. Much of the violence that is directed at female sex workers and women who inject drugs is a manifestation of gender inequality and discrimination against women more broadly. But levels of violence against both are exacerbated by the belief that women who sell sexual services or inject drugs are immoral and have strayed from socially acceptable behaviors for women.

 A broader understanding of gender-based violence

From November 25 through December 10, individuals and organizations around the world are participating in the 16 Days of Activism against Gender-based Violence campaign. Every year, this campaign brings attention to the urgent need to eliminate violence against women and girls. But, the campaign is also an opportunity to examine the root causes of gender-based violence and shed light on those who experience such violence but who are not traditionally recognized during the 16 days.

FHI 360’s LINKAGES project promotes an inclusive view of gender-based violence — one that acknowledges that it affects not only women and girls in the “general population,” but also men who have sex with men; transgender individuals; and highly marginalized groups of women, such as sex workers and women who inject drugs. These groups are often omitted from calls to end gender-based violence.

HIV and gender-based violence

Experiences of violence increase the risk of key populations acquiring HIV and deeply affect their desire and ability to obtain health care, get tested for HIV and adhere to HIV treatments. For example, epidemiologic modeling has shown that reducing violence against female sex workers would reduce new HIV infections among sex workers and adults in the general population by 25 percent and 6 percent, respectively.

We will not make sustainable gains against the HIV epidemic if we do not also address the violence that key populations experience at the hands of family, community members, health care providers and police. Here are five ways that everyone who works with key populations can address gender-based and other forms of violence:

  1. Uncover the root causes and gender dimensions of violence against key populations. By conducting gender analyses, as LINKAGES has done in Kenya and Cameroon, we can reveal how gender norms and beliefs underlie much of the violence faced by key populations and identify ways to challenge harmful beliefs and better address such violence.
  2. Support community-led solutions. Community-based organizations headed by members of key populations are taking the lead in delivering the HIV services that their community members want and need, including addressing violence. In addition, outreach workers and peer educators from key population communities can be trained to screen for violence and provide first-line response in line with global best practices.
  3. Work with police and other community power holders so that they become allies in responding to violence and building stronger crisis response systems. Programs must garner commitments from local attorneys, hospital staff, psychologists, peer educators, and police that they will offer client-centered, nonjudgmental services to all survivors of violence, and that they will facilitate key populations’ ability to report violence when it occurs.
  4. Advocate for legal and policy reforms that explicitly protect the human rights of key populations. Even in hostile legal environments, steps can be taken to prevent and respond to violence. For example, we can advocate for the explicit inclusion of sex workers, men who have sex with men and transgender people in any legislation that is created to protect women and girls from gender-based violence.
  5. Draw attention to the science and the stories on the causes, consequences and experiences of gender-based violence among key populations, as well as the evidence-based strategies for addressing such violence. Through the LINKAGES blog series, Key Population Heroes, and our project newsletter, The LINK, we amplify the voices of key population members who have bravely shared their experiences of stigma, discrimination and violence and called on us to join them in fighting for change.

 Toward a more inclusive campaign against gender-based violence

Many people think of gender-based violence only in relation to women and girls. But, by developing a more inclusive view, we can help ensure that policies, preventive efforts and response systems benefit all those who experience such violence. Understanding and addressing the broader gender-based aspect of this problem will also allow us to strengthen the networks and combine the resources of the groups that are working to dismantle gender-based discrimination and advance the human rights of all women, girls, and sexual and gender minorities.

During the remainder of the 16 Days campaign, we will hear from colleagues representing key population communities about how they are affected by gender-based violence and what they are doing about it. We invite you to subscribe to the LINKAGES blog, contribute to the conversation on social media, and join us in advocating for the right of all people to live free from gender-based violence.

 

 

Key Population Hero: I support TRANS rights, do you?

Written by Amitava Sarkar (preferred name – Amrita), Co-chair, IRGT

“Please help, somebody please help!” Despite my shouting, my two friends and I drew no attention from passersby. We were surrounded by at least 10 men who were beginning to get violent. This happened in Kolkata, a metropolitan city of India, also known as “City of Joy,” though sometimes it becomes “City of Horror” for trans people like us.

fullsizerenderGoddess Durga is the Goddess of Power, and she is worshiped in India and other places of the world, but in Kolkata she is celebrated with special zeal. Temporary temple-like structures (called Pandals) are created in and around the city, where she is worshipped by visitors from different parts of the state and country, and sometimes from outside the country as well. This incident took place in front of a huge crowd visiting one of these Pandals in South Kolkata. It was very difficult to rescue myself from that situation, but ultimately I was able to run away while the men were busy clearing space to torture the three of us. I remember that as I was trying get free, no one from the large crowd that had gathered came to our aid despite our pleas for help.

This is just one example of violence that took place in a public space, in a metropolitan city, and in front of huge crowd. One can easily imagine how frequent these experiences are for trans people, and how difficult it often is for transgender woman to escape from these acts of violence. Other kinds of violence (mainly gender-based) against transgender women take place everywhere—within families and by intimate partners, at educational institutes and work places, and when trying to access health services. Data[1] show that in 2016, 21 transgender people died from violence-related causes; however, I believe the number is much higher, because I can recall what is happening just in my own country. There was an “honor killing” of a trans women a couple of months ago, and one can imagine that many similar incidents are taking place around the world but are not documented.

The way out is to work at two different levels—building the capacity of the community to advocate for themselves and continuing effective advocacy initiatives for stakeholders and policymakers. My journey toward this goal started when I met JoAnne Keatley (co-chair, IRGT) for the first time in Mexico during the 2008 AIDS conference. After observing the handful of trans women represented and the limited coverage of trans issues in such an important and international conference, we discussed the need to build a global-level platform for trans advocacy. Finally, we are here today with IRGT, a global network of trans women and HIV, comprising 18 very active members from different parts of the globe who are leading trans activists and doing commendable jobs for our community.

IRGT seeks to safeguard the health and human rights of transgender people and is able to conduct this work through a variety of important partnerships. With LINKAGES we are working to:

  • Mobilize and sustain advocacy by trans communities for service improvements in the response to HIV and AIDS
  • Foster trans leadership skills to create a new generation of articulate, tech-savvy advocates who can present their constituencies’ needs to government, health care workers, and police
  • Provide technical support and tools to inform national policy, program design, and management for trans populations

Apart from this, IRGT is one of the 10 member organizations supported by Robert Carr Civil Society Networks Fund, to form the Consortium of Men who have Sex with Men (MSM) & Transgender Networks. This consortium is a coordinated effort to address the factors that affect MSM and transgender health and human rights, leverage our respective complementary strengths as advocacy and technical support providers, strengthen community responses via consolidated mechanisms for information exchange, and raise awareness through media outreach.

IRGT has received another important award from ViiV Healthcare for implementing training workshops for trans women and organizations spread across various parts of the globe. The project will conduct training of trainers with eminent trans leaders to help build the capacity of trans-led organizations.

Several other recent developments have raised the visibility of trans rights, many with the support of LINKAGES. This past summer, IRGT organized the first-ever trans pre-conference event in Durban, South Africa during AIDS 2016. IRGT also helped lead the development of the TRANSIT, global guideline on implementing HIV and STI programs for trans people, and has published studies about issues faced by trans women, the most recent of which is entitled, “Most Impacted Least Served: Ensuring the Meaningful Engagement of Transgender People in Global Fund Processes.”

My message to my community is this: identify your strong, positive qualities and begin using them for the development of yourself and our community. Believing in an alternative gender or sexual identity is not a crime. Don’t hide your talents and your identities; instead try to come out in true spirit to better serve yourself and your community. From my own experience I have realized that we have to make our own space and we have to support each other. Let’s stand together to take our movement forward for a better and more trans-friendly world, free from violence.

To learn more about IRGT please visit – http://transglobalactivism.org/


 

[1] http://www.hrc.org/resources/violence-against-the-transgender-community-in-2016