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

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.

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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.

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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.

Key Population Heroes: Finding meaning and renewed purpose after my HIV diagnosis

Written by Christio Wijnhard, Project Coordinator for the LINKAGES Project at Foundation He+HIV, Suriname

Even though Clarence suspected that he might HIV-positive, the 24-year-old was shocked when he first learned his status. “I cried and I cried. I wanted to commit suicide. I thought it was the end for me.”

When Clarence first accepted his sexuality, he just began experimenting and never thought about practicing safe sex. But he lived in a small village where news traveled fast. When people started talking about two of his former sexual partners being HIV-positive, he realized the risks involved.

The young Surinamese man met a health navigator working for Foundation He+Hiv (FHH), a LINKAGES implementing partner. They had met before on social media, but the health navigator invited him for a one-on-one conversation at FHH.  The health navigator then determined that Clarence had been risky in his behavior and advised HIV testing. “At first I was reluctant to go for an HIV test. But, after thinking about it, I agreed.” Clarence’s health navigator motivated him to not be afraid and pointed out the importance of knowing his status for sure. Finally, on November 7, 2016, the health navigator accompanied him to a health care facility.

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Clarence looks out the window.   Photo credit: Christio Wijnhard

 

The outcome was devastating at first. “I have two dogs, Bruce and Chulo, and I could see their chain in front of me because that was what I wanted to use to kill myself.” Clarence was embraced by his health navigator, who shared with him some surprising information that changed the way he would view his HIV-positive status.

 

“He told me he was also infected with the virus. At first I would not believe it because he was a normal-looking man on the outside.” Looking back, Clarence can honestly say that this moment changed his life. “Hearing and seeing someone that was also infected, but looked very healthy, took away the feeling of being alone and lonely. It took away my fear of dying.”

When the time came to start medication, Clarence had some difficulties. The side effects were too much to handle, and he even stopped taking his medication because of them. His health navigator and the specialist at the Academic Hospital had serious talks with him. The doctor even told him bluntly: “If you don’t take your medication, you will die. Is that what you want?” Finally, the health navigator decided to bring Clarence for a talk with the project coordinator.

The project coordinator asked Clarence about his dreams and his goals. Clarence shared that he was worried about his cousin.  “She is my favorite cousin. I love her very much but she is risky in her behavior, like I was.” Then, they started talking about the possibility of her being HIV-positive as well. When the project coordinator asked Clarence what he would do if his cousin was infected and did not take her medicine, Clarence replied, “I would tell her not to be stupid and take her medication of course!”

Clarence paused for a moment, before saying, “Okay, I get it!”

Today, Clarence is still working on accepting his status. Twice a month he attends MSM support group sessions, which focus on self-empowerment. He meets up once every few weeks with his health navigator. He also uses the psychosocial care services at FHH, and he joined the group for the annual retreat of key population members who are living with HIV.

“I feel super fantastic! Because of the coaching, I was able to define what I liked. I am very interested in photography and I would like to take dance classes, and I might pursue a career as a male model someday.” Clarence also told his health navigator that he no longer wanted to be accompanied by him when he needs to visit the health care facility. “I feel empowered enough to visit health care facilities on my own.” Clarence also started writing about his feelings in a dairy.

“I feel great, really. And I want to work on improving myself because I want to be a good example for other people dealing with acceptance of their HIV status. I want them to know that it is not easy but if I can make these changes and be happy and work towards a good life living with HIV, so can they! I want to be their inspiration.”

 

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.

 

 

Hand in Hand: Working with Key Populations to Fix a Leaky HIV Cascade

Written by Nicole Ippoliti, Technical Officer II, FHI 360

Brave. Hopeful. Committed. Determined. These are the words that come to mind as I reflect on the inspiring researchers, programmers, activists, donors and policymakers who convened at the 21st International AIDS Conference in Durban, South Africa. Though we came from different countries and play diverse roles in the HIV response, we gathered in Durban united by a singular goal: to ensure that the health and human rights of key populations (men who have sex with men [MSM], transgender people, sex workers and people who inject drugs [PWID]) were fully represented at AIDS 2016. And so they were. Unlike prior years, key populations were a central focus at the conference, starting with the launch of the first-ever transgender pre-conference event, and culminating with announcements of renewed global funding for key populations through PEPFAR, the Elton John AIDS Foundation, and the Key Population Investment Fund.

It’s no accident that key populations were center stage at AIDS 2016. Without including key populations in both biomedical and structural interventions—which address the social, political and economic factors that make people vulnerable to HIV—we will not be able to successfully respond to the epidemic, let alone achieve the 90-90-90 goals set by UNAIDS by 2030. To achieve these goals, service delivery and programming led by key populations should be a priority in our response to HIV.

These values are at the core of LINKAGES programming, which is why at AIDS 2016 we hosted the symposium session, Repairing HIV service cascades that leak: Key population communities taking the lead. During this session, we explored how key population members themselves are delivering the HIV services they want and need. They are often doing so in hostile environments that hinder their access to services and contribute to damaging “leaks” in the cascade, or stages at which people drop out of the continuum of testing, treatment, and care. The United Nations Development Programme opened the session with sobering statistics about the harmful effects of the hostile legal environments in which many key populations live. For example, sex work is illegal in 109 countries and 15 countries impose the death penalty on drug users. These harsh legal and policy environments for key populations create formidable barriers to accessing life-saving HIV information, commodities and health care services.

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Panelists at the LINKAGES AIDS 2016 symposium

The remaining panelists discussed the strengths and challenges of key-population-led service delivery approaches in Haiti, Kenya, South Africa, Indonesia and the United States. In Haiti, for example, service providers lack the skills and sensitivity to address the HIV-related needs of key populations. In response, LINKAGES Haiti is testing two service new delivery models: stand-alone clinics for MSM and female sex workers, and private sector “preferred providers” who understand key population health issues. The goal is to increase the number of key population members who get tested for HIV and to encourage those who are HIV-positive to begin and remain in care and treatment. In South Africa, the Anova Health Institute, in partnership with the Department of Health, has provided clinical training on the health needs of MSM to more than 5,000 service providers at 250 health care clinics.  In Indonesia, LINKAGES is working with, PKNI, a coalition of self-organized drug user groups across the 19 provinces with the highest prevalence of HIV and injecting drug use. PKNI is providing comprehensive and quality harm reduction services (such as safe needle and syringe exchanges or opioid substitution therapy) in 11 different provinces for PWID and other key populations who inject drugs. Due to their success as an advocacy group, PKNI has been invited by the National AIDS Commission to become an official partner in implementing HIV programming and policies at both the provincial and national levels. In Kenya, the Sex Workers Academy, led by a faculty of trained sex workers, provides leadership, project management and advocacy training to male and female sex workers strengthen their ability to provide rights-based HIV/STI programs and services to their peers. The Academy has been met with incredible success and is scaling up to implement training sessions in other African countries. The Center for Excellence on Transgender Health in San Francisco concluded our session by explaining how the best practices for reaching, engaging and retaining trans women into care are rooted in addressing social and environmental factors that affect how people live. Interventions that offer access to job training, affordable housing, mental health services, and social support are those that have demonstrated success in sustaining change in trans people’s lives.

It is clear that more than 40 years into the HIV epidemic, we are still struggling with cascades that leak. The time has come to empower key populations to lead the way in the HIV response. The time has come to work together to ensure that members of key populations are supported to get tested for HIV and get the ongoing care and treatment they need.

sex workers marching AIDS 2016

Sex work activists marching throughout the International AIDS Conference in Durban, South Africa

Commemorating the International Day Against Homophobia and Transphobia

Part 1 written by Rolande Lewis, Program Officer, LINKAGES

Part 2 written by Irwin Iradukunda, Director of Programmes for Mouvement pour les Libertés Indivduelles (MOLI) and key population activist in Burundi

Part 1

On Tuesday, May 17, The International Day Against Homophobia and Transphobia (IDAHOT), was celebrated around the world. Homophobia and transphobia adversely affect key populations (men who have sex with men, transgender people, sex workers, and people who inject drugs) and can be manifested in many ways, including discrimination, refusal of health care services, and violence. In communities where public opinion is largely negative toward lesbian, gay, bisexual, and transgender (LGBT) people and violence against them is common, such attitudes are sometimes also held by health care workers. These negative attitudes not only prevent LGBT people from accessing quality health care in general, but also discourage them from seeking HIV treatment, care, and prevention services specifically.

During a December 2015 trip to Côte d’Ivoire (to meet with LINKAGES partner organizations), I learned that a mob had attacked and severely beaten a young man (or trans woman; it is unknown which) who was on his way to attend an HIV prevention event hosted in a neighborhood in the capital, Abidjan. He was attacked because he was considered “effeminate.”  On this same day, a memorial service was held for a young man who had been poisoned by his family because they suspected that he might be homosexual.

In Côte d’Ivoire, where homosexuality is legal, violence and stigma are still obviously real dangers. In other countries, such as Burundi, penal codes against homosexual activity greatly increase the risk of violence toward the LGBT community. However, activists and advocates in Burundi (and many other countries where homosexuality is illegal) are actively working to make lasting social changes for LGBT rights both within their communities and their countries at large. Following is the perspective of one such activist.

Part 2

Burundi is one of the 33 African countries where homosexuality is criminalized and where individuals who are either perceived as or identify as LGBT are persecuted and discriminated against.

Hence, Burundi has experienced a remarkable increase in HIV prevalence within the populations of gay men, other men who have sex with men (MSM), and transwomen from 2011 to 2014.[1] Some of the main reasons for the increase include the narrow gender and sexuality norms that are relayed by opinion leaders and make homosexuality an “abomination”; the lack of competent and accepting health services for gay men, MSM, and transwomen;[2] the lack of active participation and decision-making power of key populations in the design and implementation of HIV programming; the limited support for organizing and strengthening advocacy movements by key populations; and the criminalization of homosexuality and sex work.

These crosscutting issues linked to HIV prevalence contribute to and spring from widespread ignorance related to sexual diversity, which perpetuates homophobia, biphobia, and transphobia and entrench access to health and public services both in Burundi and across the world.

Endnotes:

[1] In 2011, the CNLS conducted a HIV prevalence rate and socio-behavioral survey on HIV/AIDS focused on high-risk groups conducted that found a 2.4% rate within the MSM constituency. In 2014, the Burundi Priorities for Local AIDS Control E orts (PLACE) Report highlighted an HIV incidence amongst MSM high as 6%.

[2] A big part of the few accessible LGBT friendly health services are located in the capital city, Bujumbura.