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Everyone deserves to live free from violence: Assessing a model to increase access to holistic GBV-response services in Puerto Plata, Dominican Republic
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.
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.”
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.
Written by Chris Akolo, Technical Director, LINKAGES
Today marks the 19th World AIDS Day – a global call for unity in working toward epidemic control, support for people living with HIV, and commemoration of the more than 35 million people who have died of HIV- or AIDS-related illness since the virus was first identified in 1984.
I began work as an HIV physician in 1999 and have spent the past 18 years implementing HIV prevention, care, and treatment programs in resource-limited settings. For the past three years, I’ve served as technical director of the USAID– and PEPFAR-funded LINKAGES project, the largest global project dedicated to addressing the epidemic among key populations (KPs) including men who have sex with men, people who inject drugs, sex workers, and transgender people.
Since we first set out in 2014, the LINKAGES project has been through three major phases: (1) start-up; (2) rapid acceleration; and (3) stabilization at scale. We are now forging ahead in this third phase, providing support and technical assistance to improve HIV programming for KPs in 30 countries across Africa, Asia, and the Caribbean. Using a common core Key Population Implementation Guide, which is oriented around the HIV cascade, our support in these countries consists of a range of activities designed to identify, reach, and help KP members learn their HIV status and enable those who are HIV-positive to access care and remain adherent to treatment. Getting to this phase has not been easy, and I have learned a lot along the way. On this World AIDS Day, I share some of the most important lessons I’ve learned during my time with the project:
- Key population members themselves must be at the forefront of programming. We are most successful when KP members are directly involved in the design and implementation of services. In all of the countries where we work, we engage KPs as peer educators and outreach workers to identify others in their communities and connect them to HIV testing and other related services. We employ them as peer navigators to support others living with HIV to access and adhere to treatment. And, we undertake institutional capacity building with KP-led community-based organizations for long-term sustainability.
- Data for decision-making is key. LINKAGES has developed robust strategic information systems with custom indicators that allow us to understand – in a timely manner and with great specificity – where we are having success and where we need to adjust our programmatic approaches at different points along the cascade. We have built the capacity of country teams and implementing partners in data analysis, interpretation and use, and instituted frequent data review meetings at country level. This culture of data use has allowed us to fine-tune our programming to each country context and accelerate progress toward aggressive program targets.
- We must constantly innovate. Sometimes the data tell us we are falling short and, when that happens, we must be quick to try new solutions. For example, when we were having trouble reaching HIV testing and case finding targets in a few countries, we introduced the Enhanced Peer Outreach Approach (EPOA) to engage previously unidentified and particularly high risk KP members with HIV prevention and testing. We saw immediate improvements with this approach, which is now being scaled up in other LINKAGES countries.
- We must modernize key population programming. As new biomedical interventions are introduced – like HIV self-testing and pre-exposure prophylaxis (PrEP) – we work to ensure that KPs have access to them. LINKAGES is introducing HIV self-testing in three countries and implementing PrEP demonstration projects in two others, with plans underway to expand to three more. We also employ cutting-edge information and communications technology (ICT) solutions in our programming – leveraging social media, conducting “virtual mapping” to enumerate online spaces commonly used by KPs, introducing online appointment booking, and partnering with ICT companies like Grindr to expand our reach and impact.
- We cannot underestimate the context of violence, stigma, and discrimination in which we work. Our efforts to improve uptake of HIV testing services and link those who are positive to treatment will have limited success if we are not also addressing the structural determinants of KPs’ vulnerability to HIV. LINKAGES is dedicated to integrating violence prevention and response in our programming. Nineteen countries have implemented at least one violence prevention and response activity, with two more set to begin implementation by the end of this year. These activities have already identified more than 1,200 cases of violence, brought new KPs to HIV services, increased the provision of post-exposure prophylaxis and emergency contraception to victims of sexual violence, changed attitudes among police and other common perpetrators of violence, and helped victims of violence understand and demand their rights. In order to address stigma within health care settings, we have developed a training package with health care providers in more than 10 countries on providing KP-competent services. LINKAGES has also developed SMS2, a text message-based system for monitoring and providing real-time feedback on the quality of health services provided to KPs.
As we look to a fast-approaching new year, we will carry forward these lessons from the past and renew our call to place key populations at the forefront of global efforts to reach epidemic control and achieve UNAID’s 90-90-90 targets by 2020.
Violence Prevention and Response: An Integral Part of LINKAGES’ HIV Interventions with Key Populations
Written by Vanessa Mosenge, Gender-Based Violence Consultant, LINKAGES
In Francophone Africa, as in many other contexts, key populations (KPs) experience violence and other human rights abuses, including harassment, exploitation, rejection, and denial of health, legal, and security/safety services. As violence increases HIV risk and poses serious barriers to KPs’ ability to access HIV services, the LINKAGES project has systematically worked to integrate violence prevention and response (VPR) into HIV programs for KPs.
Community-based organizations (CBOs) in Burundi, Cameroon, the Democratic Republic of the Congo (DRC), and Mali have shown great interest in addressing violence against KPs, including ensuring that service providers – health care workers, peer educators/outreach workers, and police officers – understand that violence is a real, priority issue for KPs and provide KP-friendly VPR services. As one KP member put it, “We want to get help like any other victim would and deserves, without things turning against us.”
Recognizing this need, a central component of LINKAGES’ VPR programming is building the skills of service providers – peer educators, outreach workers, and police officers – to ask about violence and provide first-line support to KP individuals who disclose violence, including linking them to essential health, psychosocial, and legal services. I have trained teams from Burundi, Cameroon, DRC, and Mali on VPR over the past three years, and one thing that has stood out to me is that many services providers start with the harmful belief (however untrue) that KPs make choices that expose themselves to violence and cannot blame anyone but themselves. During training activities – particularly panels where KPs share personal experiences – I’ve seen service providers introspectively assess how some of their behaviors hinder KPs’ access to services. In fact, I have seen doctors, lawyers, police officers, and government officials become more receptive and affirm that KPs also have a right to live free from violence and deserve services.
In addition to changing harmful beliefs, training service providers has helped them to become more informed about violence and its link with HIV, and service providers have begun to sensitize KPs on what violence is and what support is available through peer outreach, violence screening, psychosocial counselling, and support groups. For example, a peer leader in Cameroon shared, “Violence is prevalent; people don’t respect us; our clients and police do violate us. With this training, we know what to say to our peers; we tell our peers to talk about violence because it is very important to our health.” Service providers are also better able to create a safe environment and provide support to KP survivors. A health care worker in Cameroon further noted, “Training on GBV response helps us address stigma in relation to violence in the sense that we can help survivors know that violence is not their fault, and to speak up. We can also assure survivors of confidentiality and help them feel safe to disclose violence.” In fact, soon after LINKAGES VPR trainings take place, we observe a marked increase in the number of cases of violence reported and the number of KP members receiving support.
In-country capacity building has also helped service providers, government partners, and other stakeholders come together for a coordinated, multisector response to violence among KPs. LINKAGES’ engagement of service providers and other partners is important not only to ensure that KPs get all of the services they need and deserve, but also to garner political support for VPR work. In particular, the involvement of police is critical. Police are often cited as perpetrators of violence against KPs, leaving many KPs feeling as if they have no recourse when they experience violence. In Mali and DRC, we have successfully involved police and other law enforcement personnel in VPR trainings and activities, sensitizing them to the rights and needs of KPs, helping them to see their roles as allies and protectors when KPs experience violence, and helping to build trust between KP communities and the police.
One thing is common among KPs, irrespective of country and context — the desire to live in their community without fear of being abused and mistreated and, instead, to feel safe and protected. The LINKAGES VPR work fulfils the desire and right to live free from violence and contributes to effective KP programming that is responsive to the needs of KP community members.
Written by Kim Dixon, Gender-Based Violence Consultant, LINKAGES
Before joining the LINKAGES project, I spent most of my career developing, managing, and evaluating gender-based violence (GBV) prevention and response programs for women and girls in emergency, post-conflict, and development settings, as well as in the U.S. In my role as a GBV consultant for LINKAGES, I support country programs to develop and implement violence prevention and response (VPR) programs for key populations (KPs). I have learned directly from KPs themselves about the multiple layers of stigma, discrimination, and violence that prevent them from seeking and accessing services after they experience violence.
Because KPs’ behaviors are frequently viewed as not conforming to traditional gender norms and are often criminalized (e.g., sex work, homosexuality, drug use), they are afraid to seek help after experiencing violence due to fear of being arrested, shamed, or denied services. For these reasons, unless we become proactive in identifying KP individuals who experience violence, we are missing opportunities to link victims to important post-violence services, such as HIV post-exposure prophylaxis (PEP) and emergency contraception. The chance to address any barriers that interfere with adherence to ARVs among people living with HIV – such as not taking ARVs for fear of an abusive partner finding out their HIV status – is also missed. The failure to address violence among KPs ultimately limits our ability to achieve the 90-90-90 goals.
This is why much of the VPR work in the context of LINKAGES focuses on building the capacity of project staff — including health care workers and outreach workers — to be proactive in identifying violence among KP individuals via violence screening. If we wait for KPs to disclose violence, we may not hear about it due to the barriers just mentioned. Instead, training providers to ask KP members about violence and building their skills to provide first-line support increases the likelihood that KP victims will get linked to important, time-sensitive post-violence clinical services and may increase uptake of and adherence to HIV care and treatment.
Success in South Sudan
Some LINKAGES countries that are implementing violence screening and response interventions are already showing good results. In South Sudan, health care workers were trained on core concepts related to sex and gender, harmful gender norms, and the connection between violence and HIV. They then developed skills for screening KP individuals for violence and providing first-line support to KP victims, including linking them to health, psychosocial, and legal services. Since the training, Jennifer Iden, GBV coordinator for LINKAGES South Sudan, and the rest of the team have successfully integrated VPR screening and response services into existing HIV prevention, care and treatment services. During the last quarter (July-September 2017), 608 female sex workers were screened for violence by health care workers during mobile clinics. Of those screened, 293 (48 percent) reported experiencing sexual violence in the past three months. In turn, 87 (30 percent) of those reporting sexual violence were eligible for PEP, which means that health care workers identified the sexual violence within 72 hours of the assault. Of the 87 women who were eligible for PEP, 87 (100%) received it and were able to reduce their risk of HIV infection.
The LINKAGES project in South Sudan is a success story that illustrates the direct link between violence screening and increasing KP victims’ access to critical HIV prevention services. I hope South Sudan’s success inspires others to integrate VPR activities into their HIV programming for key populations.
In 2015, 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:
- A study of sex workers from seven cities in Cameroon found that 60 percent had experienced physical or sexual violence.
- A Global Gay Men’s Health and Rights Survey reported that 69 percent of respondents knew someone who had been physically assaulted because he was gay or had sex with men.
- A Ukraine survey found that 43 percent of women who injected drugs reported having been physically assaulted by police, and 13 percent reported having been forced by police to have sex.
- A study conducted in Lebanon reported that 68 percent of trans women had experienced physical violence because of their gender identity or expression.
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:
- 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.
- 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.
- 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.
- 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.
- 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 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.