Click the image below to open the photo story of the women of LINKAGES Nepal.
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.
Written by Neo Monnapula, Monitoring & Evaluation Officer, Nkaikela Youth Group, Botswana
Nkaikela Youth Group is a nongovernmental organization that serves female sex workers 18 years and older. The organization is currently supported by LINKAGES to provide HIV prevention, care, and treatment services.
In Botswana, HIV prevalence is 18.5 percent; however, among female sex workers (FSWs), prevalence exceeds 61 percent. A 2012 behavioural and biological surveillance survey revealed that, more often than not, FSWs experience stigma and discrimination from health care providers, often leading them to shy away from accessing HIV prevention, care, and treatment services. I recall a conversation I recently had with a Nkaikela Youth Group patient who was discouraged from seeking HIV services:
“I went to a local clinic and the nurse [stigmatized me]. I will no longer go there because the nurse threatened to report me to the police if I [have] an STI.”
At Nkaikela Youth Group, we provide key population (KP)-specific services for FSWs 18 years and older; this means that we assess the health needs of FSWs and provide stigma-free services based on those individual needs. We consult with FSWs one-on-one and ask what they want most from their health care providers and what needs to change in order for them to feel welcome in local clinics.
Confidentiality is paramount. Due to the stigma and discrimination they so often face, FSWs feel that being able to trust a health worker without fear of being judged or ridiculed makes all the difference in the world. For many of our FSW patients, being able to trust us with their care means that we, too, care about their health and well-being.
“I trust Nkaikela Youth Group with my information because they care about my life. It feels good to be getting services from them. [They] helped me to live again.”
Together with the LINKAGES project, our Nkaikela Youth Group provides FSWs with important information about HIV prevention, where to go to get tested, and how to access quality care and treatment services from clinics that offer a safe environment for patients. We conduct workshops with health care workers in the community, which include seminars on values clarification and attitude transformation so that health care workers can improve service provision.
FSWs not only experience stigma and discrimination from community members and health care providers; sometimes, they face internalized stigma. Lack of knowledge of their rights – coupled with the naming, shaming, and labelling they face – too often leads to acceptance of violations to FSWs right to health. In response, we form and facilitate FSW support groups to create an enabling environment in which FSWs talk about their experiences, learn about their rights, and develop skills to advocate for themselves when facing discrimination and abuse. Other topics covered in the support groups include the importance of knowing ones’ HIV status, adherence to treatment, and screening and treatment for STIs.
Health services that are free of stigma are critical to reducing HIV among FSWs worldwide, because sex workers are human beings and they, like all people, have the right to access health services.
Walking the talk: How structural barriers thwart efforts for those at risk for HIV and what we can do about it
Written by Ben Eveslage, Technical Officer, Global Health, Population, and Nutrition, FHI 360
In 2015, I joined the LINKAGES team because I believed that the work of eradicating AIDS on a global scale would be incomplete without a focus on structural barriers to prevention, care, and treatment— including stigma, discrimination, and violence. In my experience, I saw a lot of “talk” about these issues, but less “walk.”
From 2009 to 2014, I spent time in Ghana and happened to interact with many “beneficiaries” of previous FHI 360-led key population (KP) HIV interventions. Many of these individuals became my first lesbian, gay, bisexual, and transgender (LGBT) friends — during a time when I was first coming out as a gay-identified man. While I recognize my privilege as a foreigner there, I too experienced issues of stigma and discrimination. These impressionable experiences led me to explore more broadly the experiences of sexual and gender minorities across a wide swath of society in Ghana. I interviewed more than 120 people in Ghana and explored how HIV programs, technology, and political discourse related to homosexuality affected their lives.
Structural barriers disproportionately affect key and vulnerable populations’ access to and demand for HIV services. This comes as no surprise. Often, these structural barriers are a primary reason why KP communities, including men who have sex with men, people who inject drugs, sex workers, and transgender people, are most at risk for HIV in the first place. KPs are at risk of HIV not only due to “risk behaviors” but also to social stigma that can result in stigmatizing or discriminatory health services and internalized stigma that limits KP members’ own demand for services (see evidence of these impacts on men who have sex with men and female sex workers). The evidence indicates that countering these debilitating barriers should remain at the heart of any effective HIV response with KPs. Indeed, LINKAGES conducted several KP HIV cascade assessments including in Malawi, Cameroon, Nepal, and Swaziland, and a major common theme was highlighted throughout: persistent structural barriers.
Efforts to address stigma, discrimination, and violence should be integrated throughout our work in smart ways that still recognize our mandate and scope. For instance, I have seen a few useful examples of approaches taken by HIV programs to address these structural barriers, and some include:
- Conducting HIV risk assessments that include asking about KP’s experiences of violence to tailor HIV prevention and provide violence response services
- Training networks of peer workers and powerholders to detect and respond to incidents of violence against KPs
- Developing innovative training materials for health workers on inclusive and competent services for men who have sex with men and transgender people (see the CPR online learning platform by MSMGF)
- Providing emergency funds for LGBT communities to mitigate or counter new or worsening structural barriers (Rapid Response Fund by the International HIV/AIDS Alliance)
- Monitoring how health care workers treat KP members in health facilities to ensure the availability of KP-competent and inclusive care (see examples from Health Policy Plus)
- Producing research findings on stigma and discrimination experienced by KPs and people living with HIV across various domains for advocacy and programming (see the PLHIV Stigma Index)
- Facilitating support groups and safe spaces to work against self-stigma and intragroup stigma that breaks down communities and KP individuals’ self-esteem
- Developing electronic nationally-scaleable routine monitoring systems for stigma and discrimination against KPs in health facilities and providing feedback to facilities for rapid quality improvement (LINKAGES SMS2 system)
Since the dawn of KP HIV programs I think we have struggled to conceptualize our role in addressing structural barriers. But now we know a lot more about them. We have some new tools and strategies to help us assess and address these barriers to improving public health outcomes. If HIV programs are to help reach the end of AIDS, we need to move beyond recognizing the obvious and simply talking about structural barriers. We need to program for it. We need to adapt these approaches and integrate them into our routine HIV program implementation. They need to be targeted structural interventions that can be measured, and they need to efficiently contribute to our mandate of increasing demand for and uptake of HIV services.
From peer educators to HIV testing counselors: how female sex workers are assisting their communities in Angola
Written by Celma Pedro, Technical Officer, Positive Living, Management Sciences for Health
Delfina da Costa worked eight years as a peer educator for female sex workers (FSWs) in her community in Angola, educating those at high risk for exposure to HIV. She frequented hot spots around town to share informative messages in a safe environment on how to stay healthy and prevent contracting or spreading HIV. She forged strong, trusting relationships with the women she helped, but Delfina wanted to do more. In October 2015, she was trained to be an HIV testing counselor.
“I always followed HIV testing on the side lines, watching carefully how it was performed on the women I referred. I always wanted to test. Now I can.”
Delfina administers HIV rapid tests at hot spots, screens FSWs for sexually transmitted infections, and consults with health care professionals about the specific needs of her clients. She also links HIV-positive FSWs to peer navigators and care support services. If a FSW does not want to meet with a peer navigator, Delfina supports the patient herself from the onset of treatment.
Delfina’s transition from peer educator to HIV testing counselor marked the beginning of professional development and advancement for peer educators working with key populations (KPs) in Angola. Her experience is unique, as members of KPs have not typically held positions of leadership or authority in the past, and KP-led HIV organizations are scarce. Until recently, giving KP peer educators the opportunity to train as HIV counselors was frowned upon by many civil society organizations (CSOs) in the country.
Since 2015, LINKAGES has partnered with Associação de Solidariedade Cristã Ajuda Mútua (ASCAM), a local nonprofit CSO in Luanda, Angola, and the first in country with an entirely KP-led management team. ASCAM began as an emergency support service during wartime; today, the organization works almost exclusively in HIV education. Together, LINKAGES and ASCAM recruit individuals from KP communities—primarily FSWs—to be peer educators. After serving in this position for at least one year, peer educators can train to become HIV testing counselors within their local communities. HIV testing counselor training is a two-week course with theoretical and health facility practicum requirements, conducted in partnership with the Angolan government.
Professional development for KP individuals in HIV prevention, care, and treatment services has come a long way in recent years. “When we started working in Angola in 2015, the only CSO that had key population peer educators was ASCAM,” says Ana Diaz, LINKAGES Angola program manager, “but the HIV testing counselors were not key population members. KP members had never been given the opportunity to train as counselors, but now they can.”
Establishing more prominent roles for KP community leaders in the HIV prevention, testing, care, and treatment of individuals like themselves builds trust between health provider and patient, and strengthens referral uptake of KPs to HIV service providers.
The success of these trainings in reaching previously unidentified KP individuals has made other partner organizations aware of the benefits in providing opportunities for KP peer educators. LINKAGES has trained 23 KP HIV testing counselors to date, 16 of whom are FSWs. Becoming a counselor is a big step in establishing a career in health care. Having a training certificate from the government can open many doors to other projects that may even go beyond HIV prevention, care, and treatment services.
For Delfina and other HIV educators in Luanda, empowering FSWs within CSOs is an ongoing effort to promote more accurately representative leadership.
Fatima Zua, a FSW peer educator with ASCAM, says: “When we work to empower women [key population members], everyone wins. I feel they understand our needs because they were in our position before.”
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.
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.
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.
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
- 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.