Differentiated Care for Key Populations, Part III: Haiti

Written by LINKAGES Haiti staff.


Differentiated antiretroviral therapy (ART) delivery, a part of differentiated care, aims to improve retention and viral suppression by optimizing drug and care delivery. Models fall into four categories: health care worker-managed groups, client-managed groups, facility-based individual, and out-of-facility individual. The case studies presented in this four-part series come from the USAID– and PEPFAR-supported LINKAGES project in Botswana, Haiti, Kenya, and Malawi. They are examples of the out-of-facility individual model, sometimes referred to as the community model, and can be found in Differentiated Care for Antiretroviral Therapy for Key Populations: Case Examples from the LINKAGES Project.


Through its implementing partners, LINKAGES Haiti delivers differentiated care for men who have sex with men (MSM) and female sex workers (FSWs). The goal of LINKAGES is to improve access to and uptake of HIV prevention, testing, and care and treatment services for these key populations (KPs). In Haiti, following the Ministry of Health’s adoption of the World Health Organization’s recommendation for Test and Start — an approach where people are started on ART immediately after being diagnosed with HIV — LINKAGES has scaled up access to ART among MSM and FSWs by integrating ART delivery within 10 existing KP-focused service delivery sites from October 2016 to June 2017. A multidisciplinary health care team is available at the site level (medical doctors, nurses, lab technicians, psychologist, pharmacist, and social workers). This team is trained not only in HIV counseling, care, and treatment, but also on provision of KP-friendly services to ensure that KPs are able to access services without fear of stigma and discrimination. Safe spaces were also added in the sites that did not previously have a safe space for KPs to conduct social activities and meetings.haitiFIG3

Three of the sites are operated by Fondation SEROvie, a KP-led organization that provides HIV prevention and testing services, along with critical community engagement and empowerment activities. Before the introduction of ART services at these sites, MSM who tested positive at a SEROvie center or at a mobile testing drive were referred to other public and private ART sites. After the addition of ART services at SEROvie sites, the ART initiation rate among MSM improved from less than 18 percent to over 70 percent and even reached 94 percent in one quarter (Figure 3). The increased ART initiation rate among MSM is due to the availability of ART at SEROvie, thus removing the need for referral and links to care and treatment at other health facilities.

Six other sites are operated by FOSREF, an organization that provides services for FSWs. Before ART service was added to these sites, HIV-positive FSWs were referred to other public and private clinics for ART, and the percentage of FSWs initiated on treatment was less than 17 percent. After the addition of ART services at the FOSREF sites, the ART initiation rate has been consistently 45 percent and climbed to over 78 percent in the past three quarters (Figure 4).

haitiFIG4In addition to ART provision at these centers, the ten sites offer community antiretroviral distribution to HIV-positive FSWs and MSM to reinforce patient retention in treatment and care. Dr. Rachid Dorsainvil, an HIV technical advisor with FHI 360, explains, “In Haiti, two models of differentiated care are used across the LINKAGES network: community drug distribution and multi-month scripting. Both models have contributed to the improvements in links to care and treatment observed for both MSM and FSWs in Haiti last year.”

As part of these two models, at SEROvie and FOSREF peer navigators are responsible for delivering the ART, and clients can receive an antiretroviral supply for two to three months, depending on their adherence level. This strategy is used primarily by HIV-positive patients who cannot come regularly to pick up their antiretroviral treatment because of the distance or their busy schedules.

Rafael Reynold, a MSM and a beneficiary of SEROvie’s HIV-related services, works as a chef in a restaurant. He recounts the difference community distribution and multi-month scripting have made for him: “I was diagnosed HIV positive two years ago during a mobile testing activity that was conducted in my neighborhood by a SEROvie clinical team. I was initiated on ART at the SEROvie clinic located in Port-au-Prince. As I never missed an appointment and had my viral load suppressed, I have benefitted [from a] three-month antiretroviral supply. I don’t have to stress about going every month [for an] appointment, as I work seven days a week in the restaurant. So, being able to experience the community drug distribution has really improved my life.”

 

Speed, scale, and quality: How LINKAGES implemented evidence-based key population programming in 19 countries in its first 12 months

Written by Meghan DiCarlo, Deputy Director – Program Acceleration, LINKAGES, and Lirica Nishimoto, Program Officer, LINKAGES


Caribbean acceleration

Caribbean Regional Acceleration Workshop 2017

When the USAID– and PEPFAR-supported LINKAGES project first started in June 2014, we expected a handful of countries to buy in to the global mechanism dedicated to meeting the HIV prevention, care, and treatment needs of key populations (KPs).  However, almost immediately, the demand exceeded our expectations. USAID missions in seven countries bought in to LINKAGES in the first six months, and in just over a year, LINKAGES was working in 19 countries! The exponential growth of the program across Africa, Latin America and the Caribbean, and Southeast Asia required us to re-evaluate how we could successfully deliver high-quality KP programming across such a large swath of countries, with more being added by the day.  We did not want to have disjointed country programs of varying quality. We wanted each program to be delivered efficiently and tailored to local context, but grounded in the critical, evidence-based elements of KP programming. As a global mechanism, we had a unique opportunity and an obligation to support countries to scale up quality KP programming that would achieve results.

Our answer was the program acceleration (acceleration) initiative, which was launched in December 2015. The goal of this initiative is to accelerate and strengthen service delivery for KPs at scale by providing training, capacity development, mentoring, and knowledge exchange to in-country LINKAGES staff, local implementing partners, and staff from ministries of health. One of the first steps we took under the acceleration initiative was to develop a common core KP program and guide to serve as the initiative’s foundation. The common core includes information on seven key program areas based on global guidance:

  • Engage key populations in population size estimation, mapping, and program planning
  • Key population empowerment and engagement in programs
  • Structural interventions
  • Peer outreach
  • Clinical services
  • Program management
  • Monitoring and data use

Next, we trained a core group of expert technical assistance providers and country implementers on the common core program and set up frequent, rapid, and targeted technical assistance to support countries in implementing high-quality KP programming.

Botswana acceleration

LINKAGES Botswana presents on the coupon system at the 2017 Africa Region Acceleration Workshop.

It has been almost two years since the acceleration initiative was established. Implemented in 17 countries to date, the initiative has been successfully supporting local staff and partners to deliver a comprehensive package of health services at speed, scale (within and across countries), and according to standards (a common core program).

We have documented the achievements and lessons from acceleration in two new resources. For more on how to rapidly deliver and scale up quality KP programming, see Accelerating the Implementation and Scale-up of Comprehensive Programs for HIV Prevention, Diagnosis, Treatment, and Care for Key Populations and Acceleration Country Success Stories.

Addressing violence in HIV programs for key populations: Opportunities for integration

In commemoration of the 16 Days of Activism Against Gender-Based Violence campaign, LINKAGES’ new infographic explores how HIV programs for key populations can address violence. The infographic highlights the global prevalence of HIV and violence among key populations, the impact of violence on HIV among key populations across the cascade, and six recommendations to integrate violence prevention and response into HIV programs for key populations. We hope it will be useful to those designing or implementing HIV programs for key populations as well as those who seek to advocate for greater integration between violence and HIV services.


GPV-HIV-infographic-FINAL


 

Everyone deserves to live free from violence: Assessing a model to increase access to holistic GBV-response services in Puerto Plata, Dominican Republic

Written by Robyn Dayton, Technical Advisor, LINKAGES, and Aubrey Weber, Technical Officer, Research Utilization, FHI 360


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Informational GBV materials are placed in the District Attorney’s office in Puerto Plata.

LINKAGES is partnering with the Center for the Promotion of Human Solidarity (CEPROSH), a local community-based organization (CBO), in the Dominican Republic to increase access to holistic post-gender-based violence (GBV) care, including HIV services, for members of key populations (KPs) – men who have sex with men (MSM), sex workers (SWs), and transgender women. Programs designed to decrease HIV incidence and improve the outcomes of people living with HIV (PLHIV), particularly those for KPs, must address GBV to be effective. For example, a recent study demonstrated that transgender sex workers in Santo Domingo are less likely to use condoms if they have experienced violence, thereby increasing their HIV risk. Studies from the Dominican Republic also demonstrate that violence from a sexual partner is associated with poor HIV treatment outcomes among female SWs. Evidence of the link between HIV prevalence rates and experiences of violence can also be seen among the general population – adult women in the Dominican Republic who have experienced violence are three times as likely to be living with HIV, and women in the Dominican Republic who are living with HIV are more likely to experience violence from their partners.

Given the low uptake of post-GBV care in the Dominican Republic, especially among members of KPs, and the missed opportunities to link victims of violence to services – particularly HIV services – the USAID– and PEPFAR– supported LINKAGES project, in partnership with CEPROSH, undertook an intervention in Puerto Plata, Dominican Republic to increase (1) availability of KP-friendly post-GBV services, (2) service integration for all victims of violence, and (3) post-GBV service-seeking among members of KPs. As part of the intervention, CEPROSH led the formation of a technical working group (TWG) of institutions that offer services to victims of violence, including the police, the public hospital, all local clinics for PLHIV, the district attorney’s office, and the Ministry of Women. The members of the TWG committed their institutions to providing KP-friendly services and CEPROSH trained staff from each institution. CEPROSH also led the development of materials that help identify violence, describe KP members’ rights, and list available services. These materials and outreach events were used to indicate which institutions are KP-friendly and raise awareness about and identify victims of violence. The goal of the intervention was to increase post-GBV service uptake, improving outcomes for victims of violence, including those related to HIV.

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Community leaders share the violence prevention and response services available to KPs.

To determine the impact of efforts to date, LINKAGES interviewed service providers and clients who received post-GBV care in Puerto Plata and reviewed CEPROSH programmatic data from November 2016 to August 2017. The assessment showed that the intervention achieved its desired short-term and intermediate results, demonstrating that a civil-society-led initiative can strengthen both public and private post-GBV services, make those services more inclusive, and increase their uptake by KP individuals. Pre- and post-test results from trainings demonstrate that after the trainings, attendees across sectors felt less stigma toward KPs and were less likely to blame victims for violence against them. At the same time, the intervention strengthened the overall system for violence response in Puerto Plata, with providers and clients reporting that providers across institutions now offer improved services to all victims of violence and that more members of the general population are also seeking post-GBV support. As noted by a respondent at the Ministry of Women, “Thanks to the information given by CEPROSH, the directory, and the brochure, more women are coming to get services here. Before, we might get seven girls a month. Now, we are getting six or seven daily. They have empowered themselves to come here and find assistance.”

Looking specifically at HIV services, the intervention increased access to post-exposure prophylaxis (PEP) and HIV testing, identified new HIV-positive individuals, improved antiretroviral adherence, and provided new opportunities for continuous engagement of both HIV-positive and -negative KP members. Through violence detection efforts and spontaneous disclosure, 435 people reported experiencing violence from November 2016 to August 2017. Twelve of these reports were of sexual violence in the past 72 hours, with 66 percent (8) receiving PEP. Of the 435 individuals reporting violence, 244 were members of KPs with an unknown HIV status. Forty-five percent (109) completed an HIV test as part of post-GBV care, with four new cases of HIV detected. While viral load was not specifically monitored in the assessment, doctors from HIV clinics noted that they have seen a change. One physician from the HIV clinic at the public hospital said, “Helping the clients to solve their violence situations is a direct help to their viral load, because if they are scared or suffering violence probably they won’t take their medications and their viral load will go up. We have seen in several cases, that after receiving violence response services, their adherence to the treatment has improved and therefore their viral load has declined. Their health and attitude significantly improves.”  Support groups have proven an effective way to continually engage with victims who are members of KPs. Fifty people attend the bimonthly support group meetings held at CEPROSH’s HIV clinic.

Finally, although participation in the intervention meant increased responsibilities for already overtaxed staff, service providers were enthusiastic about their new ability to address client needs and committed to offering new services. One CEPROSH staff person noted, “I have changed my way of speaking to clients and how I handle them. Before I just mentioned the issue of violence, now I’m able to help them address the issue. The attitude of the staff has changed significantly… When the activity began, some had a small notion of the GBV subject, but they said that there wasn’t any time to deal with that; now everyone feels committed.” Police respondents also indicated that trained officers took new pride in their work, “I’ve always been proud of being a police officer, but some of my partners who weren’t that proud, now they are.”

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Puerto Plata police officers attend a violence prevention and response training.

Most importantly, KP clients described a new willingness to attend services and corresponding improvements in their lives due to those services. As one sex worker who disclosed intimate partner violence said, “I understand a lot of things better. Before I was really closed inside myself. I believe that that man was everything for me; I was used to a man who was bad.  I was attached to that relationship but after the appointments with the psychologist I became stronger and understood that I deserved better. I left that relationship and feel better about myself. They lifted my self-esteem.”

These positive findings, as well as the identification of opportunities for improvement – such as the need for more messaging on the importance of reporting violence quickly to have access to PEP and other time-sensitive services – are helping to inform the expansion of the intervention beyond Puerto Plata.

The findings also demonstrate that integrated HIV and GBV programming benefits members of the general population as well as KPs. New strategies and laws are being contemplated and implemented to address the incredible burden of violence against women in countries like the Dominican Republic. Collaboration with implementers who focus on issues that intersect with violence against women, such as GBV against KPs and efforts to address the HIV epidemic, can be an important part of an effective response.