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.

Early Lessons from South Africa’s Rollout of Oral PrEP to Sex Workers

This blog has been reposted from Prepwatch.org; the original posting can be found here. Contributed by Neeraja Bhavaraju and Daniela Uribe from FSG, a member of the OPTIONS Consortium.

In June 2016, South Africa’s National Department of Health began making oral pre-exposure prophylaxis (PrEP) available to sex workers. This represented the first time that any PrEP product was made available outside of a research study or demonstration project in an African country. In the first six months, hundreds of women have started taking PrEP from a network of 11 sites across five provinces in South Africa.

Maria Sibanyoni, program manager of the sex worker program at Wits RHI, a research institute focusing on sexual and reproductive health, HIV and vaccine preventable diseases, shared some early insights on what she has learned about delivering PrEP. These are some of the first “real world” insights that we have about PrEP delivery, and they will be invaluable to the wider rollout of PrEP in South Africa and beyond.

Lesson #1: Meeting people where they are increases access and uptake

A multi-channel strategy supports PrEP uptake

“One of the approaches that we use to provide services is through fixed facilities. Sex workers are able to access these facilities anytime. The second approach is outreach. We go out with a package of services—medicines, equipment, and HIV test kits—and reach out to the sex workers in brothels. When we get to the brothels we request a room and set up a clinic to provide services in the brothel itself. The third approach is a mobile van. We are targeting those who are street-based, whether they are operating at the bush, on the highway, under the bridge, wherever, to reach those sex workers using a mobile van where we provide a comprehensive package of services. The fourth approach is using the peer educators, who form a link between the clinic and the sex workers because they do lots of referrals, they go out there, they mobilize, they also provide HIV testing services including finger pricking, give health talks, they talk about PrEP quite a lot, but also they make sure that they link the sex workers to our services so that they are able to access PrEP.”

Lesson #2: Those with high HIV-risk perception more frequently use and adhere to PrEP

Raising awareness among potential PrEP users about their own risk is a strategy to generate demand for PrEP and ensure higher levels of adherence.

“With sex workers, the ones who see themselves at risk are keen to take-up PrEP. However, those who are just worried will start coming up with excuses: ‘I can’t take a pill every day.’ They are worried for now but they are willing to take the risk. Those who see themselves being at risk know PrEP will help them. People know their lifestyle and who they engage with, they know the factors that are pushing them to request it.”

Area for further study
While it is clear that some women are “self-selecting” to use PrEP, we still don’t know whether those women who are “self-selecting” are those at highest risk for HIV transmission. Further study on this issue could mitigate concerns about the “worried-well” driving PrEP demand and will help inform plans for broader PrEP introduction.

Lesson #3: Creating a community of support increases adherence

From peer educators to friends, having a community to create accountability can make all the difference.

“We have looked at different strategies of adherence. We look at a buddy system – who are they bringing or identifying as their support person or support structure that will ensure that they take treatment on time and they come in for their check-ups. We also keep a register to ensure that those who do not honor their appointment are traced, telephonically and physically. We have peer educators who do the physical tracking. They go to the brothels to find the sex workers, even though they are mobile; the peer educators have been in the area and have a relationship with the community, and they will have feedback and information about where they are.”

Lesson #4: Engaging and supporting health care workers is essential

While PrEP represents a “breakthrough,” it also represents a significant new workload.

“PrEP is new, and as with anything that is new people will react differently. Some of the health care workers see PrEP as a breakthrough. But others see PrEP as an added responsibility that will increase their workload. A clinician used to see someone who was HIV negative and say “’stay negative and we will see you in 6 months or a year’s time.’ But with PrEP now we have to initiate you, call you after a week, call you after a month, call you after three months. So some might think ‘this is actually increasing my workload.’”

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Photos by: Dawn Greensides, Wits Reproductive Health and HIV Institute

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.”

 

Key Population Hero: Addressing stigma and discrimination among LGBT people in Kenya

Written by Levis Nderitu, co-founder, Sullivan Reed

Sullivan Reed is an organization in Nairobi, Kenya that specializes in the economic and social empowerment of LGBT people in Kenya, where homosexuality is criminalized and HIV prevalence is almost three times higher among men who have sex with men than the general population.

Many lesbian, gay, bisexual, and transgender (LGBT) people in Kenya are facing stigma and discrimination silently. They may not know how to access HIV services and, even if they do know, they wonder how will they be treated when they get there.

LGBT-friendly services do exist and we encourage people to use them. But not every provider is affirming. People are worried that they will be outed by medical staff, and with good reason. I’ve heard LGBT people talk of nurses calling other nurses over and “making an example” of them. I’ve heard of young LGBT people having their parents called. You can imagine how traumatizing this is.

People’s fears about accessing health care are compounded when they face other stigmatizing, even violent, situations. I saw this clearly recently when my friend’s boyfriend celebrated his birthday. He invited a few friends to his home, all of whom are LGBT. Then men, armed with sticks, broke in and started beating people. They said they did not want “people like [my friends]” in the neighborhood. Despite living there for two years without any complaints against them, my friends were evicted. It’s a tight-knit community and rumors soon spread. All those who had been there were scared; they had been exposed as LGBT and their lives were at risk.

Lots of LGBT people look at a situation like this and think “if I can’t even be happy in my own neighborhood, around people who know me, how do I then go to the hospital?” The impact of this type of intimidation is huge.

To help, we applied for funding through the International HIV/AIDS Alliance’s Rapid Response Fund, which issues emergency grants of up to $20,000 in 29 countries when stigma, discrimination, and violence threaten HIV services for LGBT people and MSM. Since its inception in October, the fund and has already received more than 235 applications.

The money came through quickly. We relocated all those in fear to a safe house and linked many of them to LGBT-friendly health services. Through the fund you can also apply for support for initiatives that will have a longer-term impact. I’m developing a mobile app to enable people to find LGBT-friendly services near them, and again I have turned to the Rapid Response Fund for help.

Many Kenyans are hostile to LGBT people, mainly because of the legal framework. But among younger people and in more cosmopolitan communities, attitudes have been improving. We have a new crop of people who believe in diversity and inclusion. I believe more and more straight people will begin to champion LGBT rights here and bring this community out of the margins.

We need to look at the issue of economic empowerment as many LGBT people struggle to find work. Some turn to sex work, which increases their vulnerability to HIV. We must enable people to support themselves; it’s a critical component of change.

As long as the existing penal code is in place, the fight will be tough. But when I look around me I see a lot of hope. Things are changing. Everyone should be able to live a full life, regardless of who they are and whom they love. We are working to make that happen.


To learn more about the Alliance’s Rapid Response Fund visit rapidresponsefund.org

 

 

Comprehensive violence-response services in the Dominican Republic: A spotlight on CEPROSH

LINKAGES would like to thank the clinical staff members of CEPROSH, the police chief, and the key population members in Puerto Plata who contributed to this interview.

LINKAGES has the privilege of working with many incredible community-based organizations throughout the world that offer violence-response services to key populations. Below is an interview with The Centro de Promoción y Solidaridad Humana (CEPROSH), an HIV/AIDS awareness and prevention organization based in the northern region of the Dominican Republic. CEPROSH works to improve regional capacity to deliver quality services related to HIV and gender-based violence to key populations

1. How are key populations affected by gender-based violence in Puerto Plata? What types of violence do they most experience?

Intimate partner violence, hate crimes, and stigma and discrimination are significant issues faced by transgender people and sex workers in the Dominican Republic (DR). Transgender people also face difficulty in securing employment and are often rejected because of their gender identity or sexual orientation. Transgender people who engage in sex work also experience violence at the hands of the police. Police will often handcuff them, spit on them, and pull their hair.

Stigma and discrimination against key populations are prevalent in the DR. A patient at CEPROSH relayed her experience with transphobia, which she said humiliated her and left her in a great deal of pain:

“I got in a taxi and when the driver realized that I was trans, he stopped the car, got out, opened my door, and said, ‘Get out my car you *expletive*! I don’t allow *expletive* in my car!’ In that moment, I wanted nothing more than the ground to open up and swallow me. Everyone was looking at me, and only one onlooker showed any kind of indignation at the taxi driver. I will never forget that kind of humiliation for as long as I live.”

2. What are some of the links between violence and HIV for key populations in the Dominican Republic?

The links between violence and HIV that we see through our work at CEPROSH stem mainly from:

  • Social and family exclusion
  • Lack of knowledge among key populations about their health and human rights
  • Lack of will to seek health services
  • Poor mental health
  • Stigma and discrimination

3. What kind of services does CEPROSH offer to support key populations who have experienced violence?

We work with peer outreach workers and counselors at the clinic, and counsel key populations on their rights in an effort to empower them. We also have agreements with their supervisors at their jobs (for those who are able to work), which permit key populations to leave work in order to make their appointments at the clinic. For those who are not able to visit the clinic, we offer community-based HIV testing. Additionally, we take a comprehensive approach toward offering health services to key populations by offering the following:

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CEPROSH Peer Educators

  • Crises response services
  • Clinical services
  • Psychosocial support
  • Rapid HIV testing
  • Post-exposure prophylaxis
  • STI testing and treatment
  • Emergency contraceptive
  • Mental health services
  • Legal services
  • Support groups

 

 

 

 

 

 

4. What is something you learned during your time working with key populations who have experienced violence?

We learned that it is very difficult for someone to leave the circle of violence that entraps them. We have seen how violence can rob you of your identity, your profession, your family and friends, and your willpower. We also learned that through counselling and violence-response services, you can return a sense of confidence, strength, and self-worth to victims so that they can move forward.

5. What is a lesson that you’d like to share with other organizations that offer services to key populations who have experienced violence?

In order to help key populations who have experienced violence, you need to train organizational staff and health workers on key population service delivery. This includes helping staff to confront and address any negative biases they may have toward key populations, to dismantle any myths or negative stereotypes about key populations, and to deliver correct health information in a stigma-free environment.

6. How does CEPROSH work with other members of the community (police, doctors, religious leaders) to address gender-based violence toward key populations?

We sensitize community stakeholders through informal meetings and workshops with key populations to help them to understand the ways in which systemic violence is a violation of human rights for all people. We explain that often this violence comes from a fear of the unknown, or from people operating with misinformation about key populations. We work to reverse those preconceived notions and prejudices about key populations. We also form alliances among various community services that could work to protect the health and human rights of those most vulnerable.

7. How have the attitudes of CEPROSH staff and the community members mentioned above changed as a result of the LINKAGES project?

There have been many positive changes, but there is still work to do. Many of us recognize that before receiving gender sensitivity training from the LINKAGES project, we treated key populations with disrespect. Some of us growing up were even taught to hate them because they were different. Since the trainings, we have recognized the need to not treat key populations differently, but rather, treat them with the kindness, respect, and dignity they deserve.