HIV/SRHR Integration for Key Populations

HIV/SRHR Integration for Key Populations A review of experiences and lessons learned in India and globally India HIV/AIDS Alliance India HIV/AIDS Alliance (Alliance India) is a diverse partnership that brings together committed organisations and communities to support sustained responses to HIV in India. Complementing the Indian national programme, we work through capacity building, knowledge sharing, technical support and advocacy. Through our network of partners, we support the delivery of effective, innovative, community- based HIV programmes to key populations affected by the epidemic. Our Vision: A world in which people do not die of AIDS Our Mission: To support community action to prevent HIV infection, meet the challenges of AIDS and build healthier communities

Acknowledgements Thanks are given to the many people and organisations that contributed their experiences and documentation to this publication. This report was written by Sarah Middleton-Lee (independent consultant). Alliance India would like to acknowledge the following for their contributions to this report: Sunita Grote, James Robertson, Sonal Mehta, Sophia Lonappan, Divya Bajpai and Susie McLean. This report was produced with support from the European Union.

Published in June 2012 © India HIV/AIDS Alliance Photography: Unless otherwise stated, the appearance of individuals in this publication gives no indication of their HIV or key population status. Information contained in the publication may be freely reproduced, published or otherwise used for non-profit purposes without permission from India HIV/AIDS Alliance. However, India HIV/AIDS Alliance requests to be cited as the source of the information. The contents of this publication are the sole responsibility of India HIV/AIDS Alliance and do not necessarily reflect the views of the European Commission. Recommended Citation: India HIV/AIDS Alliance (2012). HIV/SRHR integration for Key Populations: A review of experiences and lessons learned in India and globally. New Delhi: India HIV/AIDS Alliance.

This project is funded by the European Union India HIV/AIDS Alliance Kushal House, Third Floor 39 Nehru Place

New Delhi – 110019 +91-11-4163-3081 [email protected] www.allianceindia.org HIV/SRHR Integration for Key Populations

A review of experiences and lessons learned in India and globally Acronyms

ANC Antenatal care ART Antiretroviral therapy ARVs Antiretroviral drugs FHI Family Health International FP Family planning GIPA Greater involvement of people living with HIV GNP+ Global Network of People Living with HIV IPPF International Planned Parenthood Federation HCT HIV counselling and testing HPV Human papillomavirus IDU Injecting drug user KPs Key populations MNCH Maternal, newborn and child health MSM Men who have sex with men OSI Open Society Institute OST Opiate Substitution Therapy PEP Post-exposure prophylaxis PMTCT Prevention of mother to child transmission PNC Postnatal care PUD People who use drugs RTI Reproductive tract infection SRHR Sexual and reproductive health and rights STI Sexually transmitted infection SW Sex worker UNAIDS United Nations Joint Programme on AIDS WHO World Health Organisation Contents

1. Introduction 1

1.1. Content of report...... 1

1.2. Rationale and context for review...... 1

1.3. Objectives and methods of review...... 2

2. Overview of HIV/SRHR integration for key populations 3

2.1. What are the SRHR needs of key populations and why do they matter? ...... 3

2.2. What is HIV/SRHR integration?...... 5

2.3. Why is HIV/SRHR integration a vital strategy for key populations?...... 7

2.4. What strategies are being used for HIV/SRHR integration for key populations?..... 8 2.5. What lessons have been learned about HIV/SRHR integration for

key populations?...... 10 1. Promote good practice principles throughout HIV/SRHR integration for

key populations:...... 10 2. Plan and get started on HIV/SRHR integration by building on ‘what’s there’,

gathering evidence and identifying key entry points:...... 10 3. Ensure comprehensive HIV/SRHR integrated programming for

key populations:...... 11 4. Ensure effective and creative service delivery for HIV/SRHR integration for

key populations:...... 12 5. Ensure a strong ‘chain’ of HIV/SRHR integrated services for key populations,

including through high quality and systematic referrals:...... 13 6. Promote HIV/SRHR integration for key populations at all levels, including

building an enabling internal and external environment:...... 13 7. Address the political, legislative and funding context of HIV/SRHR

integration for key populations:...... 13 2.6. How do organisations ‘get started’ with HIV/SRHR integration for

key populations?...... 14

3. HIV/SRHR integration for people living with HIV 17

3.1. What does HIV/SRHR integration for people living with HIV involve? ...... 17 3.2. What are some common strategies for HIV/SRHR integration for people

living with HIV?...... 18 3.3. What lessons have been learned about good practice HIV/SRHR integration

for people living with HIV?...... 18

3.4. Case studies of HIV/SRHR integration for people living with HIV...... 20 4. HIV/SRHR integration for sex workers 31

4.1. What does HIV/SRHR integration for sex workers involve? ...... 31

4.2. What are some common strategies for HIV/SRHR integration for sex workers?....32 4.3. What lessons have been learned about good practice HIV/SRHR integration

for sex workers?...... 32

4.4. Case studies of HIV/SRHR integration for sex workers...... 34

5. HIV/SRHR integration for men who have sex with men 47 5.1. What does HIV/SRHR integration for men who have sex with men (MSM) and

transgender people involve? ...... 47 5.2. What are some common strategies for HIV/SRHR integration for men who

have sex with men and transgender people?...... 48 5.3. What lessons have been learned about HIV/SRHR integration for men who

have sex with men and transgender people?...... 49 5.4. Case studies of HIV/SRHR integration for men who have sex with men and

transgender people...... 51

6. HIV/SRHR integration for people who use drugs 61

6.1. What does HIV/SRHR integration for people who use drugs involve? ...... 61 6.2. What are some common strategies for HIV/SRHR integration for people

who use drugs?...... 62 6.3. What lessons have been learned about HIV/SRHR integration for people

who use drugs?...... 62

6.4. Case studies of HIV/SRHR integration for people who use drugs...... 64

7. Conclusions and key messages 73

HIV/SRHR Integration for KPs: Key Messages...... 75

Annex 1: List of resources for review 77

Sources of information for review...... 77

India:...... 77

Global:...... 77

India resources included in review...... 78

Resources related to HIV/SRHR integration for key populations (general)...... 78

Resources related to HIV/SRHR integration for specific key populations...... 79

Global resources included in review...... 81

Resources related HIV/SRHR integration for key populations (general)...... 81

Resources related to HIV/SRHR integration for people living with HIV...... 83

Resources related to HIV/SRHR integration for sex workers...... 84 Resources related to HIV/SRHR integration for men who have sex with

men and transgender people...... 85

Resources related to HIV/SRHR integration people who use drugs...... 86 Annex 2: Key SRHR vulnerabilities for key populations: Alliance Good Practice Guide 87

Annex 3: Gender and SRHR issues for people who use drugs: Alliance Good Practice Guide 92

Women...... 92

Lack of “women-friendly” services...... 92

Gender and vulnerability...... 92

Women and injecting – risks and vulnerabilities...... 93

Women, sex work and drug use...... 93

Pregnancy and motherhood...... 93

Annex 4: Ten essential steps to strengthen family planning and HIV service integration (Family Health International) 94

1 © Eugenie Dolberg for the Alliance

1. Introduction

1.1. Content of report Figure 1: Who are key populations? This report summarises the findings of a review commissioned by ‘Key populations’ refers to groups that are India HIV/AIDS Alliance of experiences and lessons from integrating particularly vulnerable to and affected by HIV and sexual and reproductive health and rights (SRHR) in HIV. They are key to both the dynamics of programmes for key populations [see Figure 1]. and response to epidemics. The report outlines definitions and benefits of HIV/SRHR integration Reflecting Alliance priorities, this review for key populations and presents some general lessons learned focused on five such groups: about good practice. It then addresses each of the selected key • People living with HIV populations – describing issues to consider within integrated HIV/ • Sex workers SRHR support, sharing key strategies and providing examples of • Men who have sex with men integration in action. • Transgender people • People who use drugs

1.2. Rationale and context for review The review was carried out within a context of growing interest in HIV/SRHR integration [as defined in Section 2]. There is a growing wealth of evidence that the strategy ‘makes good sense’ and brings concrete benefits – including to people, services and national health systems. The review specifically responded to the ‘push’ for HIV/SRHR integration within the changing and increasingly complex environment for responses to HIV. Within this context – one characterised by constrained resources, increased demands for cost-efficiency and political re-positioning (with HIV increasingly integrated into wider frameworks for health) – integration is clearly an important strategic option. It also, however, risks being seen as a ‘magic bullet’. In India – as well as other countries in the Asia and the Pacific Region and globally – there is increasing policy support for the concept of HIV/SRHR integration. However, there remain significant questions and uncertainties about what such programming means in practice. This is particularly the case within the context of a concentrated HIV epidemic – where little is still known about what integration should ‘look like’ (for groups such as sex workers and men who have sex with men) and what practical opportunities and challenges it involves. HIV/SRHR integration for key populations 2 different contextsandmodels the HIV/SRHRcomponentsintegrated,lessonslearned, etc.)tofacilitatecomparisonacross a templatewasusedtorecordthedetailsofprogrammes (suchasthetypeofpopulation, mappings, toolkits,policybriefingsandreports.Where adequateinformationwasavailable, agencies andUN[seeAnnex1foralist].Theresourcesincludedcasestudies, websites ofselectednationalandinternationalorganisations, includingNGOs,technicalsupport The methodologyforthereviewfocusedonassessing over 160resourcesavailableonthe groups. populations ordetailed,technicalguidanceonthe‘howto’ofintegratedprogrammingforsuch It alsodidnotaimtoprovidecomprehensivedocumentationoftheSRHRneedskey The reviewdidnotaimtoserveasasystematicormeta-analysisofallrelevantdocumentation. The objectivesofthereviewwere: needs ofkeypopulations. integration, thisstrategycannotonlyimprovetheefficiencyofprogrammesbuttrulyserve This reviewaimstoassesshow,withinthecontextofgreaterpoliticalsupportforSRHR/HIV 1.3. Objectivesandmethodsofreview contexts? Andwhatispossibleintheshort-termandgoalsshouldbesetforlong-term? example, whattype,paceandscaleofintegrationworksbestforspecificpopulationsin forkeypopulations?For ensure thatintegrationdoesnotcompromiseaccesstoservices outcomes specificallyforkeypopulations?Ifso,whatneedstobetakenintoaccount to supportHIV/SRHRintegrationasaneffectiveapproachimprovebothSRHRandHIV A numberofcriticalquestionsremainoutstanding.Theseinclude:Dowehavestrongevidence compromise outcomesforkeypopulations. interventions, integratingservicesandsystemsthatarenotreadymayintheshort-runactually While thisapproachclearlyhasthepotentialtoincreasereachandimprovequalityof into accountwhennationalresponsesaimtoscaleupSRHR/HIVintegratedprogramming. recommendations forSRHR/HIVintegratedprogrammes.Thesechallengesneedtobetaken access toservicesforkeypopulations.Thisreviewidentifiesanumberofchallengesand of programmesandsystemsthatarenotreadycould,infact,compromisethequality However, whileintegrationisadesirablegoalinthelong-run,concernsremainthatjoining 3. 2. 1. contexts ofkeypopulations. such programmesarebasedongoodpracticeandrespondtothespecificneeds integrated programmesbyIndiaHIV/AIDSAlliance–inparticularensuringthat To informthefuturedevelopment,implementationandevaluationofHIV/SRHR overall andinrelationtothefiveprioritygroupsforIndiaHIV/AIDSAlliance. lessons learnedfromHIV/SRHRintegratedprogrammingforkeypopulations–both From thatdocumentation,toidentifyandanalysesuccessfulapproaches HIV/SRHR integrationforkeypopulationsinIndiaandinternationally. To identifyandreviewaselectionofexistingdocumentationonprogrammingfor 3

2.1. What are the SRHR needs of key populations and why do they matter? According to universal commitments, key populations have the same, universal sexual and reproductive rights as anyone else. For example, they have the right to have sexual relations free from coercion, to have children and to protect themselves from infection. Key populations also share many common needs for HIV and SRHR information, support, services and commodities. For example, like other community members, they might require access to HIV testing, advice about family planning and access to maternal, newborn and child health (MNCH) services. In practice, however, there are a significant number and range of factors that mean that key populations often experience both heightened vulnerability to SRH ill health (such as STIs, unintended pregnancies and maternal mortality) and greater barriers to the support and involvement that they need [see Figure 21 for a summary and Annexes 2 and 3 for extracts from Alliance Good Practice Guides on ‘Integration of HIV and Sexual and Reproductive health and Rights’ and ‘HIV and Drug Use: Community Responses to Injecting Drug Use and HIV’]. These factors are further affected by the context of and differences between individuals, such as in terms of sex, age and status. For example: a young woman who is living with HIV might have greater family planning needs than a woman who is older; a man who has sex with men (MSM) who is married to a woman may have more complex SRHR needs than a man who is not; a sex worker who lives in a rural area may be less able to access SRHR services than one in a city; or a woman who uses drugs who is unmarried might find it harder to access SRHR services than a woman who is married.

1 Adapted from: Integration of HIV and Sexual and Reproductive Health and Rights: Good Practice Guide, International HIV/AIDS Alliance, 2010; and Who Are We Failing? How Marginalisation and Vulnerability Affect Adolescents’ Needs for and Access to SRHR, Interact Worldwide, 2011. HIV/SRHR integration for key populations 4 SRHR services accessing barriers to or stronger Additional SRHR needs more complex Specific or Factors Figure 2:FactorsthataffectkeypopulationsinthecontextofSRHR SRHR services to demand opportunities capacity or Weaker For example,compared toothercommunitymembers… • • • • • • • • • • • • • • • • • because theyare leftout of communitycapacitybuildingprojects. People whousedrugsmightlacktheskillstodefinetheir SRHRneeds making becausetheylacklegalstatus. Transgender peoplemightnotbeabletoparticipateinSRHRdecision- advocate fortheirSRHRneedstodecision-makersinhealthservices. People livingwithHIVmightlackself-esteemor‘safespaces’to projects becausetheyare a‘hiddenpopulation’. MSM mightnotbeincludedinthemonitoringandevaluationofSRHR women’s SRHR needs. Sex workersmightnotbeincludedinprovincial consultationson STIcentregovernment iftheyare criminalized. A personwhousesdrugsmightnotbeallowedtoregister ata equipment orexpertisetocarryoutano-genitalexaminations. clinicifthestaffAn MSMmightnotaccessagovernment lackthe project focusedonharmreduction. A womanwhousesdrugsmightfeelunabletodiscussSRHRneedsina they facethreats bythepolice. A transgendersexworkermightnotaccessapublicSRHRserviceif family planningclinicinnormalopeninghours. A femalesexworkermightworkatnightsandnotbeabletoaccessa mainstream antenatalservices. A womanlivingwithHIVmightfacestigmaanddiscriminationbystaff at female partnerandprevent HIVwithamalepartner. An MSMwhoismarriedmightrequire supporttoplanafamilywithhis safer sexwhileundertheinfluenceofdrugs. A manwhousesdrugsmightneedbehaviourchangesupporttoensure Antiretroviral therapy. specific adviceoninteractionsbetweenmethadone,contraceptivesand A pregnant womanwhousesdrugsandislivingwithHIVmightrequire reassignment. A transgenderpersonmightrequire specialistcounselingongender- regular accesstoSTItesting. A malesexworkermightrequire larger suppliesofcondomsandmore exposure prophylaxis. violent sex–increasing herneedforemergency contraceptionandpost- A femalesexworkermightexperiencehigherlevelsofcoerced and 5 HIV/SRHR integration for key populations “Linkages and integration enable programmes to reach more people, especially key populations, to respond more fully to their needs and to reach both HIV Linkages and SRH goals more effectively. strengthen programmes to address the root causes of SRH ill-health, including Linkages between SRH and HIV also HIV. address the social and structural issues that make people vulnerable to SRH ill-health stigma poverty, and HIV – gender inequality, and discrimination, rights violations and legal issues.” Good Practice HIV Programming International Standards, HIV/AIDS Alliance Figure 4: How HIV/SRHR integration strengthens programming International HIV/AIDS Alliance, 2010. International HIV/AIDS Alliance, 2010. . It can, for ]. These needs often ‘fall through the net’ often ‘fall through ]. These needs 7 2 [see Figure 4]. and Programming 3 4 , as well as leaders in the field 6 of the International HIV/AIDS Alliance. [See Figure 5 5 56% of those that were married had an unmet need for contraception. married had an unmet were 56% of those that in the last 3 months. symptom an STI-related 52% had experienced sex and 17% physical violence in last 3 months. 15% had experienced forced health providers. Many concealed their drug use from used condoms with clients, few used them with their regular Although 70-75% regularly partners. form of contraception, but little information was given about the most popular Oral pills were side effects. to abortion (with 10% self- Most resorted 30% had experienced unintended pregnancies. post-abortion complications. induced at home) and the majority had type of services – due to judgemental attitudes Government the least preferred clinics were and low confidentiality. India HIV/AIDS Alliance and SASO (2011). In the Shadows: The Chanura Kol baseline study on Women who inject drugs in Manipur. India. New Delhi. India HIV/AIDS Alliance and SASO (2011). In the Shadows: The Chanura Kol baseline study on Women who inject drugs Barriers to Sexual India HIV/AIDS Alliance (150 women who use drugs, aged 18-49 years in 3 sites in Manipur) India HIV/AIDS Alliance. Understanding in Andhra Pradesh). Reproductive Health for FSW. Hyderabad, India HIV/AIDS Alliance Andhra Pradesh. (146 female sex workers in 5 districts Good Practice Guide: Integration of HIV and Sexual and Reproductive Health and Rights, to guide the design, implementation and evaluation of Alliance programmes in seven areas, with each including a number of agreed standards Standards to guide the design, implementation and evaluation of Alliance programmes in seven areas, with each including a number (measurable and evidence-based benchmarks of quality). Good Practice HIV Programming Standards, International HIV/AIDS Alliance, June 2010. for Sexual and Reproductive Health For example: A Framework for Priority Linkages, IPPF, UNFPA, UNAIDS and WHO, 2005; and Rapid Assessment Tool and HIV Linkages: A Generic Guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives, 2009. For example: Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations, UCSF, WHO, UNAIDS, UNFPA and IPPF, 2009; and Good Practice Guide: Integration of HIV and Sexual and Reproductive Health and Rights, Based on description of Standard 4.1 in Good Practice HIV Programming Standards, International HIV/AIDS Alliance, June 2010. Examples of key populations’ unmet SRHR needs, India populations’ unmet SRHR needs, Figure 3: Examples of key in Manipur found that: A study of women who use drugs • • • • A study of female sex workers in Andhra Pradesh found that: • • • • As a result of these multiple and often overlapping factors, key populations can experience can experience factors, key populations and often overlapping of these multiple As a result for SRHR [see Figure 3 unmet needs significant for the 11 good practice standards]. The review was also informed by key normative documents on integration produced by the International Planned Parenthood Federation (IPPF) and partner UN agencies (UNFPA, UNAIDS and WHO) 2 3 4 5 6 7 2.2. What is HIV/SRHR integration? In this review, integration refers to one or more components of into (or ‘joined with’) one SRHR programming being integrated or vice versa. This or more components of HIV programming; to another, with the overall includes referrals from one service aim of providing more comprehensive support of integration in India, notably PATH India. There is increasing evidence and recognition that HIV/SRHR integration brings multiple benefits at multiple levels of SRHR services (that are often designed for the general public and focus on mainstream and focus on mainstream the general public designed for services (that are often of SRHR are often designed to address people’s planning) and HIV services (that services, such as family person’). rather than looking at the ‘whole high risk behaviours, This review was based on the understanding of HIV/SRHR integration promoted by the Good Practice Guide Standards example increase and improve: an individual’s access to a wider HIV/SRHR integration for key populations 6 protection frombothHIVandunwantedpregnancy) are particularlyevidentintheuptakeofkey‘cross-over’services,suchascondoms(fordual including the2011UN HIV/SRHR integrationhasbeenincreasinglyrecognizedinkeyglobalpolicycommitments– and 6(combatHIV,malariaotherdiseases). seen ascriticaltoachievingbothMillenniumDevelopmentGoals5(improvematernalhealth) 10 9 8 resources; andahealthsystem’scollaborativeplanningmanagement range ofbothHIVandSRHRsupport;aservice’sefficientusehumanfinancial 11 10 9 8 7 6 5 4 3 2 1 International HIV/AIDSAlliance Figure 5:GoodpracticeprogrammingstandardsforHIV/SRHRintegration, AFrameworkforPriority Linkages,WHO,UNFPA,UNAIDS andIPPF,2005. Political Declarationon HIV/AIDS:IntensifyingourEffortstoEliminate HIV/AIDS Sexual andReproductive HealthandHIVLinkages:EvidenceReview andRecommendations, services andsupport. which undermineprotective behavioursandactasbarrierstoaccessingSRHHIV Our organisation has apolicyandprogramme toaddress stigmaanddiscrimination, address gender-based andsexualviolenceabuseinitsHIVSRHresponse. In collaborationwithothers,ourorganisation promotes and/orprovides interventionsto address genderandsexualityasanintegralcomponentoftheSRHHIVresponse. Our organisation workswithotherstopromote and/orimplementprogrammes that capacity ofserviceproviders tobettermeettheneedsofourbeneficiaries. feasible ratherthansettingupparallelservices.We collaborate withandbuildthe Our organisation promotes andrefers userstoquality, user-friendly serviceswhenever condoms. Our organisation promotes and/orprovides STIeducation,diagnosis,treatment and Our organisation promotes andincreases uptakeoftheessentialelementsPPTCT. HIV thatisintegratedwithreproductive andoptions. concerns Our organisation promotes and/orprovides information,educationandcounselingon specific andtailored topeople’s needs. increases knowledge,self-esteemandskillsissociallyculturallycontext- Our organisation promotes and/ordeliverssexualityeducationthatiscomprehensive, involved atallstagesoftheproject cycle. The peoplemostaffected byHIVandSRHproblems are meaningfullyandconsistently people. In collaborationwithothers,ourorganisation promotes theSRHneedsandrightsofall programmes andservices. Our organisation promotes thelinkingandintegrationofSRHHIVinpolicies, Political DeclarationonHIV/AIDS , UNGeneralAssembly, June2011. 9 . UCSF, WHO,UNAIDS, UNFPAandIPPF,2009. 10 – andnationalframeworks.Itis 8 . Thebenefits 7 HIV/SRHR integration for key populations . However, on the whole, 13 . This is because – beyond the generic benefits to all . This is because – 11 ]. 12 – increasing key populations’ key populations’ support – increasing Provides a ‘one stop shop’ for both HIV and SRHR and continuous support. access to and uptake of comprehensive person’ approach – going beyond a focus on ‘disease Promotes a rights-based and ‘whole someone as a ‘whole person’ who has the right to have satisfying sexual to treating control’ etc. a family, relations, key related to HIV and/or key populations – increasing Reduces stigma and discrimination issues and needs. populations’ access to services by ‘normalising’ of HIV and SRHR services – by enabling them to Increases the quality and appropriateness complex needs of key populations. be ‘tailor made’ to the specific and sometimes the for key populations, for example by reducing Improves the efficiency of services work, transport costs, time off people’s appointments (reducing of health-related frequency etc.). and human resources for HIV/SRHR programmes for Makes good use of scarce financial key populations. Adapted from: Thematic Segment: Sexual and Reproductive Health Services with HIV Interventions in Practice: Background Paper, 26th Meeting of the , UNAIDS Programme Coordinating Board, June 2010; and Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations WHO, UNFPA, IPPF, UNAIDS and UCSF, 2008 A Guidance Package, GNP+, ICW, Young Positives, Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: EngenderHealth, IPPF and UNAIDS, 2009. Potential benefits of HIV/SRHR integration for key populations Figure 6: Potential benefits of HIV/SRHR • • • • • • In response, an increasing number of organisations working with key populations in a variety of with key populations in a variety number of organisations working In response, an increasing practice. This involves a broad spectrum putting HIV/SRHR integration into different settings are specific components to full-scale comprehensive of approaches – from the joining of small, integrated programming. community members – integration has the potential to address some of the specific factors, address some of the specific factors, – integration has the potential to community members vulnerability. For example, it can help that heighten such groups’ SRHR needs and challenges and relevance of SRHR services discrimination and increase the quality to reduce stigma and [see Figure 6 11 For example: A Framework for Priority Linkages, IPPF, UNFPA, UNAIDS and WHO, 2005. 12 13 Based on these experiences, there is some emerging consensus about ‘what matters’ and Based on these experiences, there is ‘what works’, for example in HIV/SRHR integration for PLHIV Within dialogue on HIV/SRHR integration, it is often indicated that the strategy particularly HIV/SRHR integration, it is often indicated Within dialogue on key populations ‘makes sense’ for 2.3. Why is HIV/SRHR integration a vital strategy for key for a vital strategy integration is HIV/SRHR 2.3. Why populations? and especially for the other populations – sex workers, people who use drugs, MSM and and especially for the other populations – sex workers, people who use drugs, good practice transgender people – there remain important questions about what constitutes the strategy into for integration, and what opportunities and challenges are involved in putting practice. HIV/SRHR integration for key populations 8 strategies forHIV/SRHRintegrationkeypopulations: The reviewidentifiedthattherearearangeofexamplesinterestingand/orsuccessful for keypopulations? 2.4. WhatstrategiesarebeingusedforHIV/SRHRintegration Sex workers HIV programme Figure 7:ExamplesofstrategiesforHIV/SRHRintegrationkeypopulations People livingwithHIV PMTCT andART) services, e.g. followed byother HCT (often for PLHIV General services and support) PMTCT orcare HCT (alsooften (especially HCT) components or selectedHIV Comprehensive (plus widerHIV) HIV prevention services forSWs specific, key HCT orother HIV prevention Advocacy onHIV care andsupport) ART (alsooften HIV) HCT (andbroader Integration ↔ SRHR programme violence) or gender-based related toSTIs of SRHR(e.g.support Selected components SRHR) FP (alsooftenbroad and/or broad SRHR) FP (alsooftenSTIs condoms) (especially STIsand components or selectedSRHR Comprehensive wider SRHR) STI prevention (plus condoms) (especially STIsand Broad SRHR dual protection Female condomsfor STIs andcondoms) SRHR, especially FP (andbroader Advocacy onSRHR SRHR) FP (alsooftenbroad Case studiesinthisreport • • • • • • • • • • • • • • • • • • • • • • • • • Alliance inUganda,Uganda HIV/AIDS International Gheskio, Haiti MAMTA, India PSI, Zimbabwe HCT Centres, Ethiopia HCT Centres, Kenya POZ, Haiti Ministry ofHealth,Kenya TASO, Uganda TOP, Myanmar Concern/HMAP, Pakistan Community Support ISH, Serbia YPSA, Bangladesh CSI, India PATH India,India Avahan programme, India CEMOPLAF, Ecuador FPAM, Malawi EC-CAP, Caribbean KANCO, Kenya Aastha Project, India SAATHII, India FHOK, Kenya Republic PROFAMILIA, Dominican ABEF, Rwanda 9 HIV/SRHR integration for key populations SAATHII, India SAATHII, PKBI, Indonesia Puskesmas, Indonesia FPA India, India FPA Colombia PROFAMILIA, RHAC, Cambodia Mythi clinics (Avahan India Programme), Nadu State AIDS Tamil and APAC Society, Control India TAI, Bandhu Social Welfare Bangladesh Society, and Pakistan PAVNHA Pakistan Society, Blue Diamond Society, Nepal North Africa Regional InternationalProgramme, HIV/AIDS Alliance Espace Confiance, Cote D’Ivoire India Humsafar Trust, Malaysia DICP, Korsang, Cambodia OSI, Ukraine SASO, India Five Hearts Service Centre, China • • • • • • • • • • • • • • • • • • • Broad SRHR or Broad primary health care Advocacy on SRHR SRHR (especially condoms and STIs and often specifically including women’s health) SRHR, especially STIs STIs Selected components of SRHR FP (and broader FP (and broader SRHR, especially STIs) → → ← ← ← → → HIV and harm reduction HCT (and other HCT (and HIV services) HCT (and other HIV services) General HIV services Selected components of HIV Advocacy on HIV HIV and harm reduction People who use drugs Men who have sex with men/transgender people have sex with men/transgender Men who 10 HIV/SRHR integration for key populations • • key populations: 1. Promote goodpracticeprinciplesthroughout HIV/SRHRintegrationfor findings highlightthatitisimportantto: communities thataremarginalisedandvulnerableinthecontextofHIV/SRHR.Thereview’s specific tointegration,manyserveasareminderofgoodpracticeforanytypeworkwith important lessonsaboutHIV/SRHRprogrammingforallkeypopulations.Whilesomeare Based onthecasestudiesdescribedinfollowingsections,reviewidentifiedmany integration forkeypopulations? 2.5. WhatlessonshavebeenlearnedaboutHIV/SRHR 19 18 17 16 15 14 • there’, gatheringevidenceandidentifyingkeyentrypoints: 2. PlanandgetstartedonHIV/SRHRintegration bybuildingon‘what’s • • India, August2011. Linking SRHAndHIVTo MeetTheNeedsOfMSM&Transgender People:ExperiencesfromIndia,(powerpointpresentation), FamilyPlanningAssociationof Positively Caring(powerpointpresentation), InternationalHIV/AIDSAlliance,March2011. Planned ParenthoodFederation, 2005. Models ofCareProject:LinkingHIV/AIDSTreatment, CareandSupportinSexualReproductive HealthCareSettings:ExamplesinAction, Planned ParenthoodFederation,2005. Models ofCareProject:LinkingHIV/AIDSTreatment, CareandSupportinSexualReproductive HealthCareSettings:ExamplesinAction, Amitrajit Saha,AnnaZakowicz,DawnAverittBridge, JillGay,RobertCarr,(PresentationatInternationalAIDSConference),July Exploring IntegratedSRHandHIVModels ProgrammingExamplesfromaVariety ofSettingsin Countries/AreaswithConcentratedHIVEpidemics, SRHR/HIV Integration:AllianceIndiaExperiences andReview,(powerpointpresentationatICAAP2011),India HIV/AIDSAlliance,2011. increase insafersexpractices provision ofclinicalserviceswithraisingawarenesssexworkers’rights–leadingtoan For example:theFamilyPlanningAssociationofTrinidadandTobagocomplements including tosexuality,havechildrenandmakechoicesabouttheirownSRHR. Use arights-basedapproachthatrecognizeskeypopulations’individualrights, discrimination) access toservices;andaddresscriticalbarriersforkeypopulations(suchasstigma gather evidenceoftherealHIV/SRHRneedskeypopulations;facilitatepopulations’ groups –especiallythosethatarebyandforkeypopulationsinauniquepositionto: HIV/SRHR integration.Forexample,theIndiaHIV/AIDSAlliancehasseenthatcommunity Recognise thecentralityofcommunityorganisationsandsystemsforhighquality harm reductionNGOtobemulti-disciplinaryratherthan recruitspecialistSRHRstaff.Only become ‘sexworkerfriendly’ratherthansetupaseparate clinic;ortrainexistingstaffata than startingfromscratch.Forexample,wherepossible:supportalocalSRHRclinic to Develop integratedprogrammesthatbuildon‘what’s there’forHIVandSRHR,rather training tothestaffoftheirSRHRclinic and PROFAMILIA,Colombia,employedmenwhohavesexwithtodesigndeliver relevant support) to thestigmaassociatedwiththeirparents,mayalsoexperiencechallengesinaccessing male partnersoffemalesexworkersortheMSM)andchildren(who,due learned thatthisincludeslookingattheHIV/SRHRneedsofpeople’spartners(suchas populations, butthosearoundthem.Forexample,theInternationalHIV/AIDSAlliancehas Take afamily-centredapproachthatsupportsnotonlytheHIV/SRHRneedsofkey as community-basedvolunteersandmembersofitsManagementAdvisoryBoards Options KenyainvolvesPLHIVthroughoutthecycleofitsintegratedprogramme,including populations atallstagesofintegratedprogramming.Forexample:FamilyHealth Ensure theprincipleofgreaterinvolvementPLHIV(GIPA)andotherkey transgender peopletoimprovefamilyacceptanceand understanding oftheirneeds 14 . 18 . FPAIfounditimportanttoworkwiththefamilymembersofMSMand 15 . 17 . 2010. 19 International International . 16 ; 11 HIV/SRHR integration for key populations . 29 ; 26 Family ; and a study of sex workers . 24 25 ; and Bandhu Social Welfare 22 ; ensuring attention to taboo 28 . 20 . 23 . 21 . For example, this might involve: integrating SRHR services such as safe 27 For example: an India HIV/AIDS Alliance study found that young Relationship status. For example: an India HIV/AIDS Alliance to become pregnant and have children married women living with HIV face pressures in Guntakal, Andhra Pradesh, found that, while the priority for 21-30 year olds was safe in Guntakal, Andhra Pradesh, found pregnancy testing abortion, for 31-40 year olds it was free and a study among MSM in Warangal, Andhra Pradesh, found that 33% of the men were and a study among MSM in Warangal, married to women. be a migrant or use Other status or behaviours. For example: a sex worker might also with HIV. drugs; or an MSM might also be living r example, women who use drugs may have significantly different SRHR Gender. For example, women who use drugs may needs to men who use drugs. that young people living with HIV had intensive Age. For example Alliance Zambia found due to their age SRHR needs, but less access to services, • subjects, such as anal STIs for sex workers; and addressing the SRHR needs that often ‘fallsubjects, such as anal STIs for sex workers; and addressing the SRHR needs combining HIV- through the net’, such as of women who use drugs who require a package programming,related interventions (such as opiate substitution treatment, needle and syringe MNCH services education about safe injecting and overdose prevention) with key SRHR and • Identify and start with the most needed and obvious ‘entry points’ for integrating with the most needed and obvious Identify and start by to the context, but can be identified These will vary according HIV and SRHR services. services match their needs. For services people use and how those understanding what sex workers’ visits for post-abortion Andhra Pradesh, India, found that example: a study in provide family planning services served as an opportunity to Identify, understand and respond to the diversity of HIV/SRHR needs within key Identify, understand and respond populations. Consider factors such as: • • Use a situational analysis (of the community and the wider environment) to analysis (of the community and the Use a situational and/or possible in a type of HIV/SRHR integration is effective understand what to access women living with HIV may be able specific context. For example, some who are sex workers – may services, while others – such as those mainstream SRHR services require specialised Society, Bangladesh, found that providing general health care was a good way to start Society, Bangladesh, found that providing engaging MSM on issues of SRHR set up new services where there is a clear added value and/or a neglected area, such as neglected area, such value and/or a there is a clear added services where set up new who use drugs sex workers or women MNCH for Use comprehensive definitions of HIV and SRHR that go beyond the ‘usual suspects’Use comprehensive definitions of HIV and SRHR that go beyond the for integration abortion that – while still not commonly integrated with HIV for the general public – can beabortion that – while still not commonly integrated with HIV for the general particularly vital for key populations, such as sex workers Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: A Guidance Package, GNP+, ICW, Young Positives, Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: EngenderHealth, IPPF and UNAIDS, 2009. Health International. People Living with HIV in Zambia: Briefing Paper, International HIV/AIDS Alliance, 2011. Needs, Challenges and Opportunities: Adolescents and Young Guntakal and Piler Sites of Sexual and Reproductive Health Needs of FSWs, MSMs and TGs: Research Report on Quantitative Findings from Warangal, Alliance in Andhra Pradesh, SWASTI Health Resource Centre, December 2008. International HIV AID Alliance in India. Issue Brief: Sexual and Reproductive Health and Rights – Key Issues for Adolescents Affected by and Living with HIV, and Potential Strategic Work Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Alliance Programmes and Policy Partnerships, International HIV/AIDS Alliance. and Potential Strategic Work Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Alliance Programmes and Policy Partnerships, International HIV/AIDS Alliance. HIV and Drug Use: Good Practice Guide, International HIV/AIDS Alliance, 2010. Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Alliance Programmes and Policy Work and Potential Strategic Work Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Alliance Programmes and Policy Partnerships, International HIV/AIDS Alliance. Guntakal and Piler Sites of Sexual and Reproductive Health Needs of FSWs, MSMs and TGs: Research Report on Quantitative Findings from Warangal, Alliance in Andhra Pradesh, SWASTI Health Resource Centre, December 2008. Summary Report of Key Findings and Programme Recommendations: From FHI MSM Programme Evaluations (Bangladesh, Indonesia and Nepal), • • • 24 25 26 27 28 29 20 21 22 23 3. Ensure comprehensive HIV/SRHR integrated programming for key HIV/SRHR integrated programming comprehensive 3. Ensure populations: • 12 HIV/SRHR integration for key populations • 36 35 • • for keypopulations: 4. Ensure effective andcreative servicedeliveryforHIV/SRHRintegration 34 33 32 31 30 • • • Exploring theLinksbetweenDrugUseandSexual Vulnerability amongYoung FemaleInjecting DrugUsersinManipur,PopulationCouncil,2008. August 2011. Advancing Sexualand Reproductive HealthandRightsforSexWorkers, (powerpointpresentation atICAAP2011),UNFPAAsiaPacificRegional Office, HIV andDrugUse:Community ResponsestoInjectingDrugUseand HIV: GoodPracticeGuide,InternationalHIV/AIDS Alliance,2010. Integration ofHIVandSexual andReproductiveHealthRights:Good PracticeGuide, in India,(draft),FamilyPlanningAssociationof2010. Advocacy Brief:IntegrationofSexualandReproductive HealthandHIV-Related forMenWho HaveSexwithMen(MSM)andTransgender Services People Gateways toIntegration:ACaseStudyfromSerbia , WHO,UNFPA,UNAIDSandIPPF,2009. Zakowicz, DawnAverittBridge,JillGay,Robert Carr,(PresentationatInternationalAIDSConference),July SRH andHIVModelsProgrammingExamples fromaVariety ofSettingsinCountries/Areaswith ConcentratedHIVEpidemics,AmitrajitSaha,Anna PATH, India:HIV-SRH Convergence, PolicyandPracticeUpdate4,HIV-SRHConvergenceProject,PATH,December 2009;andExploringIntegrated self-esteem –leadingtogreaterhealthseekingbehaviour Andhra Pradesh,India,foundthatpeereducatorshelpedMSMtobuildself-confidenceand especially foraddressingsensitiveorcomplexissues.Forexample:Mythriclinicsin Recognise peereducationasacriticalstrategyinHIV/SRHRforkeypopulations, use drugsisalwaysdeliveredbyfemaleworkers of Korsang,Cambodia,areallcurrentorformerdrugsusers,whilesupportforwomenwho mobile supportat‘hotspots’ reaches sexworkersthroughcombiningcentre-basedservices,communityoutreachand Offer flexibleservicedelivery.Forexample:theInstituteforStudentsHealth,Serbia, previously beentargetedforHIVpreventionandisolatedfromSRHRsupport. (such asaccompanimentbyvolunteers)toaccessservices;andsexworkersmayhaveonly PLHIV maynotknowthattheyhavetherighttoSRHorneedactiveencouragement Create demandaswellsupplyforHIV/SRHRintegratedservices.Forexample: those withanSRHRproblemsoughtsupportatafacility also sexworkers,only20%usedcondomswiththeirregularboyfriendsandhalfof study among15-34yearoldwomenwhousedrugsinManipur,India,foundthatmanywere different typesandlevelsofvulnerabilityinter-relate.Forexample,aPopulationCouncil Within thedevelopmentofintegratedprogrammes,addresshowkeypopulations’ to integratedservices PATH’s trainingonstigmaforhealthprovidersandsexworkersledtoanincreaseinaccess populations) asafundamentalbarriertointegratedprogrammes.Forexample,inIndia, Proactively addressstigmaanddiscrimination(relatedtobothHIVkey service providersanddecision-makers a partnershipbetweensexworkersandserviceproviders,aswellwithotherHIV/SRHR stakeholders. For example, in countries such as Myanmar, UNFPA has found it vital to build Work inpartnershipbothwithinaprojectandwiththecommunityother government clinic referral toin-houseservicesatanNGO,aCommunityPreferredPrivatePractitioneror Programme-III inIndia,programmesforMSMtoprovideSTIsupportcandosothrough 33 . 31 . 32 ; and,intargetedinterventionsfortheNationalAIDSControl 36 . 35 . InternationalHIV/AIDS Alliance,December2010. 30 34 . ; andthestaffpeereducators 2010. 13 HIV/SRHR integration for key populations . . 41 40 ; and 37 . . 38 39 Ensure that training to support integrated programming for key populations is Ensure that training to support integrated and high quality. This includes: targeting all staff appropriately targeted, comprehensive management and clinical personnel – at both the and volunteers – including administrative, technical aspects of HIV/SRHR programming ‘home’ site and referral facilities; addressing being led by or, at least, actively involving and attitudes towards key populations; and in Myanmar, TOP (supported by UNFPA) found it members of key populations. For example, sex workers vital to train staff in specific clinical services for female, male and transgender the Family Planning Association of India found it necessary to offer MSM who are married Association of India found it necessary the Family Planning them to men who were not accessing services (to avoid ‘outing’ different options for married) Complement the provision of integrated services with local/national advocacy on Complement the provision of integrated services with local/national Examples legislative, structural and policy barriers to HIV/SRHR for key populations. programmes; include: advocating to local health or policie authorities to support integrated advocating to national policy-makers to change laws that criminalise same-sex acts people; and between consenting adults or do not recognise the identity of transgender key populations. advocating to legal authorities for recourse in instances of violence against matter and Advocating to donors about why the HIV/SRHR needs of key populations how integration is a critical ‘investment opportunity’. For example, where possible, individuals, demonstrate to donors the cost-efficiency of integrated programmes – for services and health systems. Build a multi-level approach to HIV/SRHR integration for key populations that Build a multi-level approach to HIV/SRHR of joint services. For example, ensure that includes, but goes beyond, the provision of key populations’ rights and supporting them to programmes include raising awareness demand appropriate integrated services. of and ‘friendliness’ to key populations. For Build an organisation’s knowledge steps to create an enabling environment example, FPAI found it vital to take proactive their SRHR clinics and treat clients with dignity and for MSM and transgender people in respect If integration involves referrals, ensure the quality, confidentiality and ‘key population- referrals, ensure the quality, If integration involves to support systems and services. For example, programmes friendliness’ of referral Institute, Ukraine, only provide supported by the Open Society women who use drugs as a ‘bridge’ for clients and trained services, with staff acting referrals to trusted If necessary, reconfigure an organisation’s physical space to provide integrated If necessary, reconfigure an organisation’s needed to refurbish some facilities and programmes. For example, Puskesmas, Indonesia, clinic within its primary health care services provide a separate entrance for a methadone Making Harm Reduction Work for Women: The Ukrainian Experience, Open Society Institute, 2010. for Women: Making Harm Reduction Work People Services for Men Who Have Sex with Men (MSM) and Transgender Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related in India, (draft), Family Planning Association of India, 2010. People: Experiences from India, (powerpoint presentation at ICAAP 2011), Family Meet The Needs Of MSM & Transgender Linking SRH And HIV To Planning Association of India, August 2011. Advocacy Brief on People Who Use Drugs, Indonesia, IPPF East and South Asia and Oceania Region, Linking Sexual and Reproductive Health and HIV: 2011. (powerpoint presentation at ICAAP 2011), UNFPA Asia Pacific Regional Office, Advancing Sexual and Reproductive Health and Rights for Sex Workers, August 2011. • 37 38 39 40 41 • • 7. Address the political, legislative and funding context of HIV/SRHR the political, legislative and 7. Address integration for key populations: • • 6. Promote HIV/SRHR integration for key populations at all levels, integration for key populations HIV/SRHR 6. Promote environment: internal and external including building an enabling • 5. Ensure a strong ‘chain’ of HIV/SRHR integrated services for key services for key integrated of HIV/SRHR ‘chain’ a strong 5. Ensure referrals: and systematic high quality through including populations, • 14 HIV/SRHR integration for key populations organisational ‘pitfalls’,suchas International (FHI)–seeAnnex4].Thelessonsalsoincludethatitisimportanttoavoid Essential StepstoStrengthenFamilyPlanningandHIVServiceIntegrationbyHealth step approach[seeFigure8,informedbyarangeofpublications,forexampleincludingTen SRHR integrationforkeypopulations.Theseincludethatitisvitaltotakeasteady,step-by- The reviewparticularlyhighlightedlessonslearnedaboutgoodpracticeininitiatingHIV/ integration forkeypopulations? 2.6. Howdoorganisations‘getstarted’withHIV/SRHR 42 • • • • • • • • • IPPF, UCSF,UNAIDS, UNFPA andWHO,2008. Informed bymultipledocuments andadaptedfromthegeneric‘helps’ and‘hindrances’identifiedin support (withlosstofollow-up). Having ‘weaklinksinthechain’,suchasunsupportivereferralservicesorlittlecommunity Lacking appropriate/adequateinfrastructure,equipmentorcommoditiesforintegration. Expecting stafftoprovidebroaderservices,butnotsupportingthemthroughtraining,etc. Failing tobackupintegratedprogrammingwithappropriatepoliciesandprocedures. Starting toobig–andriskingover-loadofstaff/servicesbuildingfalseexpectations. Lacking sustainablefundingtosupportincreasedintegrationforkeypopulations. Having HIVandSRHRcomponentsthatjust‘co-exist’ratherthanarecomplementary. Simply ‘doingmore’withoutconsideringthemosteffectivewaystodointegration. wants todo. Doing integrationbecauseit’s‘therightthingtodo’ratherthansomethingtheorganisation 42 : Linkages:EvidenceReview andRecommendations, 15 HIV/SRHR integration for key populations

– particularly among the organisation’s management and governance. management the organisation’s Internally – particularly among of key populations. the wider health community and leaders Externally – including among specific needs and population’s assessment to identify the key A participatory community barriers to services. issues such as and explore to HIV and SRHR relation in desires and SRHR in terms of for HIV there’ already to identify ‘what’s An environment mapping cost, etc. accessibility, funding, types of providers, existing data, services, infrastructure, available and accessible to community members. already What HIV or SRHR components are – to integrate with each other cheapest and/or most effective would be easiest, What areas (such as condoms for dual protection). areas with particular attention to ‘overlapping’ or vice works best (e.g. integrating SRHR into an HIV programme integration Which direction versa). provision of services or referralThe extent to which integration will involve to other facilities. funding with existing and/or renegotiating Securing resources for integrated programming donors. sites. as well as referral Providing training to all staff involved in the programme, to barriers to services identified in the needs Developing specific strategies to respond assessment, such as stigma and discrimination. For example, Preparing/re-organising space and infrastructure within health facilities. the number of confidential counselling spaces. increasing or areas reception shared creating Re-organising/managing commodities. For example, integrating supply management systems. Developing protocols and guidelines for integrated programming. related Strengthening project management to deal with additional challenges or processes to integrated programming. facilities are As necessary, building a strong referral system, including ensuring that referral technical expertise. ‘key population friendly’ and have relevant Strengthening systems for patient monitoring, including to track clients ‘journey’ within the to other organisations. including referrals integrated programme, Strengthening the monitoring and evaluation system, with indicators for integrated programming. 7. Build a ‘key population-friendly’ and ‘HIV/SRHR-friendly’ environment throughout 7. Build a ‘key population-friendly’ and ‘HIV/SRHR-friendly’ environment understands/ that: an HIV organisation integrated programming. For example, ensure or an SRHR organisation SRHR services; the changes needed to provide addresses safe and non-stigmatising services to the changes needed to provide understands/addresses key populations. 1. Mobilise the key population community to create demand for HIV/SRHR integrated population community to create demand 1. Mobilise the key services. both: for the concept of integration among all key stakeholders 2. Secure the ‘buy-in’ • • such as combining: to gather evidence and assess needs, 3. Start with steps • • guidance (such as National AIDS Programme 4. Based on the assessment and technical and of HIV and SRHR information, services guidelines), identify an essential package of the key population. commodities to meet the specific needs environment mapping, develop an organisational 5. Based on the essential package and strategy for HIV/SRHR integration. Consider issues such as: • • • • been agreed, plan and implement a series of key steps 6. When the type of integration has to ‘make integration happen’. These might include: • • • • • • • • • • Ten key steps to developing an HIV/SRHR integrated programme for integrated programme an HIV/SRHR steps to developing Ten key Figure 8: key populations 16 HIV/SRHR integration for key populations authorities. example betweenserviceproviders andcommunitymembersbetweenanNGOhealth 10. Planon-goingopportunitiesfordialoguetoenhanceknowledgeandrespect, before integratingmore complexoptions(suchasART). For example,anSRHRprogramme mightstartwith‘easyfit’options(suchasHCTandPMTCT) 9. IntegrateHIVorSRHRcomponentsovertime,buildinguptoafullerrangeofintegrated. improve themodelbeforescalingup. 8. Startwithapilotproject(perhapsfocusingonsome‘easywins’forintegration),then 17

3.1. What does HIV/SRHR integration for people living with HIV involve? The review indicated that – building on a generic essential package for HIV/SRHR – there are a number of components that may need specific attention within integrated programming for people living with HIV. These include information, support and services related to43: • Psycho-social support, including focused on sexuality and sexual health (e.g. sexual desires, safer sex) for both men and women. • FP (e.g. counselling on safe ways to become pregnant and access to a full range of contraceptive options, including long-lasting ones). • Interactions between different drugs, such as ART, hormonal contraceptives and methadone. • Pregnancy and birth, including PMTCT, ANC, delivery and PNC. • MNCH, including infant feeding and treatment. • Positive health, dignity and prevention (e.g. information on ‘positive prevention’, support for voluntary disclosure). • Empowerment on sexual and reproductive health rights. • Full range of treatment, including second/third line ARVs and for opportunistic infections. • Full range of STIs (e.g. rapid testing, treatment). • Male and female condoms (e.g. supplies, support for negotiation skills) for dual protection. • Sexual dysfunction (e.g. low libido related to ART). • (Where legal) safe and confidential abortion and (in all contexts) post-abortion care. • Sexual and intimate partner violence (e.g. support after rape or gender-based violence following disclosure of HIV status), including PEP. • Sero-discordant couples (e.g. information on safer sex, counselling on disclosure, biomedical prevention services). • HPV, cervical and anal cancer (e.g. vaccination, regular screening).

43 Referenced from case studies and literature review, in particular: Convergence of HIV and SRH Services in India: Impacts on and Implications for Key Populations: A Literature Review, HIV-SRH Convergence Project (India), PATH, January 2007; Sexual and Reproductive Health for HIV-Positive Women and Adolescent Girls: Manual for Trainers and Programme Managers, ENGENDERHEALTH and International Community of Women Living with HIV, 2006; Sexual and Reproductive Health of Women Living with HIV: A Flipbook, India HIV/AIDS Alliance; Sexual and Reproductive Health of Women Living with HIV/AIDS: Guidelines on Care, Treatment and Support for Women Living with HIV/AIDS and Their Children in Resource-Constrained Settings, WHO, 2006; Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: A Guidance Package, GNP+, ICW, Young Positives, EngenderHealth, IPPF and UNAIDS, 2009; and Case Study: Zimbabwe, Integration of Family Planning and HIV Services in Zimbabwe: Hormonal Implants and Dual Protection Messages, PSI Zimbabwe. 18 HIV/SRHR integration for key populations • seen intheliteratureanddemonstratedcasestudiesbelow,examplesinclude: on someofthemosteffectivestrategiesforHIV/SRHRintegrationpeoplelivingwithHIV.As The reviewidentifiedthat,comparedtootherkeypopulations,thereisemergingconsensus integration forpeoplelivingwithHIV? 3.2. WhataresomecommonstrategiesforHIV/SRHR 45 IssueBrief:Sexualand ReproductiveHealthandRights–KeyIssues forHV-Affected, InternationalHIVAIDAlliance inIndia. Widows , FamilyHealthInternational, 2010. StudyofFamilyPlanningand HIVIntegratedServices 44 AFive-Country • important to: section 2.5]applytopeoplelivingwithHIV.Inaddition, somespecificlessonsincludethatitis The genericlessonslearnedforHIV/SRHRintegratedprogramming forkeypopulations[see HIV/SRHR integrationforpeopleliving withHIV? 3.3. Whatlessonshavebeenlearnedaboutgoodpractice HIV programme with HIV Figure 9:ExamplesofstrategiesforHIV/SRHRintegrationpeopleliving ART) e.g. PMTCTand by otherservices, HCT (oftenfollowed Advocacy onHIV PLHIV General servicesfor support) PMTCT orcare and HCT (alsooften and support) ART (alsooftencare Republic andEthiopiafound thatwomenlivingwithHIVweremorelikelythanmen tohave: programmes. Forexample,anIPPFstudy ofstigmainBangladesh,theDominican Address thegenderdimensions ofHIV/SRHRandtheimplicationsforintegrated stigma) many womenlivingwithHIVwereactuallynotsexually active (duetoissuessuchasself- although astudybyFHIinfivecountriesfoundlittleunmet needforFP,thiswasbecause Not makepresumptionsabouttheSRHRneedsor desires ofPLHIV.Forexample, risk (suchasrelatedtoviolence andsexwork)haveunmetneedsforSRHRservices Andhra Pradeshfoundthat widows livingwithHIVaresexuallyactive,experience heightened 44 . Meanwhile, an Alliance India study in Maharashtra, Manipur, Tamil Nadu and . Meanwhile,anAllianceIndiastudyinMaharashtra,Manipur, TamilNaduand Integration ↔ ← → SRHR programme violence) or gender-based related toSTIs of SRHR(e.g.support Selected components Advocacy onSRHR SRHR) FP (alsooftenbroad SRHR) FP (alsooftenbroad and/or broad SRHR) FP (alsooftenSTIs Examples incasestudies • • • • • • • • • • • • • Uganda Alliance inUganda, HIV/AIDS International Gheskio, Haiti MAMTA, India transgender people) Section 5onMSMand SAATHII, India[see FHOK, Kenya Republic PROFAMILIA, Dominican ABEF, Rwanda PSI, Zimbabwe HCT Centres, Ethiopia HCT Centres, Kenya POZ, Haiti Ministry ofHealth,Keny TASO, Uganda 45 . 19 HIV/SRHR integration for key populations ]. This 49 People living with HIV have the freedom People living with HIV have the freedom consensual and of choice regarding pleasurable sexual expression. People living with HIV have the freedom reproduction, of choice regarding marriage and family planning. People living with HIV have the fundamental right to access sexual health information and comprehensive sexual health services. Figure 10: Amsterdam Statement on SRHR for people living with HIV • • • . 50 . 47 . 48 . A report by the International Community of Women Living with HIV found Living with Community of Women by the International . A report 46 that women who are living with HIV and pregnant faced increased gender-based violence. gender-based faced increased HIV and pregnant who are living with that women men living with HIV can also lack HIV/AIDS Alliance study found that Meanwhile, an India education on condom use and have many unmet needs, such as knowledge of FP and contraception access to emergency Pay particular attention to the HIV/SRHR needs of sero-discordant couples. For to the HIV/SRHR needs of Pay particular attention couples said that their sexual study in Nigeria found that 58% of such example, a GNP+ different HIV status. It also found negatively affected by learning of their intimacy had been received SRHR counselling from used condoms and most had not that 40% had never health facilities decided not to have sex; decided not to have children; and chosen, or been coerced into, or been coerced children; and chosen, not to have to have sex; decided decided not sterilisation Use integrated programme as a means to look at the full, Use integrated programme as a means HIV, rather than the needs holistic needs of people living with confined to their HIV status [see Figure 11]. developed for HIV to,Build on the safe and supportive services of pregnancy-related needsin particular, address the full range of women living with HIV. Such approaches involve integrating ANC,services such as FP, pregnancy counselling/testing/screening, post-abortion care.PNC and, if required, safe abortion and Piecing It Together for Women and Girls: The Gender Dimensions of HIV-Related Stigma: Evidence from Bangladesh, Dominican Republic and Ethiopia, Stigma: Evidence from Bangladesh, Dominican Republic and Dimensions of HIV-Related and Girls: The Gender for Women Piecing It Together IPPF, 2011 “Clients typically seek SRH services need or for one particular an STI, abortion (where legal) and post-abortion problem – e.g. FP, care, or some aspect of maternal health care – and health workers typically respond However, to that one particular need or problem. people living with HIV may have other needs or concerns that contribute to their primary problem, but that are never identified By not addressing those or addressed by a service provider. needs, health workers may miss key opportunities to improve clients’ overall health status. This problem of missed opportunities is particularly serious in SRH services, given the potentially life-threatening consequences of pregnancies, STIs and AIDS, and both the social stigma associated with HIV and AIDS and the discomfort that many clients and health workers feel about discussing these issues.” and Women Health for HIV-Positive Sexual and Reproductive Managers, and Programme Adolescent Girls: Manual for Trainers Engenderhealth and ICW How integration avoids ‘missed opportunities’ Figure 11: How integration avoids ‘missed to address critical needs of PLHIV • • • 46 47 Sexual and Reproductive Health of Males-at-Risk in India: Service Needs, Gaps and Barriers, International HIV AID Alliance in India, May 2008. and the Ukraine, GNP+, HRSC and University of Witwatersr, 2009. 48 HIV Discordant Couples – An Exploratory Study: Insights from South Africa, Tanzania GNP+, December 2007. 49 Amsterdam Statement on Sexual and Reproductive Health and Rights for People Living with HIV, Consultation Report, GNP+ and UNAIDS, April 2009. 50 Positive Health, Dignity and Prevention: Technical includes ensuring that positive health dignity and prevention (‘positive prevention’) programmes includes ensuring that positive health living with HIV, including to confidentiality, respect both the rights and responsibilities of people informed consent and voluntary disclosure Recognise the centrality of sexual rights for people living with HIV [see Figure 10 Recognise the centrality of sexual 20 HIV/SRHR integration for key populations with HIV 3.4. CasestudiesofHIV/SRHRintegrationforpeopleliving Integrating Family Planning and Antiretroviral Therapy Services inUganda,FamilyHealthInternational, 2010. 51 IntegratingFamilyPlanning andAntiretroviralTherapyServices 51 integration HIV/SRHR Key population type Programme Provider type Country Organisation: TheAIDSSupportOrganisation(TASO) learned Lessons • • • • • • • • • • • PLHIV (individualsandcouples) HIV Civil society Uganda (Mbale) services forcouples,etc.). in project design,developingmaterialsinlocallanguages, providing Demand hastobebuiltforservices(e.g.byinvolvingthe community and mobilizingvolunteers. organization, training alllevelsofstaff, buildingthe skillsofsupervisors inthe It iscriticaltoinvestinpeople–delineatingFPtasksfor everyone supplies ofcondomsandotherFPcommodities. toensuresystems forFPandadvocate/workwithgovernment regular To avoidstock-outs, anHIVNGOmustfamiliariseitselfwithsupply an opportunitytosupportadherence toART). HIV andFPserviceshavemutualbenefits(e.g.follow-up forFPprovides demand. Service provision complementedbycommunityadvocacytostimulate triage, counselling,information). nurses andvolunteerswere trainedtoprovide support services(e.g. developed atrainingcurriculumandtrainedtrainersinFP. Community TASO alsoupdateditsprotocols, adaptedFPmaterialsforitsclients, Health commoditysupplyprocesses. referral system;improving itsdatacollection;andusing Ministryof start-up phase,TASO thenstrengthened itsworkby:formalizingthe partnerships withreferral sites;andmonitoringperformance.Aftera Critical stepstoimplementintegrationincluded:staff training;building existing HIVprovider. training; andclientswouldprefer toreceive FPservices from their refer totheregional hospitalforsupplementaryservices; staff needed These stepsshowedthat:TASO hadgoodinfrastructure andcould • • Start-up forintegrationinvolved: among PLHIV. Previously onlyprovided condoms,butsawmassiveunmetneedforFP raising onFP(e.g.radioshows). and permanentFPmethods.Complementedbycommunityawareness- emergency contraceptives).Referralstoregional hospitalforlong-acting FP services(includingcondomsfordualprotection andoral/injectable/ Centre providing comprehensive HIVservices(includingART) integrating practices andneeds–tounderstandthecontextbuildownership. Doing aparticipatoryneedsassessmentofclients’FPknowledge, capacity (human,physical,financial,technical)foraddingservices. Using aframework(developedbyACQUIRE)toassessorganization’s Intervention type Donor HIV epidemic 51 (supportedbyFHI) community outreach Facility-based; USAID Generalised 21 HIV/SRHR integration for key populations 52 Generalised Government of the Netherlands Facility-based; mobile HIV epidemic Donor Intervention type ‘New Start’ network of 19 static and 23 mobile HCT units integrating ‘New Start’ network of 19 static and 35,000 over FP (for people testing positive or negative) and reaching (with follow-up to providers clients per month. Referrals to FP service success). ensure (12 managed by local NGOs) and ‘New Life’ network of 15 centres psycho- ANC sites) providing mobile units (including at hospitals and In October 2008 – January FP. social support to PLHIV and integrating living with HIV and couples. 104,000 women 2010 , reached communication – in one-to-one or couple sessions Inter-personal information materials, counselling and and including tailor-made demonstrations of male and female condoms. including for dual protection, creation and demand Awareness and campaigns. radio and TV programmes through including implants, Marketing and distribution of contraceptives, contraceptive pills. injectables and emergency Inter-personal communication is vital for enabling individual PLHIV Inter-personal and make and couples to understand the benefits of dual protection informed decisions about the best contraceptive methods for them. an important option for women, including Hormonal implants provide contraception longer-term those living with HIV – as they both provide as transport). costs for accessing services (such and avoid recurrent a need to be mindful of interactions between is also, however, There some hormonal contraceptives and ART. Programme focused on dual protection (from unintended pregnancy unintended pregnancy (from focused on dual protection Programme couples and young discordant sero PLHIV, and HIV) and targeting women (aged 15-29 years). combines: Programme • • emphasises: Programme • • • out in 5 ‘New Start’ pilot carried avoid loss of clients within referrals, To hormonal contraceptive to provide to train nurse counsellors centres implants on-site. In collaboration with Ministry of Health, PSI built capacity of public health workers. In the first 7 months, 16,502 implants and demand increased. provided were integration included training 250 ‘New Start’ and 100 Key steps towards counselling and referrals. ‘New Life’ counsellors in FP service delivery, • • Civil society HIV couples discordant women) and sero PLHIV (particularly • • • • • Zimbabwe Lessons learned Key population HIV/SRHR integration Population Services International (PSI)/Zimbabwe Services International Population Organisation: Country type Provider Programme type 52 Case Study: Zimbabwe, Integration of Family Planning and HIV Services in Zimbabwe: Hormonal Implants and Dual Protection Messages, PSI Zimbabwe. 52 22 HIV/SRHR integration for key populations 53 53 GatewaystoIntegration: ACaseStudyfromHaiti,WHO,UNFPA,UNAIDS andIPPF,2008. 53 type Programme integration HIV/SRHR Key population Provider type Country Opportunistes (GHESKIO) Organisation: GroupeHaïtiend’ÉtudeduSarcomedeKaposietdesInfections • • • • • • • • • • • • PLHIV (includingsero-discordant couples) HIV Civil society de Dieu) neighbourhoods ofCite Haiti (two 24% inthecatchmentpopulation. Results includethatcontraceptiveprevalence increased from 6%to adapted to22publicandprivatehealthcentres. Model hasbeenscaledupandinfluencednational practice–being providing confidentialcounseling rooms. Clinics were re-arranged toprovide integratedservices,including HCT). Provision ofsupportforsurvivors ofsexualviolence(includingfast-track discrimination, includingusingmethodssuchasrole plays. is provided, notonlyinHIVandSRHR,butissuessuchasstigma understanding ofeachother’s work).Training andon-goingeducation in anyoftheclinics(sotheycanstandforeachotherandhave Took amulti-skilledapproach –withallmedicalstaff trainedtowork significant increase inuptake. partners andchildren ifneeded).PMTCTprogramme hasexperienceda formula. ART isprovided towomenattendingMCH (aswellastotheir PMTCT includesprovision ofART, educationsessionsandinfant and enablingpeopletomaketheirowndecisions. HIV transmissiontopartners.Emphasisisplacedonexploringfeelings condoms aloneorwithothercontraceptives);PMTCT; andprevention of and options(includingfordiscordant couples);dualprotection (using Counselling forPLHIVincludes:informationaboutreproductive rights well asTBandmalaria. provides anentrypointtoafullrangeofservicesforHIVandSRHR,as 90% ofclientsinitiallyvisitforHCTand16%are PLHIV. NowHCT free ofcharge. Emphasis isplacedonmaleandfemalecondoms–whichare provided such asPMTCT. Started withapilotintegratingFPintoHCT, thenaddedcomponents in otherfacilitiesandexperiencedunwantedpregnancies. Rationale forintegrationwasthatmanyPLHIVwere deniedSRHRcare services related toFP, STIs,MCHandgender-based violence). promotion/provision forHIVprevention) andintegratingSRH(including Clinics providing HIVservices(includingHCT, ART, PMTCTandcondom 53 Intervention type Donor HIV epidemic Facility-based Generalised 23 HIV/SRHR integration for key populations Generalised USAID Facility-based (supported by FHI) 54 HIV epidemic Donor Intervention location Holding sensitization meetings with health officers and supervisors. in FP. Centres Care of Comprehensive staff Training FP aids (e.g. an FHI tool on FP for PLHIV) to support women/ Proving couples. Ministry of Health and FHI carrying out supportive supervision visits. developing its own plan for Centre Care Each Comprehensive integration. Men are influential in their partners’ decisions about contraception. But Men are support and FP to male clients of HIV care, opportunities to promote often missed. are treatment Comprehensive Care Centres providing HIV care, support and treatment support and treatment HIV care, providing Centres Care Comprehensive and integrating FP (including condoms for dual protection). integration included: Steps towards • • • • • in the use of modernResults included a significant increase contraceptives by PLHIV. Partnerships – with government, donors and research institutions – are institutions – are – with government,Partnerships and research donors integrated approaches. critical to fully integrated and essential to providing are Multi-skilled staff support and services. comprehensive such but issues to HIV, – not just in relation Stigma and discrimination barrier to a significant violence – remain as sexual and gender-based integrated services. other services at the if people can access Uptake of HCT increases good opportunities to and post-test counseling provide same time. Pre SRH. counsel people on be may if they are HIV-positive, stated that: “Women, A Gheskio report deterred discrimination from seeking sexual by their status and fear of and If there is advocacy for, and reproductive health services directly. and other sexual and reproductiveautomatic access to, family planning health services HIV prevention, on the same site as VCT and other treatment and care services, many of the practical and psychological barriers to access are removed.” • HIV PLHIV • • • Kenya (Coast and Rift Provinces) Valley Government • • • • • Lessons learned Key population HIV/SRHR integration Type of Type provider Main programme type Ministry of Health, Goverment of Kenya Organisation: Ministry of Health, Goverment of Country Lessons Lessons learned Integrating Family Planning into HIV Care and Treatment Services in Kenya, Family Health International, 2010. 54 Integrating Family Planning into HIV Care and Treatment 54 24 HIV/SRHR integration for key populations 55 55 IPPF) integration HIV/SRHR Key population type Programme Provider type Country Organisation: AssociationpourleBien-EtreFamilial(ABEF) learned Lessons Planned ParenthoodFederation, 2005. Models ofCareProject: LinkingHIV/AIDSTreatment, CareandSupportinSexual andReproductiveHealthCareSettings:Examples inAction, Butare) Rwanda (Kigaliand • • • • • • • • • • PLHIV SRHR Civil society development ofPLHIVsupportgroups. Integrated programming hasbeenbeneficialtothecreation and and efficientfollowupbetweenorganisations. Referrals systemsneedclearprocesses toensure consistent feedback new areas. As wellastraining,staff needhands-onopportunitiestobuildskillsin a majorbarriertointegratedprogrammes. Involving PLHIVandthewidercommunityiscriticaltoreducing stigma– reduced numberofhospitaladmissions. Results includesignificantincrease inuptakeofservicesbyPLHIVand • • • • Started integrationwithasiteassessment.Asresult, stepsincluded: home basedcare. generating activities(e.g.related tonutritionandshelter),combinedwith In partnershipwithcommunitygroups, PLHIVsupportedwithincome HIV andotherneedsofPLHIV. Developed aholistic‘patienttrackingsystem’–addressing theSRHR, opportunistic infections,etc.). follow-up tosupportclinicstaff (ART adherence, treatment of Work inpartnershipwithPLHIVgroups. PLHIVvolunteersdocommunity adherence andmonitoring. hospital forCD4testsandART, withARBEFthenproviding follow-upfor and support.IfclientstestHIVpositive,theyare referred togovernment SRHR clinics(providing FP, etc.)integratingHCTandHIV-related care Recruiting more medicalandlaboratorystaff. Buying laboratoryequipment. Adding counsellingrooms. Improving clinicreception areas. Intervention type Donor HIV epidemic 55 (supportedby community outreach Facility-based; Generalised International 25 HIV/SRHR integration for key populations

56 , Interntional GTZ Facility-based; community outreach HIV epidemic Donor Intervention type It is important to promote HIV services as part of a ‘package’ of support It is important to promote but confidentiality, HIV services require and not become an ‘HIV centre’. their PLHIV like everyone else both reduces not separate clinics. Treating isolation and minimizes disruption to the organization. Reducing stigma and discrimination has many benefits. For example, to access HIV services. relatives now bring their own staff PROFAMILIA then scale-up. The model, develop it and to choose a proven It is effective model needs to be supported by the development of institutional protocols. is critical to integrated The ‘buy in’ of the executive of organisations programming. gender dimensions, such as the Integrated services must address partners if they from implications of HCT for women (e.g. violent reactions found to be HIV positive). are risks involved (such as PLHIV are there is a practical strategy, While referral putting As such, before clients being stigmatized by other health providers). into action, it is critical to mobilise key decision-makers in the referrals wider health sector. SRHR clinics (providing FP, etc.) integrating HIV services (focused on HCT, (focused on HCT, etc.) integrating HIV services FP, SRHR clinics (providing support). and and care ART to ART, adherence clinical care, – providing Team Developed a Model Care family/partner education, etc. emotional support, safer sex counselling, in one clinic (Santo Domingo), aiming to Started with a pilot project Then adapted model to a for PLHIV. and treatment access to care increase second clinic. seven key elements: training of health involves Integrated programme counselling; post-test counselling; pre-test workers; laboratory tests; care support team; and monitoring ART multi-disciplinary support groups; adherence. stable on ART, support. Once clients are adherence ART Clinics provide and 3-monthly session with a they have a monthly session with a nurse doctor. like all other clients. As a PLHIV at Santiago clinic treated PLHIV clients are sit in the same room. We said: “I feel like any other person in the waiting seats and share the same room as everyone else, and thus, I do not feel room that I am HIV positive”. pinpointed. No one knows in the waiting due to (largely to ART levels of adherence Results include impressive establishment of monthly PLHIV support groups counselling) and treatment issues such as self-esteem, nutrition, legal issues and gender- (addressing based violence). • • • • • • Civil society SRHR PLHIV • • • • • • • Dominican Republic Dominican Republic (Santo Domingo and Santiago) Planned Parenthood Federation, 2005. Models of Care Project: Linking HIV/AIDS Treatment, Care and Support in Sexual and Reproductive Health Care Settings: Examples in Action Models of Care Project: Linking HIV/AIDS Treatment, Lessons learned Provider type Provider Programme Programme type Key population HIV/SRHR integration Asociación Dominicana Pro-Bienestar de la Familia (PROFAMILIA) Pro-Bienestar de Dominicana Asociación Organisation: Country (supported by IPPF) (supported 56 56 26 HIV/SRHR integration for key populations 57 Community-BasedCare andSupportProgramme:2000-2010,MAMTAHealthInstitute forMotherandChild,2011. 57 integration HIV/SRHR Key population type programme Main provider Type of Country Organisation learned Lessons MAMTA HealthInstituteforMotherandChild India (districtsofDelhi) • • • • • • • • • PLHIV (includingchildren) Child health Civil society development was a great learning forthe organisation.” learning development wasagreat ofchildhealthand and variousotheraspects.Thiscomprehension ART immunisation, nutrition and followup.Itisaboutbreastfeeding, Executive Director ofMAMTA says:“Childhealthisjustnotabout HIV whoare pregnant. between HIVandMCHservicestoensure supportforwomenlivingwith (According toaprogramme evaluation),greater linksare needed key stakeholders,isvitalforintegratedprogrammes. Continuous communityinvolvement,combinedwithcapacitybuildingof organisations. Alsosupportedbyadvocacyonareas suchasPMTCT. Service provision complementedbynetworkingandlinkageswithother Assessments in9sites3districts. key populations.ThiswasfollowedbyParticipatoryCommunity planning amongpartners,includingNGOsfocusedonchildren and Programme startedwithRapidSituationAnalysis,followedbystrategic care. and PLHIV–coveringissuessuchasSTIs,safersexhomebased Capacity buildingprovided topeereducators,healthserviceproviders communities toaddress stigmaanddiscrimination. Emphasis on:peereducation;involvementofPLHIV; andempowering key populations(suchasSaharaworkingwithPUD). Development; ANCHALCharitableTrust; andSahara.Somefocuson Baalak Trust; AshaDeepFoundation;BhartiyaAssociationforRural Programme implementedby6NGOs:ChildSurvivalIndia;Salaam hospitalsforHCT andcare,government supportandtreatment. services (suchasearlydiagnosisandtreatment ofSTIs).Referralsto materials, condompromotion andsafersexpromotion) andSRHR services (suchasbehaviorchangecommunication,information (particularly women)livingwithandaffected byHIV. IntegratingHIV Health anddevelopmentprogramme supportingchildren andadults location Intervention Donor HIV epidemic community outreach Facility-based; Abbott FundUSA Concentrated 57 27 HIV/SRHR integration for key populations , Interntional Generalised GTZ Facility-based; community outreach (supported by IPPF) (supported 58 HIV epidemic Donor Intervention type Building FPAK’s capacity. Building FPAK’s Delivering integrated services. and involving PLHIV. demand for services Creating and monitoring and evaluation. Carrying out research Key staff need to be open to adapting both their services and working practices. Key staff services must go of treatment the provision Within an integrated approach, etc. to also include psycho-social support, FP, beyond ART services brings benefits to SRHR services (particularly in a HIV-related Providing new service users. generalised epidemic) by reaching involvement of people living with HIV) principles into (greater Putting the GIPA having PLHIV as volunteers to on the Management and Advisory practice, from among PLHIV and to an SRHR organization of FHOK, adds credibility Boards HIV NGOs. the SRHR needs of It is necessary to take specific steps to engage and address men, including those living with HIV. laboratory tests, drugs, is costly (with ART The ‘package’ involved in providing to have sustainable resources. SRHR organisations etc.) and requires SRHR clinics (providing FP, etc.) integrating HIV services (such as HCT, (such as HCT, etc.) integrating HIV services FP, SRHR clinics (providing and PLHIV support groups). and support, HIV prevention care ART, PMTCT, home based care, community volunteers providing Complemented by Referral of complicated cases to the provincial counselling and HIV prevention. hospital. key components: Integration involved attention to four • • • • carrying out a site preparedness through: Started the integration process team of staff. assessment; and training a core used existing HCT and PMTCT HIV services added over time. For example, necessary Adaptions were to then integrate ART. as an entry point programmes integrated more site. These included: providing ART to become an accredited sophisticated client doing more counselling and psycho-social support; and buying buying/managing ARVs; monitoring; establishing systems for equipment (fridges and computers). for STIs and is subsidized by the government. but Treatment is not free, ART with minimal medical care, into regular opportunistic infections is integrated a barrier. but could still present reduced, fees. Laboratory fees were trained team who were service delivery support integration, developed a core To training to and then designed/delivered in intensive HIV clinical management said: “HIV affects almost every As a member of clinic staff area of other staff. avoid dealing with it.” sexual and reproductive health work, so you can’t providing central to the programme, Community volunteers (including PLHIV) are strategies prevention and discussing to ART psycho-social support, adherence contraceptives, condoms and medicines They also: deliver ARVs, with PLHIV. them to the clinic). (referring people for ART and ‘recrui’t for home-based care; men living with HIV. Some SRHR initiatives have specifically targeted • • • • • • Civil society SRHR (clients of SWs) PLHIV and truckers • • • • • • • • Kenya Family Health Options Kenya (FHOK) Options Kenya Family Health Models of Care Project: Linking HIV/AIDS Treatment, Care and Support in Sexual and Reproductive Health Care Settings: Examples in Action Models of Care Project: Linking HIV/AIDS Treatment, Planned Parenthood Federation, 2005. Lessons learned Key population HIV/SRHR integration Organisation Country type Provider Programme type 58 58 28 HIV/SRHR integration for key populations 60 59 59

60 type programme Main type Programme Provider type Country Organisation: HIVCounsellingandTestingCentres learned Lessons integration HIV/SRHR Key population provider Type of Country Organisation: Promoteursd’ObjectifZerosida(POZ) learned Lessons integration HIV/SRHR Key population HIV/AIDS Alliance) Integrating Family Planning Services intoVoluntaryIntegrating FamilyPlanning Services CounselingandTesting CentersinKenya:OperationsResearch Results,FamilyHealthInternational, 2006. HIV/AIDS Alliance(accessed 13.4.11);http://www.aidsalliance.org/linkingorganisationdetails.aspx?id=31 Good PracticeGuide:Integration ofHIVandSexualReproductive HealthandRights • • HIV Kenya • • • • PLHIV HIV Civil Society Haiti • • Training giventoserviceproviders onintegration. • • • • integration: HCT Centres integratingFP. EachCentre offers oneoffourlevels address stigmaanddiscrimination. programming –providing anopportunitytobuildself-esteem and Support groups (facilitatedbyPLHIV)are animportant forintegrated those livingwithHIV, tosexwork. turning changes, suchastheincreased numberofyoungwomen,including Note: Project hascontinuedsinceearthquakeinHaitiandadaptedto friends. Programme addresses theHIV/SRHRneedsofPLHIV, theirfamiliesand providing economicsupportandreferrals forservicesnotprovided. SRHR (e.g.supportrelated tosexualviolenceandSTItreatment). Also PLHIV supportgroups, nutritionalsupport)integratingcomponentsof Centre Espoir(HIVorganization providing servicessuchasHCT, of integratedprogrammes. Record keepingandcommodity supplyare criticalforeffective scale-up STIs andevenlesssopregnancy. predominantly spoketoclients aboutcondomspreventing HIV, lessso integrated programming. For exampleresearch foundthatproviders There isaneedtomonitor theperformanceofstaff indelivering Provision offullrangeFP methods. As in‘2’,plusintrauterinecontraceptivedevices. As in‘1’,plusinjectablecontraceptives. information onFP, STIsandHIV; andprovision ofpillsandcondoms. Risk assessmentofpregnancy, STIsandHIV; counsellingand Donor Intervention type HIV epidemic location Intervention Donor HIV epidemic , InternationalHIV/AIDS Alliance,2010;andwebsiteofInternational 60 59 (supportedbyFHI) (supportedbyInternational Facility-based Generalised Facility-based Generalised 29 HIV/SRHR integration for key populations Generalised Facility-based Generalised Community-based , International HIV/AIDS Alliance, December 2010; and Good HIV epidemic Donor Intervention location HIV epidemic Donor Intervention location Sensitization of all administrative and health service staff. Sensitization of all administrative and health service staff. of condoms and Then, HCT counsellors trained on FP and the provision contraceptives. Nurse counsellors also trained in injectable contraceptives. To support integration, it is important to maintain partnership with district support integration, it is important to maintain partnership To district health team meetings and health mechanisms (e.g. by attending sharing reports). starting in some districts and then scaling from benefit Integrated approaches number. up to a larger Community-based HIV outreach integrating SRHR through referral. Project Project referral. through integrating SRHR HIV outreach Community-based access to/use of services. networks to improve of PLHIV aimed to expand role community- training of PLHIV to offer integration combined: Steps towards material and counselling, HIV prevention adherence ART based palliative care, PLHIV to be Network Support Agents support for OVC; and training of some them to services such as and refer to mobilize PLHIV to use existing services and STI diagnosis and treatment. PMTCT FP, to health access to health services, referrals Results included increased service delivery. facilities and involvement of PLHIV in It is important to train all staff in what integration is and why it matters, not just It is important to train all staff clinical services. those that provide Eight HCT centres integrating FP services. Eight HCT centres Start-up for integration included: • • for specific HCT clients, including those testing HIV Developed protocols relating to FP. positive, and modified counsellors’ logbooks to include information in the discussion of SRHR issues (such as Results included dramatic increase contraception, fertility options and condoms) in HCT sessions. 61 • • Civil society HIV PLHIV • • • Uganda • Ethiopia (4 focus regions) Civil society and government HIV PLHIV • • • • Practice Update: Linkages and Integration of Sexual and Reproductive Health, Rights and HIV: The Alliance Approach, International HIV/AIDS Alliance, Practice Update: Linkages and Integration of Sexual and Reproductive Health, Rights and HIV: March 2009. Integration of HIV and Sexual and Reproductive Health and Rights: Good Practice Guide Lessons learned Main type of programme Key population HIV/SRHR integration Type of Type provider HIV Counselling and Treatment Centres (supported by Pathfinder Organisation: HIV Counselling and Treatment International) Country Lessons learned Main type of programme Key population HIV/SRHR integration International HIV/AIDS Alliance in Uganda (supported by International (supported by in Uganda HIV/AIDS Alliance International Organisation: Alliance) HIV/AIDS Country of Type provider 61 61 30 HIV/SRHR integration for key populations 62 62 by IPPF) programme Main typeof learned Lessons integration HIV/SRHR Key population provider Type of Country Organisation: ReproductiveHealthAssociationofCambodia(RHAC) Reproductive Healthin People’s Lives,IPPF,2008;andInaLife:LinkingHIV SexualandReproductiveHealthinPeople’s Lives,IPPF,July2010. In aLife:LinkingHIVTreatment, CareandSupportinSexualReproductive HealthCareSettings Cambodia (Kurn Potproh)Cambodia (Kurn • • • • PLHIV (includingsero-discordant couples) SRHR Civil society on-going supportforHIV/SRHR. It isvitaltoback-upclinicalserviceswithcommunityoutreach toensure my wife.” thetransmissionofHIVto andtoprevent pregnancy condom: toprevent whyIalwaysusea tworeasons are held.There monthly meetingsare where offer condomsandwecanalsogetthemfromthehealthcentre taught howtouseacondomproperly. team Thehome-basedcare I alwaysusecondomwhenhavesexwithher. MywifeandIwere As aclientlivingwithHIVsaid:“‘IamHIV-positive, butmywife isn’t. Programme provides tailor-made supportforsero-discordant couples. Provision ofloansforincomegeneratingactivities. supplements. home care kits(withbasicmedicinesandcondoms)food programme, withvolunteersreferring clientstoclinicsandproviding complicated opportunisticinfections).Complementedbycommunity other providers forservicesnotavailable(e.g.referral tohospitalfor opportunistic infections,condomsfordualprotection). Referralto SRHR clinicsintegratingHIVservices(e.g.ART, treatment for Intervention location Donor HIV epidemic , IPPF,2006;InaLife:LinkingHIVand Sexualand community outreach Facility-based; Concentrated 62 (supported 31 © Eugenie Dolberg for the Alliance 4. HIV/SRHR integration for sex workers

4.1. What does HIV/SRHR integration for sex workers involve? The review indicated that – building on a generic essential package for HIV/SRHR – there are a number of components that may need specific attention within integrated programming for sex workers. These vary according issues such as whether sex workers are male, female or transgender. They can include information, support and services related to63: • ‘Tailor made’ HIV prevention and behaviour change communication. • Male and female condoms and lubricant (e.g. negotiation skills, regular supplies for dual protection). • Safer sex negotiation skills, counselling and risk-reduction (including for anal sex). • Full range of FP support and contraceptive options (to, for example, prevent pregnancy from clients and plan a family with a partner). • Sexual violence (e.g. prevention strategies, counselling). • Emergency PEP for rape or sexual assault. • Full range of STIs, including attention to anal infections and re-occurring infections. • Pregnancy and birth, including supportive and non-judgemental ANC, PMTCT, delivery, PNC and MNCH. • Empowerment on sexual and health rights. • Negotiation skills to deal with stigma and criminalised status (e.g. sexual harassment by police). • (Where legal) safe and confidential abortion and (in all contexts) post-abortion care.

63 Referenced from case studies and literature review, in particular: Advancing the Sexual and Reproductive Health and Human Rights of Sex Workers Living with HIV: Policy Briefing, GNP+ and NSWP, May 2010; Convergence of HIV and SRH Services in India: Impacts on and Implications for Key Populations: A Literature Review, HIV-SRH Convergence Project (India), PATH, January 2007; Exploring Integrated SRH and HIV Models and Programming Examples from a Variety of Settings in Countries/Areas with Concentrated HIV Epidemics, Amitrajit Saha, Anna Zakowicz, Dawn Averitt Bridge, Jill Gay, Robert Carr, (Presentation at International AIDS Conference), July 2010; Sex Work, Violence and HIV, International HIV/AIDS Alliance, 2008; and Integrating HIV Prevention and Family Planning Services: The Aastha Project in Mumbai, India, Family Health International, 2010. 32 HIV/SRHR integration for key populations literature anddemonstratedinthecasestudiesbelow,examplesinclude: effective HIV/SRHRintegrationstrategiesspecificallyforsexworkers.However,asseeninthe The reviewindicatedthat,asyet,thereappearstobelittleclearconsensusonthemost 4.2. 65 64 • to: section 2.5]applytosexworkers.Inaddition,somespecificlessonsincludethatitisimportant The genericlessonslearnedforHIV/SRHRintegratedprogrammingkeypopulations[see HIV/SRHR integrationforsexworkers? 4.3. Whatlessonshavebeenlearnedaboutgoodpractice HIV programme Figure 12:ExamplesofstrategiesforHIV/SRHRintegrationsexworkers (especially HCT) components or selectedHIV Comprehensive wider HIV) HIV prevention (plus for SWs specific, keyservices HCT orother HIV prevention HIV) HCT (andbroader Good PracticeGuide:Integration ofHIVandSexualReproductive HealthandRights Alliance inAndhraPradesh, SWASTIHealthResourceCentre,December 2008. Sexual andReproductive HealthNeedsofFSWs,MSMsandTGs:Research ReportonQuantitativeFindingsfrom Warangal,GuntakalandPilerSitesof and 6%inbrothels–affectingboththeirneedsaccess toservices found that35%werestreet-based,27%home-based, 26%basedinsecret,7%lodges of sexworkers.Forexample,astudyamongworkersinGutakal,Andhra Pradesh Identify, understandandrespondtothedifferentSRHR/HIV needsofdifferenttypes male ortransgender experience differentlevelsofvulnerabilityandneedsaccording towhethertheyarefemale, integration forsexworkers? What aresomecommonstrategiesforHIV/SRHR 65 Integration , aswellotherfactorssuchtheirageandincome level. ← ← SRHR programme wider SRHR) STI prevention (plus condoms) (especially STIsand Broad SRHR dual protection Female condomsfor and condoms) SRHR, especiallySTIs FP (andbroader condoms) (especially STIsand components or selectedSRHR Comprehensive , InternationalHIV/AIDS Alliance,2010. Examples incasestudies • • • • • • • • • • • • Avahan programme, India CEMOPLAF, Ecuador FPAM, Malawi EC-CAP, Caribbean KANCO, Kenya Aastha Project, India TOP, Myanmar Concern/HMAP, Pakistan Community Support ISH, Serbia YPSA, Bangladesh CSI, India PATH India,India 64 . Also,sexworkers 33 HIV/SRHR integration for key populations , Bihar, . In 68 . Meanwhile, 66 Figure 13: SRHR needs of sex workers living with HIV “Sex workers living with HIV who become “Sex workers living with HIV who become pregnant be given a full range need to of options and not coerced to have terminations. sex workers report Many that it is assumed that any pregnancy they have must be unwanted. Pressure on HIV-positive sex workers to have terminations is reported most in most countries. Due to this focus, pregnant women do not get HIV-positive the full range of options explained to them and, if they decide to continue with the often receive sub-optimal care.” pregnancy, Advancing the Sexual and Reproductive Health and Human Rights of Sex Workers Policy Briefing, GNP+ Living with HIV: and NSWP . 67 , IPPF, 2006. . 70 . Meanwhile, a study in Guntakal, Andhra . 71 . 69 72 Pradesh, found that some sex workers were forced to have abortions by their caretakers/family members, with the procedure sometimes taking place in their own homes Not make assumptions about sexual ‘norms’ and Not make assumptions about sexual needs of sex workers. For example, within integrated diagnosis and programmes, sex workers may need during treatment services for anal STIs or support pregnancy. for sex Address the wider socio-political context workers. For example, in Nepal, the Family Planning Mahila Samanwaya Association partnered with the Durbar in Sonagachi Committee (a sex workers’ cooperative SRHR/HIV district, Kolkata, India) to design integrated services for young girls and women being trafficked for sex work that address the holistic needs the holistic needs that address services integrated Provide comprehensive infection to clients. ‘transmitters’ of treating them as , rather than of sex workers a workers wanted found that sex in four states in India a PATH study For example, and delivery services, including FP, abortion, ANC full range of SRHR Pay specific attention to the SRHR needs of sex workers who are living with HIV, to the SRHR needs of sex Pay specific attention PMTCT, MNCH services access to a non-discriminatory contraception, including providing Figure 13]. and abortion [see partners in issue of violence. For example, Alliance Address the cross-cutting work is common and affects have found that violence against sex different countries account in the development of programmes their vulnerability, yet is rarely taken into a study in Cambodia found that under 5% of sex workers used a modern found that under 5% of sex workers a study in Cambodia partner (other than condoms) with their contraceptive method response to such challenges, the Avahan Programme, India, combined advocacy to the response to such challenges, the Avahan to protect themselves/hold perpetrators to police with capacity building of sex workers account Advocate on the benefits of integration to gatekeepers within sex workers’ Advocate on the benefits of integration and HMAP in Pakistan found communities. For example, Community Support Concern the development of that it was critical to engage pimps in integrated programming Sexual and Reproductive Health Needs of FSWs, MSMs and TGs: Research Report on Quantitative Findings from Warangal, Guntakal and Piler Sites of Sexual and Reproductive Health Needs of FSWs, MSMs and TGs: Research Report on Quantitative Findings from Warangal, Alliance in Andhra Pradesh, SWASTI Health Resource Centre, December 2008. Options and Challenges for Converging HIV and Sexual and Reproductive Health Services in India: Findings from an Assessment in Andhra Pradesh Maharashtra, and Uttar Pradesh, PATH, June 2007. A Guidance Package, GNP+, ICW, Young Positives, Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: EngenderHealth, IPPF and UNAIDS, 2009. and HIV, International HIV/AIDS Alliance, 2008. Violence Sex Work, in India: Responses among Female Sex Workers Learning from the Results of Monitoring and Evaluating Community-Led Violence and Sex Work: Violence Think Piece, India HIV/AIDS Alliance. Affect Adolescents’ Needs for and Access to SRHR, Interact Worldwide, 2011. Failing? How Marginalisation and Vulnerability Who Are We Care and Support in Sexual and Reproductive Health Care Settings In a Life: Linking HIV Treatment, • • • • • 72 66 67 68 69 70 71 • 34 HIV/SRHR integration for key populations 4.4. CasestudiesofHIV/SRHRintegrationforsexworkers 73 integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: Avahan,India Treatment forKeyPopulation,(posterpresentation), India HIV/AIDSAlliance,AvahanInitiativeand Mythri. Services amongFemaleSexWorkersSTI/HIV Services , (posterpresentation), India HIV/AIDSAlliance,AvahanInitiativeand Mythri;and Questionnaire –Scaling upSRHR/HIVIntegration:Avahan Programme,IndiaHIV/AIDSAlliance; IntegrationofSRHCommunication andFamilyPlanningwith Integration ofHIVandSexual andReproductiveHealthRights:Good PracticeGuide • • • • • • drugs SWs (andtheirclients),MSM,transgenderpeople,PLHIV, peoplewhouse HIV/STI prevention Civil society;government Andhra Pradesh) Telengana Districts, India (Rayaleemaand access toSRHRservicesfor SWslivingwithHIV. to keypopulationissuesamong doctors(asaresult of training);and by SWs;capacityofoutreach staff tocommunicateonSRHR;sensitivity unwanted pregnancy; uptake acceptabilityofSTIservicesand, inturn, Results includeincreases in:uptakeofdualprotection againstSTIsand • • • • Key integrationstrategieshaveincluded: services, HCT(byreferral) andSTItesting/treatment onsite. in accordance withNACOguidelines).Supportwillinvolveone-to-one outreach workersfrom outsideofcommunity(focusing onmonitoringrole, Outreach wasbySWsandotherkeypopulationpeers.InPhase2,is Facility servicescomplementedbyoutreach work,includingat‘hotspots’. specifically focusesonSTItreatment, with referrals tootherservices. andcommunity Phase 2(2009-13)involvestransitiontogovernment needs ofclients,suchassexworkers. providing treatment. Expanded,includinginresponse tounmetSRHR HIV, through behaviourchangecommunication,promoting safersexand Programme startedin2004.Originallyaimedtoreduce STIs,including and othersupport(suchasPLHIVnetworks). screening andurinepregnancy testing.Referralsfor HCT, ART, PMTCT and MCH).Ownlaboratoriesat16siteswithfacilitiessuchassyphilis delivery, FP, menstrualhygiene,cervicalcancerscreening, safeabortion and widerSRHRcomponents(suchaspregnancy testing/care/safe condom promotion/ provision andSTIprevention/screening/testing) components (suchasbehaviourchangecommunication,male/female HIV/STI prevention programme withMythriclinicscombiningHIV/STI Having anemphasisondualprotection andwomen-centricFPmethods. management. presumptive treatment, monthlycheck-ups,counsellingandpartner SWs andotherkeypopulations.STIservicesincludemanagement, At theMythriclinics,providing arangeofappropriate servicesfor clinics. to-one support,group sessions andmobilisationtoaccesstheMythri Building acommunity-drivenapproach [seeabove],combiningone- issues suchasANC,PNC,FP, PAP smearsandmenstrualhygiene. Training outreach workers,medicalofficersandcounsellors,covering 73 location Intervention Donor HIV epidemic , InternationalHIV/AIDS Alliance,December2010;andMapping community outreach Facility-based; ofIndia Government Foundation, then Bill &MelindaGates Concentrated Focused STIPrevention and 73 35 HIV/SRHR integration for key populations It may be better to mainstream services into government initiatives from into government services from initiatives better to mainstream It may be service points and set up specific rather than a programme, the start of among community members. raise expectations support on- a baseline situation analysis to It is important to conduct of an integrated programme. going assessment good are is critical to ensuring programmes Community ownership originally had friendly’. The programme quality and ‘key population each from representatives committees involving quarterly service review regular exit issues (including identified through clinic site and raising coordinator. with the project interviews with clients) issues such as health’ (and using services as ‘women’s Promoting a means to discuss the as an entry point) provides menstrual hygiene sensitive subject of STIs. Simple systems can help Referral systems need to include follow-up. point and then collected to to the referral taken (such as slips that are to enforce. assess success), but can be difficult some governmentChallenges include limited access to services for living with HIV needing support some populations, such as for women for delivery or abortion. • • • • • • Lessons Lessons learned 36 HIV/SRHR integration for key populations 74 74 Key population integration HIV/SRHR programme Main typeof provider Type of Country Organisation: ChildSurvivalIndia(CSI) learned Lessons Alliance) Linking SRHRandHIV – ACommunity-CentredApproachtoAchieving UniversalAccess Delhi) Phase 1,NorthWest India (HolumiKalan • • • • • • SWs andPLHIV SRHR andHIV Civil society • • and accesstocommodities. sense ofsupport(amongPLHIV)andbettercoordination ofservices Results included:increased uptakeofPMTCT, condomuseand outlets forcommodities. sanitary pads(toprovide asource ofincome)and community-based fostering economicenterprise,suchastheproduction oflowcost Strengthened communitysystemsbytrainingpeereducatorsand • • • • • Steps forintegratedprogramming included: commodities beingunaffordable. women’s access toservicesbeingcontrolled bytheirfamilies;and Programme aimedtoaddress socialandhealthissues, suchas: the numberofreferrals toPMTCTandHCTservices. Group sessionsorganized ANCclinics–increasing atgovernment dispensary). mechanism toproviders suchasANCclinicsandgovernment to provide a‘onestopshop’orformal,timelyreferrals (withreferral menstrual hygiene,genderdynamicsandviolationsofrights.Aim a comprehensive understandingofSRHR,includingMCH,STIs, Integrated programme amongrelocated slumcommunity, using design, aspeereducators,etc. parallel structures, andactively engagethecommunityinproject It isimportanttoinvestinexistingsystems,ratherthan develop are trainedintheuseof commodities). condoms, contraceptives,etc.supportedbylocalshop ownerswho (e.g. through surakshahaats –community-basedoutletsfor Health systembenefitsneedtobebrought closertothecommunity Sessions withfamilymembersandsexualpartnersofPLHIV. (community-based informallegalredress systemfor women). Sensitisation ofcommunitygatekeepersandmahilapanchaya Engagement withmen(e.g.todiscussFPdecisions). Community sensitizationandmobilization. etc. leading toincreased awareness aboutSRHR,power dynamics, Support groups andcounselling(includingforSWsPLHIV)– 74 (supportedbyIndiaHIV/AIDS Intervention location Donor HIV epidemic , (draft),IndiaHIV/AIDS Alliance. Foundation Hewlett Concentrated 37 HIV/SRHR integration for key populations Concentrated Facility-based; community outreach (supported by (supported 75 , International HIV/AIDS Alliance, 2010. HIV epidemic Donor Intervention location Service delivery for integrated programming needs to be flexible (as Service delivery for integrated programming hours). working very mobile and have unpredictable SWs are and include must have non-judgmental staff Integrated programmes medical, psychological and behavioural components. HIV centre (providing services such as HIV information and (providing HIV centre behaviour change communication and education, HCT, and integrating SRHR opportunistic infection management) and STI screening condom education and provision, (such as FP, for breast screening smears for cervical cancer, management, PAP to sexuality/ skills related cancer). Also build understanding and for income generation. Referral for ART support safer sex and offer and TB services risk of HIV sex, reduce levels of unprotected aims to reduce Centre access to services. SWs’ infection and increase training. appropriate received Staff they out to SWs where SWs trained as peer educators who reach work and socialize. and HIV services. their clients to STI SWs refer respond to SWs’ needs. flexible – to are Opening hours of centre services per day; Results include: up to 300 SWs accessing increased for SWs living with HIV; establishment of support group of SWs; and reports uptake of HCT and health services among clients. behaviour change among SWs and their • • • • • • • • • Civil society SWs and their clients Kenya HIV Good Practice Guide: Integration of HIV and Sexual and Reproductive Health and Rights Lessons learned International HIV/AIDS Alliance) International of Type provider Key population HIV/SRHR integration Kenya AIDS NGO Consortium (KANCO) NGO Consortium Kenya AIDS Organisation: Country Main programme type 75 75 38 HIV/SRHR integration for key populations 76 76 (supported byInternationalHIV/AIDSAlliance) integration HIV/SRHR Key population type programme Main provider Type of learned Lessons Country Organisation: EasternCaribbeanCommunityActionProject(ECCAP) AIDS Alliance. Study,Caribbean: Country ofAchievements, ProgressandChallengesunder IMPACT Studies:AGlobal Summary AllianceCountry 2010,InternationalHIV/ SWs HIV Civil society Nevis) Barbuda, StKittsand Caribbean (Antiguaand • • • • SWs tofacilities. accessing services.Forexample,communityanimatorsaccompany When providing referrals, itisimportantthatSWsfeel secure about male client. addressing situationssuchasnegotiatingcondomusewithadrunk Programme usesinnovativecommunicationtools,includingcomic from homeisland. carried outinhomelanguages.Alsoprogramme collaborateswithNGO As manySWsare migrants,SRHR/HIVmaterialsandoutreach work socialize. ReferralsforHCTandotherservices. integrated informationandcondomsinvenueswhere theyworkand dual protection. Communityanimators(includingSWs)reach SWswith HIV programme integratingSRHRthrough focusonfemalecondomsfor location Intervention Donor HIV epidemic Community outreach 76

39 HIV/SRHR integration for key populations Concentrated DfID; Hewlett and Foundations Packard Facility-based; community outreach HIV epidemic Donor Intervention location 77 Creating demand (by raising awareness and creating interest in SRHR in SRHR interest and creating awareness demand (by raising Creating workers). outreach including through services among SWs and PLHIV, of SRHR service providers Ensuring supply (by building the capacity SWs and PLHIV). to the needs of to respond In Bihar, assessment of IPC showed that: uptake of services by SWs In Bihar, HIV was becoming ‘normalised’ and PLHIV and PLHIV increased; communication of discrimination; and programme’s aware more were services. information about good for increasing methods were they can discuss SRHR and SWs particularly welcome sessions where knowledge about using increased and benefit from HIV as a group condoms for dual protection. SRH facilities (run by government and government/ in Andhra Pradesh support. private sector in Bihar) integrating HIV-related SRHR showed SWs and PLHIV needed more project before Research The main barrier to services was services, especially FP and abortion. stigma by providers. Government, SW and PLHIV private sector and civil society (including the design stage of the project. from involved were groups) on: focused pilot project PATH • • of key populations and PLHIV to train SWs and with groups Worked communication (IPC), with a solving interpersonal PLHIV in problem for services for referral focus on SRHR. Also developed a mechanism not provided. interaction sessions between In Andhra Pradesh, used face-to-face and PLHIV to discuss issues about their and SWs service providers facilitated by PLHIV These were and access to service. health care prejudices. networks and NGOs and reduced training to government provided and private sector service PATH (including doctors, nurses, counsellors and laboratory staff). providers to SRHR access stigma and increased Results included decreased A SW in services (including abortion) by SWs and women PLHIV. said: “The women who have never visited a hospital before Muzaffarpur have started going now.” complemented by national advocacy and stakeholder Service provision meetings. • • Government and private sector HIV and SRHR SWs and PLHIV • • • • • • • • • India (Srikakulan, Andhra India (Srikakulan, and Pradesh and Patna Bihar) Muzaffarpur, Exploring Integrated Convergence, Policy and Practice Update 4, HIV-SRH Convergence Project, PATH, December 2009; and India: HIV-SRH PATH, Countries/Areas with Concentrated HIV Epidemics, Amitrajit Saha, Anna of Settings in SRH and HIV Models and Programming Examples from a Variety Zakowicz, Dawn Averitt Bridge, Jill Gay, Robert Carr, (Presentation at International AIDS Conference), July 2010. Lessons learned Main type of programme Key population HIV/SRHR integration Organisation: PATH India Organisation: Country of Type provider 77 77 40 HIV/SRHR integration for key populations 78 78 type programme Main learned Lessons integration HIV/SRHR Key population provider Type of Country Organisation: FamilyPlanningAssociationofMalawi(FPAM) IPPF) In aLife:LinkingHIVand SexualandReproductiveHealthinPeople’s Lives,IPPF,July2010. Malawi • • • • • SWs SRHR Civil society confidence tolook aftertheirownsexualhealth. condoms, etc)with providing sexworkerswiththeinformationand of arangeservices(pregnancy testing,STIinformation,VCT, free Initiatives forsexworkersworkwelliftheycombinetheprovision current orformersexworkers. judgemental way, forexamplebypeereducatorswhoare themselves It isvitalthatintegratedservicesforsexworkersare provided inanon- address incomeinsecurity skillsforsustainablelivelihoodsto opportunities forwomentolearn empowerment, forexample–alongsideSRH/HIVservicesproviding Within integrationstrategiesforsexworkers,itisimportanttopromote Community-based peereducatorsrefer SWstotheclinic’s services. income generationtrainingforSWs(e.g.incateringandhairdressing). condoms forSWs)integratingHIVservices(e.g.HCT).Alsoprovide SRHR clinics(e.g.providing pregnancy testing,STItreatment andfree Intervention location Donor HIV epidemic 78 (supportedby community outreach Facility-based; Generalised 41 HIV/SRHR integration for key populations Concentrated Facility-based; community outreach (supported by Interact (supported 79 HIV epidemic Donor Intervention location They have high levels of STIs, such as gonorrhoea, but They have high levels of STIs, such as It is critical to acknowledge and work through local gatekeepers, through It is critical to acknowledge and work key HIV/SRHR issues among marginalised such as pimps, to address populations such as SWs. experience stigma at mainstream SRHR services – not able to access experience stigma at mainstream clinics alongside other service users. issues of starting by addressing builds up incrementally, Approach moving on contraception) before general health (e.g. personal hygiene, and rights. abortion) HIV, specific issues (e.g. to more Programme providing integrated HIV/SRHR support to highly integrated HIV/SRHR providing Programme and community Centre Drop-In adolescents through marginalised outreach. 12 years, many having highly vulnerable – some starting at SWs are exploited by law enforcement experienced sexual abuse and often officials. • • • Civil society SRHR and HIV MSM and transgender people (Adolescent) SWs, Pakistan (Punjab) • Who Are We Failing? How Marginalisation and Vulnerability Affect Adolescents’ Needs for and Access to SRHR, Interact Worldwide, 2011. Failing? How Marginalisation and Vulnerability Who Are We Worldwide) Lessons learned Type of Type provider Main type of programme Key population HIV/SRHR integration Community Support Concern and HMAP Support Concern Community Organisation: Country 79 79 42 HIV/SRHR integration for key populations 80 80 type Programme learned Lessons integration HIV/SRHR Key population Provider type Country Organisation: InstituteforStudents’Health(ISH) Gateways toIntegration: ACaseStudyfromSerbia,WHO,UNFPA,UNAIDS andIPPF,2009. SWs, MSMandPUD Serbia (Belgrade) • • • • • HIV andSRHR Civil society the policewhooftenharassSWsduetotheirillegalstatus). It isimportanttorespond toachallengingenvironment (e.g.bytraining populations. Staff trainingiscriticaltoresponding toprejudices aboutkey populations, forexampleproviding HCTclinicsintheevening. It isimportanttohaveaflexibleapproach toserviceprovision forkey • • • • • • Steps involvedinintegrationincluded: services. Alsomobilevanprovides outreach atSWhotspots. including distributionofcondoms,counsellingandmobilisationtoseek Prevention’ outreach project withSWsaddressing SRHRandHIV, and HepatitisBCcare). Centre iscomplementedby‘Powerof STI treatment, FPandSRHcounselling)HIV(includingHCT populations. Provides integratedservicesrelated toSRHR(including Centre originallyfocusedonstudentsandthenexpandedtokey Building partnershipswithotherorganisations. NGOs. Reaching keypopulations,includingSWs,through collaborationwith friends. Providing mentoringandsupporttoPLHIV, theirpartners,familyand Expanding theprovision ofservices. Securing fundingforintegratingprogramming. Upgrading theskillsofstaff. Intervention type Donor HIV epidemic 80 outreach; mobile community Facility-based; Concentrated 43 HIV/SRHR integration for key populations Concentrated Facility-based; community outreach 81 HIV epidemic Donor Intervention location Challenges to integrated programmes include: illegal status of services; Challenges to integrated programmes and poor national policies lack of capacity; stigma and discrimination; policies on integration. on integration; and fragmented donor to meet the multiple needs of SWs. an opportunity Integration provides issues of a natural entry point to explore provides Condom promotion with SWs. and contraception dual protection to women accessing provided for children Incentives (such as day care demand for can help to create HCT and STI diagnosis and treatment) services. Community involvement is key to ownership and sustainability of integrated efforts. Integrated Health Centre (IHC) providing integrated services for SRHR (IHC) providing Integrated Health Centre and counselling) diagnosis, treatment STI (e.g. condom promotion, needle and syringe exchange, and HIV (e.g. ‘one stop shop’ HCT, complemented by peer education and information materials). Centre services not available. Referral system for outreach. SWs and and targets on dual protection focuses Condom promotion at night spots provided are their clients. Condoms and lubricants work. outreach through trained as peer educators. SWs are Street-based to PUD at the IHC and through provided Needles and syringes are outreach. and leaders, landlords advocacy to religious supported by Services are authorities. • • • • • Civil society SRHR and HIV SW and PUD • • • • • Bangladesh (Chittagong) Bangladesh , Young Power in Social Linking Reproductive Health to HIV & AIDS Prevention Projects: Case of Integrated Health Centers (IHCs) in Chittagong, Bangladesh Action, 2008. Lessons learned Main programme type Key population HIV/SRHR integration Young Power in Social Action (YPSA) in Social Action Young Power Organisation: Country of Type provider 81 81 44 HIV/SRHR integration for key populations 82 82 type programme Main learned Lessons integration HIV/SRHR Key population provider Type of Country Organisation: FrontiersPreventionProgramme,CEMOPLAF Kimirina –LinkingOrganisationofInternationalHIV/AIDSAlliance) Programme, JavierHourcadeBellocq, LACTeam,(powerpointpresentation),International HIV/AIDSAlliance. Partnerships, InternationalHIV/AIDS Alliance;andWorking Together SRH&HIV/AIDSNGOsand CBOSinEcuador:TheExperienceofFrontiers Prevention Integration ofHIVandSexual andReproductiveHealth&Rights(SRHR): ReportonExistingAllianceProgrammes andPolicyWork andPotential Strategic Ecuador • • • • • • • • Key populations,includingSWs SRHR Civil society services. M&E iscriticaltoensure constantfeedbackonthequalityofintegrated and ‘therest ofthepopulation’. the waitingrooms) andtensionsbetweenworkingwithkeypopulations CEMOPLAF experiencedachangedimage(forexample,havingSWsin Integrated efforts canaffect theprofile ofanSRHRorganisation. CEMOPLAF havinganetworkofclinics. Results includeSWsgainingbetteraccesstoservices–due Challenges includehowtoreach SWswhoare’ hidden’. their accesstofree STIandSRHRservices. programmeincluded supportinganationalmaternity forSWs–ensuring became anHIVadvocateandpolicy-makeratthenationallevel.This populations andtheirinvolvementinadvocacy. AlsoCEMOPLAFitself Service provision complementedbysupporttolocalgroups ofkey advisors andstaff. Key populationsare involvedintheclinicsandservices,includingas discounted/subsidised servicestokeypopulations. Strategies includesocialmarketingofcondomsandproviding particular relevance toSWs. comprehensive SRHRservicesandintegratingHIVcomponentsof Large SRHRorganisation (with5clinicsintheProgramme site)offering Intervention location Donor HIV epidemic 82 (supportedby Facility-based Concentrated 45 HIV/SRHR integration for key populations Concentrated Bill and Melinda Gates Foundation Facility-based; community outreach (supported by FHI) (supported 83 HIV epidemic Donor Intervention location Assessment involving SWs, brothel owners and bar managers. Assessment involving SWs, brothel and staff (such as clinic infrastructure, Review of systems and resources management information system). to include FP. Revising counselling and training modules FP during HIV counselling and STI to offer providers health care Training management sessions. Upgrading and expanding services availability at clinics to include tests or gynaecological problems. for pregnancy of FP services. network of local providers referral Establishing a strong activities. Conducting community outreach Within integrated programmes, referrals can be an important mechanism to can be an important referrals Within integrated programmes, give SWs access to a wider range of contraceptive options. support, for example with Aastha peer require also referrals However, educators accompanying clients to other facilities. Clinic and outreach work providing HIV and STI services and integrating FP HIV and STI services and integrating work providing Clinic and outreach in bars and at home. Services include: FP street, on the for SWs in brothels, of male partners); oral contraceptives; information and counselling (including information on sexuality and risk reduction; condoms for dual protection (covering fertility desires, (especially for young clients); client assessment (for etc.); strategic behaviour communication risk of unintended pregnancy, choices); and counselling on informed decision-making about contraceptive partners to use condoms). Referrals negotiation skills (e.g. to persuade male for other contraceptive methods. to 67,500 SWs in 16 clinics, 36 satellite clinics In 4 years, services provided and 380 monthly health camps. and then and ART referral) HCT (through Integration started with providing added FP. First steps for integration were: • • included: Steps for integrated programming • • • • • on counselling provide about STIs and HIV, Peer educators raise awareness FP and advocate for community members to use the services. FP into HIV and peer educators trained in integrating providers Health care services. also supported development of first SW federation in India. Project of SWs and significantly proportion a much larger Results included reaching uptake of services. As a female SW said: “The concerns of a increasing need a lot of advice on family planning, We sex worker go beyond HIV. pregnancy we get all the and other basic needs of a woman. At Aastha, answers to our problems, and we would wish that none of the Aastha clinic services ever be withdrawn.” should India • • HIV and transgender) SWs (female, MSM • • • • • • • • • Civil society Integrating HIV Prevention and Family Planning Services: The Aastha Project in Mumbai, India, Family Health International, 2010. Country Lessons learned Key population HIV/SRHR integration Aastha (‘To Care About’) Project Care About’) Aastha (‘To Organisation: of Type provider Main programme type 83 83 46 HIV/SRHR integration for key populations 84 84 type programme Main learned Lessons integration HIV/SRHR Key population provider Type of Country Organisation: TOP Figure 14:IntegratedapproachtoHIVpreventionandSRHR,TOP(Myanmar) Advancing Sexualand Reproductive HealthandRightsforSexWorkers, (powerpointpresentation), UNFPAAsiaPacificRegionalOffice,August 2011. OIs ser Peer outr TB treatment&RHser Inf Fr Education andcommunication Condom andlubedistr Clinical ser iendship/community b or IEC mater P mation aboutDiCser ost STIcounselling vices andAR STI treatment VCCT each activities ials distr vices Myanmar • • • • • • SWs (female,maleandtransgender) SRHR andHIV T ser 84 services withcommunityoutreach andsupport. It isimportantforintegrationtobecommunity-led,combiningclinical PSI provides trainingtoprivateinstitutionsandpeeroutreach workers. referrals totrainedPSIclinics. Out ofthe19drop-in centres, 15haveclinics,while theother4provide sex workersinthecountry. Programmes in19cites,reaching over75%ofthe estimatednumberof community outreach. Combines peeroutreach, drop-in centres, clinicalservicesand antenatal servicesandcervicalcancerscreening). (including oral/injectable/emergency contraception,pregnancy testing, ART andcommunitycare andsupport)withexpandedSRHRservices Community-led intervention,combiningHIVservices(suchasVCT, (supportedbyUNFPA) ib vices ution ib vices uilding ution vices T echnical Assistance Advocacy Intervention location Donor HIV epidemic Tr ained v National networ olunteer HIV car Inf or DiC basedactivities “b Self carebooklet Enter mation /Educationalactivities Saturda k ofpositiv uddies” P e andsuppor eer suppor tainment /Recreation Socializing pro y Club centres outreach; drop-in community Facility-based; Concentrated e MSMandFSWs vide suppor t group t s t andcare 47

5.1. What does HIV/SRHR integration for men who have sex with men (MSM) and transgender people involve? The review indicated that, building on a generic essential package for HIV/SRHR, there are a number of components that may need specific attention in integrated programming for men who have sex with men and transgender people85. These include information, support and services related to86: • ‘Tailor made’ HIV prevention and behaviour change communication. • Sexuality and sexual health (e.g. counselling on sexual identity, risk-reduction strategies). • Support for transgender people on gender reassignment (e.g. surgery and post- operative care for complications) and feminising procedures (e.g. clean needles for injecting hormones, information of interactions between hormones and ART, advice on increased risk of breast cancer due to prolonged oestrogen use). • STIs (including diagnosis and treatment for anal and oral STIs for male and female partners). • Negotiation within sexual relationships (e.g. between kothi and panthis in India). • Hepatitis information and vaccination. • Sexual violence, including PEP after rape/assault. • Screening, vaccination and support in relation to HPV and anal cancer (at high levels among MSM, especially those living with HIV). • Sexual dysfunction (e.g. related to ART). • Condoms and lubricant (access to continuous supply of free or cheap high quality commodities).

85 Note: In this report, men who have sex with men and transgender people are combined as one group – due to the lack of specific information found about transgender people. However, it is acknowledged that these are, in reality, two diverse communities, often with different needs in relation to integrated programming. 86 Referenced from case studies and literature review, in particular: Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related Services for Men Who Have Sex with Men (MSM) and Transgender People in India, (draft), Family Planning Association of India, 2010; Sexual and Reproductive Health of Males-at-Risk in India: Service Needs, Gaps and Barriers, International HIV AID Alliance in India, May 2008; HIV and Men Who Have Sex With Men in Asia and the Pacific: UNAIDS Best Practice Collection, UNAIDS, 2006; Advancing the Sexual and Reproductive Health and Human Rights of Men Who Have Sex with Men Living with HIV: Policy Briefing, GNP+ and MSMGF, May 2010; and Priority HIV and Sexual Health Interventions in the Health Sector for Men Who Have Sex With Men and Transgender People in the Asia-Pacific Region, WHO, UNDP, UNAIDS, APCOM and Department of Health of Hong Kong (China), 2010. 48 HIV/SRHR integration for key populations below, examplesinclude: transgender people.However,asseenintheliteratureanddemonstratedcasestudies effective HIV/SRHRintegrationstrategiesspecificallyformenwhohavesexwithand The reviewindicatedthat,asyet,thereappearstobelittleclearconsensusonthemost people? integration formenwhohavesexwithandtransgender 5.2. WhataresomecommonstrategiesforHIV/SRHR • • • • programme HIV sex withmenandtransgenderpeople Figure 15:ExamplesofstrategiesforHIV/SRHRintegrationmenwhohave HIV Advocacy on HIV components of Selected services General HIV HIV services) HCT (andother HIV services) HCT (andother family members. Counselling andsupportfordisclosureofsexualityand/orHIVstatustospouse other SRHRservicesforfemalepartners. Support forsexualpartners(male,female,transgender).IncludingFP,MNCHand their changedgenderidentity). Legal support(e.g.fortransgenderpeoplewhocannotregisterservicesunder alternatives topenetrativesex). Safer sex(e.g.strategiesforreducingnumberofpartners,condomnegotiationand Integration ↔ → → → → → SRHR programme Advocacy onSRHR SRHR Selected componentsof STIs SRHR, especiallySTIs especially STIs) FP (andbroader SRHR, Examples incasestudies • • • • • • • • • • • • SAATHII, India Humsafar Trust, India D’Ivoire Espace Confiance,Cote HIV/AIDS Alliance Programme, International North AfricaRegional Blue DiamondSociety, Nepal Society, Pakistan PAVNHA andPakistan Society, Bangladesh Bandhu SocialWelfare TAI, India Control Society, APAC and Tamil NaduStateAIDS section onsexworkers] Programme), India[see Mythri clinics(Avahan RHAC, Cambodia PROFAMILIA, Colombia FPA India,India 49 HIV/SRHR integration for key populations Family , while . 88 87 . 89 Emphasise the rights of sexual minorities and of men who have sex with men and Emphasise the rights of sexual minorities with HIV [see Figure 16]. transgender people who are living partners of men who have sex with men – who Provide specific support to the female from services. For example, Bandhu Social may be especially stigmatised and marginalised partners to mainstream SRHR services Welfare Society, Bangladesh refers female the Family Planning Association of India provides services for both men who have sex with the Family Planning Association of India together or separately) in its SRHR clinics men and their female partners (either Recognise and address the fact that most SRHR services are designed for Recognise and address the fact that can include providing heterosexual people, especially married couples. Responses non-government (often NGO) facilities to refer intensive training to SRHR staff or identifying people. men who have sex with men and transgender Understand the different types of men who have sex with men and transgender types of men who have sex Understand the different kothis and For example, in India, different HIV/SRHR needs. people and, in turn, their may also have different types of roles within sex and each hijras have penetrative/receptive multiple male partners or paying as long-term male or female partners, relationships (such of social stigma and discrimination. clients), as well as different experiences and needs of transgender people. For example, Recognise the specific vulnerability are particularly highly marginalised from society and in many contexts, transgender people understood or addressed. services, with their SRHR needs poorly HIV/SRHR needs or desires of men who have sex Not make presumptions about the Alliance found For example, a study by India HIV/AIDS with men and transgender people. may want to have children and need FP that men who have sex who are married Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related Services for Men Who Have Sex with Men (MSM) and Transgender People Services for Men Who Have Sex with Men (MSM) and Transgender Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related Health International. People Services for Men Who Have Sex with Men (MSM) and Transgender Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related in India, (draft), Family Planning Association of India, 2010. Summary Report of Key Findings and Programme Recommendations: From FHI MSM Programme Evaluations (Bangladesh, Indonesia and Nepal), • • • 89 87 in India, (draft), Family Planning Association of India, 2010. 88 The generic lessons learned for HIV/SRHR integrated programming for key populations [see for key populations [see learned for HIV/SRHR integrated programming The generic lessons transgender people. In addition, some to men who have sex with men and section 2.5] apply that it is important to: specific lessons include • • • 5.3. What lessons have been learned about HIV/SRHR HIV/SRHR learned about have been lessons 5.3. What and transgender sex with men who have for men integration people? 50 HIV/SRHR integration for key populations MSMGF, May2010. Reference: AdvancingtheSexualandReproductiveHealthHumanRightsofMenWhoHaveSexwithLivingHIV:PolicyBriefing,GNP+ support theHIV/SRHRrightsofMSMlivingwithHIV Figure 16:Recommendationsforprogrammemanagersandpolicy-makersto 4. 4. 3. 2. 1. confidentiality, andthespecificchallengesfacingyoungMSM. the specificneedsandprioritiesofMSMlivingwithHIV, includingstigma reduction, Health serviceproviders andadvocatesshouldreceive sensitivitytrainingrelated to psychosocial supportservices. including STIscreening andtreatment, hepatitisimmunisation,mentalhealthandother transgender) shouldhaveaccesstoafullandcomprehensive rangeofSRHservices All MSMlivingwithHIV, includingyoungMSMandtheirsexpartners(male,female,or with HIV. favour oflawsthatguaranteetherightsgaymenandotherMSM,includingMSMliving in National lawscriminalisinghomosexualityandHIVtransmissionshouldbeoverturned and unethicalpublichealthpractice. testing isscaledup–casefindingwithoutappropriate servicesconstitutessubstandard with disproportionately highnumbersofMSMlivingwithHIVatthesametimethat Systems forHIVprevention, care, treatment andsupportmustbestrengthened todeal HIV –basedonconfidentiality, informedconsentandcounseling. must beexpandedandtailored tomeetthespecificneedsandprioritiesofMSMlivingwith Voluntary andaffordable STIandHIVprevention, care, treatment andsupportservices 51 HIV/SRHR integration for key populations , International Concentrated (general 0.4%; MSM 18%) GTZ Facility-based HIV epidemic Donor Intervention location SRHR clinics (providing FP, etc.) integrating HCT. FP, SRHR clinics (providing with a 3-day sensitization workshop for over Started integration process This was designed and facilitated by in 3 clinics. 200 service providers sexuality gender, issues such as diversity, and addressed MSM groups identity and relationships. and guide, alongside specific information Developed a service protocol materials for MSM and their female partners. bisexual and transgender gay, Also campaigned for the rights of lesbian, people. and that some have Recognise the diversity of the MSM community female partners who may be highly marginalised. to gain expertise and build trust. with MSM groups in collaboration Work transgender people. Develop a specific strategy to support MSM, female partners of MSM and women living with HIV MSM, female partners of MSM and women • • • • • • • Colombia Civil society (IPPF affiliate) SRHR 90 Planned Parenthood Federation, 2005. Models of Care Project: Linking HIV/AIDS Treatment, Care and Support in Sexual and Reproductive Health Care Settings: Examples in Action Models of Care Project: Linking HIV/AIDS Treatment, Lessons learned Key population HIV/SRHR integration Type of Type provider Main programme type Asociacion Pro-Bienestar de la Familia Colombiana de la Familia Colombiana Organisation: Asociacion Pro-Bienestar (PROFAMILIA) Country 90 90 5.4. Case studies of HIV/SRHR integration for men who have for men who integration of HIV/SRHR studies 5.4. Case people transgender men and sex with 52 HIV/SRHR integration for key populations 91 92 91

92 learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: BandhuSocialWelfareSociety Key population type programme Main provider Type of Country Organisation: FamilyPlanningAssociation(FPA)ofIndia in India,(draft),FamilyPlanning AssociationofIndia,2010. Advocacy Brief:Integration ofSexualandReproductiveHealthHIV-Related forMenWhoHaveSexwith (MSM)andTransgender Services People Health International. ReportofKeyFindingsandProgramme Recommendations:FromFHIMSM Programme Evaluations(Bangladesh,Indonesia andNepal) Summary Bangladesh (6cities) MSM, femalepartnersofMSMandtransgenderpeople SRHR Civil society Kolkata andKohima) India (Mumbai,Chennai, • • • • • • MSM (includingthoseinvolvedinsexworkandwithfemalepartners) SRHR andHIV Civil society integration, aswelltoactivelyengagewiththegovernment. It iscriticaltoinvolvecommunitymembersinstrategicplanningfor point forapproaching SRHRforMSM. Providing comprehensive generalhealthcare provides agoodentry relating toMSM. Service provision complementedbynationaladvocacyonissues MSM). Training andsupporttopeereducatorsoutreach workers(whoare Female partnersofMSMare referred tootherservices. and sexualhealthawareness; andHCT. Alsoatelephonehelpline. counselling; condomsandlubricantdistribution;socialgroups; general providing drop-in servicesfor:syndromic management;psycho-sexual safer sex)andSRHR(suchasSTIinformation).Referraltoclinic as: condomandlubricantdistribution;HIVinformation;educationon 60 MSMcruisingsites.Servicesincludethoserelated to:HIV(such Integrated HIVandSRHRservicesincommunities,includingatover Intervention type Donor HIV epidemic Intervention location Donor HIV epidemic 91 92 (supported byIPPF) outreach Community Embassy) DfiD, Norwegian UNDP, MSI, Various (e.g. Concentrated community outreach Facility-based; (for pilot) Japan Trust Fund 41%; general0.7%) transgender 18- (MSM 7%; Concentrated , Family 53 HIV/SRHR integration for key populations Having staff focus group discussions with MSM to understand their discussions focus group Having staff needs and inform a funding proposal. (including NGOs working Holding an initial meeting with stakeholders seek collaboration. The NGOs: with MSM and transgender people) to referred posts; trained clinic staff; suggested candidates for staff feedback on how to provided MSM and their partners to services; and services. improve such as with: long opening appropriate, Ensuring that services were services or make an appointment; and for hours; options to drop-in for MSM, transgender people and the general waiting areas shared stigma) public (to reduce Integration was helped by the clinics: already having good already Integration was helped by the clinics: having externalinfrastructure; (i.e. non-government) funding; building and starting and non-clinical staff; positive attitudes among both clinical with a pilot. to challenging initially caused tensions (e.g. due waiting areas Shared with local MSM by dialogue resolved behaviour by hijras), but they were and transgender leaders. among MSM and transgender It is vital to understand differences For example, MSM who people and dynamics within the community. given three being ‘outed’ about having female partners were feared to other referred their confidentiality: couple to be options to protect clinic day; for a non-drop-in clinics; couple to make an appointment FPA or husband and wife to attend the clinic separately. free for example by providing It is important to ‘popularise’ projects, HBV vaccination which attracts clients. But it is also important to manage expectations and clarify what services can or cannot be surgery). to sex reassignment (e.g. in relation provided extensive technical training require Both clinical and non-clinical staff that goes beyond just ‘sensitization’ about MSM and transgender issues. SRHR clinics integrating HIV services for MSM and female partners, and female partners, services for MSM integrating HIV SRHR clinics include: SRH services Free work and drop-in. by outreach supported and STI screening termination of pregnancy; services (e.g. FP; medical and counselling; outreach and HIV services (HIV prevention treatment); condoms (including and post-test counselling; pre HCT – rapid tests, lubricant; diagnosis of water-based social marketing outreach); through and transgender HBV vaccination (for MSM free of Hepatitis B and (at for: ART Referrals support groups. people); and psycho-social income centres); TB (at governmentgovernment DOTs centres); procedures. and surgical generation; legal issues; included: for integration Key steps to prepare • • • non-discrimination; Results include that MSM clients welcomed: time and money. and saving HIV; getting information on both SRHR and (as it often hesitant to bring their female partners MSM were However, MSM). Also some had larger would ‘out’ their married status to other CD4 testing. expectations for services, such as free • • • • • • • • Lessons learned HIV/SRHR HIV/SRHR integration 54 HIV/SRHR integration for key populations 94 93 93

94 Key population programme Main typeof provider Type of Country Organisation: ReproductiveHealthAssociationofCambodia(RHAC) integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: TamilNaduStateAIDSControlSociety,APACandTAI learned Lessons integration HIV/SRHR In aLife:LinkingHIVTreatment, CareandSupportinSexualReproductive HealthCareSettings in India,(draft),FamilyPlanningAssociationofIndia, 2010. Advocacy Brief:IntegrationofSexualandReproductive HealthandHIV-Related forMenWho HaveSexwithMen(MSM)andTransgender Services People India (Tamil Nadu) • • • • MSM SRHR andHIV Civil society Cambodia (SiemReap) • • • • MSM andtransgenderpeople HIV civilsociety Government; populations). clinics(increasingof services)andRHAC/government reach topriority Partnership bringsbenefitstobothMSMgroups (increasing therange clients toclinicsfortestingandtreatment. Trained peereducatorstodisseminateSTIandHIVinformationrefer and entertainmentworkersthrough outreach. In SiemReap,builtpartnershipswithlocalorganisations toreach MSM services. SRHRclinicsintegratingSTIandHCT RHAC andlocalgovernment discriminatory environment forMSMsandtransgenderpeople. facilitiesupgradedtoprovideGovernment awelcomingandnon- specific healthissuesofMSMandtransgenderpeople. serviceprovidersGovernment (doctorsandcounsellors)trainedonthe Strategy withinthetargeted interventionsapproach ofNACP-III. HIV) forMSMandtransgenderpeople. communicable andnon-communicablediseases,includingSTIs hospitals toprovide free ‘masterhealthcheck-up’(coveringmajor Collaborative programme byStateAIDSControl Societyforgovernment Intervention location Donor HIV epidemic Intervention location Donor HIV epidemic , IPPF,2006. Facility-based Concentrated community outreach Facility-based; Concentrated 93 94 55 HIV/SRHR integration for key populations ), Family Concentrated Facility-based; community outreach Concentrated Council European Facility-based; community outreach HIV epidemic Donor Intervention location HIV epidemic Donor Intervention location 96 It is critical to have strong working relationships with other with other working relationships It is critical to have strong for stigmatised the quality of referrals to ensure especially organisations, populations such as MSM. the integrated services, it is important to address As well as providing in which MSM live and work. For example, as extortion environment fosters common for MSM, programme are of exposure and threat each other from solidarity among the men using public parks to protect blackmailers, thieves and the police. Integrated programme providing SRHR and HIV services. Drop-In Drop-In SRHR and HIV services. providing Integrated programme counselling, one-to-one education, (‘safe house’) provides Centre sessions on HIV and STIs, condoms and clinical services, group providing workers complemented by outreach lubricant. Centre for STI services. information, condoms and referrals and also 9am-6pm open to MSM seven days a week from Centre videos, training and social events. provides is supported by social marketing of condoms. Programme Challenges include the need to develop positive relations with the positive relations Challenges include the need to develop pimps of those who sell sex). gatekeepers of MSM networks (e.g. the Clinics integrating SRHR and HIV, including services for primary health including services Clinics integrating SRHR and HIV, sex practices and condom and lubricant distribution, safer HCT, care, for PUD. harm reduction and and support groups Clinics complemented by peer education involvement of key populations in programmes. STIs, basic health and trained in rights, gender, Community organisers and support. HIV and care hygiene, HCT, and support. care prevention, Developed models for integrated HIV (supported by Interact Worldwide) (supported • • MSM sexual health MSM and (female) SWs • • • • Nepal (Kathmandu) Civil society Civil society SRHR and HIV partners), PUD and PLHIV MSM, SWs (and their • • • • Pakistan (Sindh) 95 Website of Interact Worldwide (accessed 12.4.11). Summary Report of Key Findings and Programme Recommendations: From FHI MSM Programme Evaluations (Bangladesh, Indonesia and Nepal August 2003. Health International; and Between Men: HIV/STI Prevention for Men Who Have Sex With Men, International HIV/AIDS Alliance, Lessons learned Key population HIV/SRHR integration Organisation: Blue Diamond Society Country of Type provider Main type of programme Lessons learned Main programme type Key population HIV/SRHR integration Pakistan Voluntary Health and Nutrition Association (PAVNHA) and Association (PAVNHA) and Nutrition Voluntary Health Pakistan Organisation: Society Pakistan Country of Type provider 96

95 96 95 56 HIV/SRHR integration for key populations 98 97 97

98 en Côted’Ivoire) Organisation: EspaceConfiance(supportedbyAllianceNationalecontreleSIDA learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country AIDS Alliance) Organisation: NorthAfricaRegionalProgramme(supportedbyInternationalHIV/ integration HIV/SRHR type programme Main provider Type of Country Key population Partnerships, InternationalHIV/AIDS Alliance. Integration ofHIVandSexual andReproductiveHealth&Rights(SRHR): ReportonExistingAllianceProgrammes and PolicyWork andPotential Strategic Partnerships, InternationalHIV/AIDS Alliance. Integration ofHIVandSexual andReproductiveHealth&Rights(SRHR): ReportonExistingAllianceProgrammes andPolicyWork andPotential Strategic 97 98 Morocco, Tunisia Algeria, Lebanon, • • • • • MSM MSM Health andsupportfor Civil society MSM HIV andSRHR Civil society Cote D’Ivoire • • planning andbudgeting. to address unsupportivenationalpolicies–amajorbarrier).Itrequires Advocacy isacriticalcomponentofintegratedprogrammes (including attention tothestructuralbarriersSRHRandHIV. A comprehensive approach tointegrationisneeded thatincludes and highrankinglawenforcement officials. discrimination (astrong barriertoservices).Targets healthprofessionals Service provision iscomplementedbyadvocacytocombatstigmaand in allstages,includingneedsassessment,servicedeliveryandadvocacy. Emphasis onpeereducationandsupport.AlsoinvolvementofMSM and supportservices. condoms andlubricantinformationmaterials).Referralstomedical Organisations provide arangeofHIVandSRHRservices(includingHCT, • • • • Key stepstodeveloptheintegratedprogramme included: use, STIsandHIVprevention). sessions onbehaviourchangecommunication(focusing oncondom Clinic providing STIscreening andtesting,complementedbyeducation Developing targeted informationmaterialsonSTIs andHIV. Training MSM peereducators. and coordination among community groups. Using thefindingsofneedsassessmenttocarryout jointplanning groups. Starting withaneedsassessmentamongMSMandcommunity Intervention location Donor HIV epidemic Intervention location Donor HIV epidemic community outreach Facility-based; USAID Low/concentrated AMFAR Generalised 57 HIV/SRHR integration for key populations Concentrated Various Facility-based; community outreach HIV epidemic Donor Intervention location 99 Clients say the advantages of integration include: non-judgmental less time and money spent accessing services; attitudes of providers; include fear The disadvantages quality time with providers. and more living with HIV and SWs fearing of stigma (e.g. with MSM who are detrimental impacts on work if their HIV positive status is revealed). needs different with diverse groups, MSM and transgender people are and, sometimes, tensions among them – which can impact on service provision. It can be necessary to try out options to identify ‘what works’. Humsafar for MSM and specific service provider tried having a separate room HIV positive. but that system ‘identified’ those that are living with HIV, for such MSMs, but the clients They also tried having a separate centre wider set of services. wanted to access the organisation’s is a For an NGO focused on MSM and transgender people, referral the needs of female partners. critical option to address NGO clinic focused on MSM/transgender health that has integrated on MSM/transgender health that has NGO clinic focused Provides over time [see timeline below]. HIV and SRHR services on HIV and STIs; outreach services, including: comprehensive counselling on mental health, distribution of condoms and lubricant; and testing; HCT etc.; nutrition support; STI screening sexuality, and support on violence; prevention (government-accredited centre); MSM and support (including at home, supported by care HIV-related MSM; and support relating health workers); counselling for married Referral to government hospitals for STI to sexuality and disclosure. and to services (e.g. CD4 count and ART) and specific HIV treatment psychologists (e.g. for support community-friendly psychiatrists and sexuality). to gender identity and related to Mumbai branch of Family referred Female partners of MSM are and free B screening Planning Association, including for Hepatitis Hepatitis B vaccination. on the phone or via e-mail. face-to-face, Counselling is provided location to MSM involved in sex work at a different is provided Outreach (Juhu). a pilot intervention which was Started with a mapping of MSM, then scaled up. at the such as training staff sector, Has built partnerships with the health issues and having hospital general hospital on MSM and transgender interns clinic. at its • • • • Civil society Health for sexual minorities people MSM and transgender • • • • • • India (Mumbai) Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related Services for Men Who Have Sex with Men (MSM) and Transgender People Services for Men Who Have Sex with Men (MSM) and Transgender Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related in India, (draft), Family Planning Association of India, 2010. Lessons learned Key population HIV/SRHR integration Humsafar Trust Humsafar Organisation: Country of Type provider Main type of programme 99 99 58 HIV/SRHR integration for key populations ser ser related related MSM, HumsafarTrust(India) Figure 17:TimelineofintegrationHIVandSRHRservicesintosupportfor SRH- Y Y Y HIV ear ear vices vices ear - Drop-in centreandsupportgroupsaddressingHIV Drop-in centreandsupportgroupsaddressingsexualitygenderissues 1994 1994 1994 Counselling (face-to-face,andtelephone)onsexualitySTI-relatedissues Counselling (face-to-face,andtelephone)onHIV (outreach education,condom/lubedistrbution,STI/HIVtestingreferrals) MSM/TG targetedHIVinter Sensitisation ofhealthcareprovidersandpoliceontheissuessexualminorities(periodic) Sensitisation ofhealthcareprovidersontheissuesfacedbyHIV STI referralstoHumsafarclinicandgovernment/privateclinics Mapping ofMSMhotspots(periodic) 2000 2000 2000 -related issues Annual HIVserosur -related issues supplements, supportgroups,homevisits,mentalhealthissues Ser vices forMSMandtransgenderpeoplelivingwithHIV vention projects veillance amongMSM (later establishmentofcrisisinter Addressing physical/sexualviolencefacedbyMSM/TG (all kindsofissuesincludingSRHissues) In-house mentalhealthcounselling 2005 2005 2005 relationship issues psychiatrists/psychologists for Referrals tocommunity-friendly -positive MSM/TG(periodic) vention cell) : nutritional general SRHclinics partners ofMSMto Referrals ofwomen 2010 2010 2010 59 HIV/SRHR integration for key populations 100 Concentrated (MSM 7%; transgender 18- 41%; general 0.7%) and (Provincial national advocacy) HIV epidemic Donor Intervention location Starting an HIV Support Centre Project focused on: building Project Starting an HIV Support Centre rights, sexual health and HIV; human sexuality, knowledge on gender, to the HIV response. for skills related technical support and providing working with MSM and Of the 9 main partners (some groups of PLHIV) most had experience transgender people, others networks but not SRH. in HIV, (the Coalition-Based Advocacy Beginning a 5-year follow-up initiative the advocacy capacity of partners by assisting to strengthen Project) needs of sexual minorities and them to understand the specific SRHR PLHIV. and 22 (Orissa) members of two state-level Bengal) Having 33 (West training each agency through coalitions, with the work strengthened advocacy agenda. and a workshop to develop on a common Developing a common HIVF/SRHR advocacy agenda for sexual focused on issues such as access to services minorities and PLHIV, and stigma and discrimination. Supporting policy-level advocacy. Implemented/planned activities HIV and SRH policies (including include: policy paper on how current the specific needs plan) address the NACP/ NRHM convergence advocacy action plan to address of sexual minorities and PLHIV; gaps; and advocacy to articulate the identified policy and programme issues of sexual minorities and PLHIV in the next specific SRH-related phases of the NACP and RCHP. Supporting healthcare system-level advocacy: The coalitions’ for sexual on issues providers activities include sensitizing healthcare and advocating for technical training for service minorities and PLHIV; providers. NGO for key populations coordinating advocacy coalitions on SRHR NGO for key populations coordinating and HIV. integration included: HIV/SRHR Key steps towards • • • • • • Civil society Support to key populations and PLHIV networks MSM and transgender organisations • • complements its advocacy by supporting over 40 agencies SAATHII Bengal and Orissa) to integrate SRHR components (including in West for MSM and transgender people. interventions into HIV targeted for survivors and care Examples of SRH components include prevention for the female partners of MSM and of sexual violence, health promotion counselling on gender transition for transgender people. include: integration results SAATHII’s India (West Bengal and India (West Orissa branch) What Works? Sexual and Reproductive Health (SRH) and HIV Linkages for MSM and Transgender People, (Draft), International Planned Parenthood Sexual and Reproductive Health (SRH) and HIV Linkages for MSM and Transgender What Works? Federation, 2011. Key population HIV/SRHR integration Type of Type provider Country Solidarity and Action Against the HIV Infection in India (SAATHII) in India the HIV Infection and Action Against Solidarity Organisation: Main programme type 100 100 60 HIV/SRHR integration for key populations 1. learned Lessons • • • • • policies – to help the Government todoitsjobbetter.policies –tohelptheGovernment itisalsoimportanttohighlightgapsinitsservicesand Government, coalition emphasisedthat,whileitisimportanttocollaboratewiththe or providing supporttosexualminoritiesandPLHIV. Inresponse, the coalitions –suchaslosingfundingduetocriticisingthegovernment Some agenciesfeara‘backlash’ofinvolvementinSAATHII’s agencies. strengthening theirlinkswithothermainstream SRH andhumanrights PLHIV. Thiswillrequire furtherwork,withSAATHII andthecoalitions actions inrelation toSRHRandHIVlinkagesforsexualminorities even thoughtheyare notformalmembers–theywillsupportadvocacy coalitions. However, manyotherSRHagencieshaveclarifiedthat– limited numberofsuchagencieshaveregistered asmembersofthe The involvementofmainstream SRHagenciesischallenging.Onlya and transgenderpeopleamonggeneralSRHservices. among mainstream PLHIVnetworks;andthespecificneedsofMSM transgender people;issuesaffecting MSMandtransgenderpeople on: SRHRamongagenciesproviding HIVservicesforMSMand found itnecessarytocombinebuildingunderstandingandcapacity A multi-pronged approach isneededtocapacitybuilding.SAATHII NRHM’s plandoesnotmentiontheSRHofsexualminoritiesandPLHIV. activities forthegeneralpopulationare fundedbyRCHP-II/NRHM.The HIV-related activitiesare fundedbyNACOthrough NACP-III, SRH mechanism toadvancetheSRHRofsexualminoritiesandPLHIV. While The coalitionswere challengedbythelackofaspecificfunding constituencies. by buildingashared understandingoftheover-lapping issuesofthe coalitions, suchasMSMandPLHIVgroups. Thesecanbeaddressed There canbetensionsamongdifferent membersofHIV/SRHR 61

6.1. What does HIV/SRHR integration for people who use drugs involve? The review indicated that – building on a generic essential package for HIV/SRHR – there are a number of components that may need specific attention within integrated programming for people who use drugs (PUD). These vary according to factors such as people’s gender, age, social status and HIV status. They can include information, support and services related to101: • Full range of options to prevent HIV, STIs and unwanted pregnancy, including (but also going beyond) condoms. • Interactions between different types of drugs (e.g. methadone, ART, contraceptives). • Safer sex practices while under the influence of different types of drugs (e.g. risk reduction, skills to improve condom efficacy). • Specific SRHR issues for people who use drugs (e.g. sexual dysfunction for men, impact on menstruation and fertility for women). • Female drug users who are pregnant (e.g. information on methadone use and dosage during pregnancy), with access to full range of supportive PMTCT, ANC, delivery, PNC and MCH. • Empowerment on sexual and health rights. • SRHR needs of female partners of men who use drugs (e.g. family planning options). ‘Drug user-friendly’ SRHR options, including a full range of appropriate contraception (e.g. long-lasting contraceptives) and male and female condoms. • Sexual violence, including PEP in relation to rape or sexual assault. • Sexual counselling (e.g. on the relationship between sexual drive, performance and drug use). • Family welfare services, to support people who use drugs to maintain custody of their children. • Hepatitis B and C (e.g. information, diagnosis and treatment).

101 Referenced from case studies and literature review, in particular: Advancing the Sexual and Reproductive Health and Human Rights of Injecting Drug Users Living with HIV: Policy Briefing, GNP+ and INPUD, May 2010; HIV and Drug Use: Community Responses to Injecting Drug Use and HIV: Good Practice Guide, International HIV/AIDS Alliance, 2010; Targeted Interventions Under NACP III: Operational Guidelines Volume 1: Core High Risk Groups, National AIDS Control Organisation, October 2007; and Making Harm Reduction Work for Women: The Ukrainian Experience, OSI, 2010. 62 HIV/SRHR integration for key populations integration forpeoplewhousedrugs? 6.3. WhatlessonshavebeenlearnedaboutHIV/SRHR seen intheliteratureanddemonstratedcasestudiesbelow,examplesinclude: effective HIV/SRHRintegrationstrategiesspecificallyforpeoplewhousedrugs.However,as The reviewindicatedthat,asyet,thereappearstobelittleclearconsensusonthemost integration forpeoplewhousedrugs? 6.2. WhataresomecommonstrategiesforHIV/SRHR 102 • • important to: section 2.5]applytopeoplewhousedrugs.Inaddition,somespecificlessonsincludethatitis The genericlessonslearnedforHIV/SRHRintegratedprogrammingkeypopulations[see • • programme HIV drugs Figure 18:ExamplesofstrategiesforHIV/SRHRintegrationpeoplewhouse reduction HIV andharm reduction HIV andharm needs forsupportandservices having sexualrelationswithwomen,menandhijras–all associatedwithdifferentissuesand drugs. Forexample,anIndiaHIV/AIDSAlliancestudyfoundthat maledrugusersmaybe Not makepresumptionsabouttheHIV/SRHRbehaviours orneedsofpeoplewhouse other. and medicines(suchasmethadone,hormonalcontraceptives andART)interactwitheach people whousedrugsinrelationtosexualpleasureand risktakingandhowdifferentdrugs reduction, HIVandSRHR,suchashowdrugusecanaffectthechoicesordecisionsof Assess, recogniseandaddressthecomplexinteractionsbetweendruguse/harm Diagnosis andtreatmentforTB. abortion care(includingincasesofunsafeorillegalabortion). (Where legal)accesstosafeandconfidentialabortion(inallcontexts)post- Sexual and Reproductive Health of Males-at-Risk in India: Service Needs,GapsandBarriers, IndiaHIV/AIDSAlliance, May2008. Sexual andReproductive HealthofMales-at-RiskinIndia:Service Integration 102 SRHR programme women’s health) specifically including and STIsoften SRHR (especiallycondoms health care Broad SRHRorprimary . Examples incasestudies • • • • • • • Centre, China Five HeartsService SASO, India OSI, Ukraine Korsang, Cambodia DICP, Malaysia Puskesmas, Indonesia PKBI, Indonesia 63 HIV/SRHR integration for key populations

Supporting the SRHR Figure 19: Supporting the SRHR who needs of women who use drugs are living with HIV “Contraception is a very important issue for menstruation IDU women living with HIV; often ceases with regular use of opiates, which can make it difficult to detect It is vital that the full range of pregnancy. contraceptive options be made available, and that women are not forced to use a with particular method in order to comply contraception stipulated by service-ART providers. Family planning and abortion choices should be made with the same who range of choices available to women pressured or forced are not HIV-positive; to the sterilisation is diametrically opposed HIV human rights of IDU women living with and should be specifically outlawed.” Advancing the Sexual and Reproductive Health and Human Rights of Injecting Drug Users Living with HIV, GNP+ and INPUD ; and GNP+ emphasises the need ; and GNP+ emphasises 103 . . 104 105 Women who use drugs of drug users, Women who are partners widows including wives and Women who use drugs and sell sex and Pregnant women who are using drugs mothers who are using drugs drugs Women living with HIV who are using drugs Young women and girls who are using Making Harm Reduction Work for Women: The Ukrainian Experience, OSI, 2010. for Women: Making Harm Reduction Work 1: Core High Risk Groups, National AIDS Control Organisation, October 2007. Interventions III: Operational Guidelines Volume Under NACP Targeted to support women who use drugs who are living with HIV [see Figure 19]. Meanwhile, the who use drugs who are living with HIV to support women is paid to: Alliance recommend that attention International HIV/AIDS • • • • • • – acknowledging that women can be affected by drug use, HIV and SRHR in different ways and SRHR in different by drug use, HIV can be affected that women – acknowledging and both male-orientated who use drugs are to support people programmes and that many for women to discuss pregnancy). (making it difficult, for example, focused on drug use/HIV Institute in Ukraine found that supported by the Open Society For example: programmes women who use drugs and that provided little outreach to pregnant OST programmes was lacking in maternity settings substitution treatment Within integrated programming, address the cross-cutting issue of gender dynamics cross-cutting address the programming, Within integrated [See Annex 3 for extract from HIV and Drug Use: Use and Community Responses to Injecting Drug Good Practice Guide, International HIV/AIDS HIV: Alliance]. of integrated Provide a comprehensive package use drugs. HIV/SRHR support for people who that, For example, NACO in India recommends and for Drop-In Centres, this includes: condoms package; STI diagnosis and treatment in a core and the SRHR support for women who use drugs behaviour female partners of men who use drugs; partners; and change communication among sexual services accompanied referrals to other SRHR HIV and Drug Use: Community Responses to Injecting Drug Use and HIV: Good Practice Guide, International HIV/AIDS Alliance, 2010. Definition from: HIV and Drug Use: Community Responses to Injecting Drug Use and HIV: • 103 104 105 • 64 HIV/SRHR integration for key populations drugs 6.4. CasestudiesofHIV/SRHRintegrationforpeoplewhouse 106 106 integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: PerkumpulanKeluargaBerencanaIndonesia(PKBI) learned Lessons 2011. Linking SexualandReproductive HealthandHIV: Advocacy BriefonPeopleWhoUseDrugs,Indonesia , IPPFEastandSouth Asia andOceaniaregion, • • • • • • • • PUD, SWs,MSMandtransgenderpeople SRHR affiliate) Civil society(IPPF Jakarta) Indonesia (Pisangan, HIV andinteractionsbetweenmethadoneART). services (e.g.inrelation to contraceptiveoptionsforwomenlivingwith Staff needtobuildspecific technicalexpertisetodeliverintegrated who are usingdrugs,living withHIVandpregnant. Non-judgmental attitudesare critical,forexamplesupportingwomen drugs. for integratedprogrammes forkeypopulations,suchaspeoplewhouse Combining clinic-basedservicesandcommunityoutreach workswell critical forkeypopulations. Strategy responds toNAC’s recognition ofHIV/SRHRintegrationas Clinics workoncost-recovery basis,withcharges keptminimal. with HIV). hospitals forotherservices(includingPMTCTpregnant womenliving but donotprovide ART ormethadone.Clientsare referred tomain Clinics provide simplelaboratoryservicesforSTIsandrapidHIVtests, • • • Integrates three packages: clinics. and harmreduction servicesforkeypopulations.Partofnetwork26 SRHR clinicandcommunityservicedeliverypointsintegratingHIV information, outreach andsupportgroups. Harm reduction forPUD,includingneedleandsyringeexchange, populations. HIV, includingHCT, PMTCT, STIandHIVprevention forkey abortion, managementofpost-abortioncare andcervicalscreening. SRHR, includingFP, ANC,PNC,counselling,prevention ofunsafe Intervention location Donor HIV epidemic community outreach Facility-based; Fund, UNFPA) Various (e.g.Global PUD: 52%) (general: 0.2%; Concentrated 106 65 HIV/SRHR integration for key populations Concentrated Ministry of Health Facility-based; community outreach (supported (supported 107 HIV epidemic Donor Intervention location It is critical to develop specific integrated strategies for women PUD – It is critical to develop specific integrated not women-friendly and do not are services as many harm reduction or MCH. issues such as pregnancy address Drop-In Centre providing HIV and harm reduction services and HIV and harm reduction providing Centre Drop-In integrating information, condoms integrating SRHR services (including to medical facilities. Also and safer sex counselling). Referrals and SWs. to PUD community outreach exchange – as part of a national of needle and syringe Provision advocacy by MAC. from resulting programme set up by former PUD. Organisation • Malaysia (Pahang) Civil society HIV PUD and SWs (Women) • • • Hidden Women (web page on women who inject drugs in Malaysia) (page of www.aidsalliance.org; accessed 5.4.11). Hidden Women by Malaysian AIDS Council – linking organisation of International HIV/AIDS HIV/AIDS of International – linking organisation AIDS Council by Malaysian Alliance) Lessons learned HIV/SRHR integration Drug Intervention Community Pahang (DICP) Community Drug Intervention Organisation: Main programme type Key population Country of Type provider 107 107 figure text check italicsin 66 HIV/SRHR integration for key populations 108 108 integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: Korsang learned Lessons HIV andDrugUse:Community ResponsestoInjectingDrugUseand HIV: GoodPracticeGuide,InternationalHIV/AIDS Alliance,2010. • • • • • • • • PUD (includingwomen) Harm reduction Civil society Cambodia (PhnomPenh) Centre, theydon’tCentre, needasmuchmedicalattention.” and havealotofmedicalissues.Sinceweopened,the 24hourDrop-In theywould getbeatenup,injured and,inthemorning, the streets theyusedtosleep on Before, usersspendthenighthere. of ourservice services. Director Korsang says:“We a24hourprogramme.Alot are It isimportanttoprovide comprehensive andflexibleintegrated and lastingrelationships. dress casuallyandrelate toserviceusersonequalterms,buildingtrust provides supporttoPUD on theirowngrounds. Theoutreach team to theDrop-In Centre forfearofpoliceprosecution. Korsang’s approach are unaware oftheservicesavailabletothemand/or unwillingtocome Outreach iscriticalinacontextsuchasPhnomPenhwhere manyPUD themselves. staff, peereducatorsandvolunteersare current orformerdrugusers A peerapproach iscriticaltointegratedservices.MostofKorsang’s discarded needlesinpublicplaces. with localcommunities,whoappreciate efforts toreduce thenumbersof reduce discriminationagainstPUD.Havealsobuiltgoodrelationship Service provision complementedbyadvocacywithlocalauthoritiesto worker, HIVadvisor, peereducatorandspecialistinwomen’s health). Outreach delivered byfourmulti-disciplinaryteams (eachwithahealth Drop-In Centre. motorbikes toplaceswhere PUDliveortakedrugs.Alsothrough a Programme delivered through dailycommunityoutreach invansoron livelihoods. Attention tohumanrightsabuses,safespacesandsupportfor woman). treatment. Women offered accesstoSRHRadvice(delivered bya infections andhelpPUDtoaccessotherservices,suchashospital on women’s health).Healthworkersattendtominorcuts,bruisesor and bloodtests)integratingSRHR(includingcondomsinformation and syringes,informationaboutHIV, informationaboutsafeinjecting Harm reduction andHIVprogramme (withservicesincludingneedles 108 (supported byKhmerHIV/AIDSNGOAlliance) Intervention location Donor HIV epidemic outreach Community Programme EU, World Food Global Fund, AusAID, USAID, Concentrated 67 HIV/SRHR integration for key populations Concentrated Facility-based (supported by International HIV/AIDS by International (supported HIV epidemic Donor Intervention location 109 Subsiding treatment is critical to increasing uptake. For example, to increasing is critical Subsiding treatment medical consultations receiving between years 1-2, the number of PUD by 250%. on STIs increased the partners of PUD with condoms. Challenges include how to reach Drop-In Centre providing harm reduction and HIV services (including harm reduction providing Centre Drop-In of SRHR (including needle exchange) and integrating components including. Referrals to methadone services to PUD, STI treatment) maintenance clinic. peer educators and involves PUD supported by PUD Programme community. infections and STIs. for drug-related subsidised treatment Provides building carried out and methods for community involvement Team developed. including to the police. by advocacy, complemented Service provision estimated 70% of PUD in the Emei area. an Results include reaching China (Sichuan Province) • • Civil society; government HIV and harm reduction PUD • • • • • • Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Alliance Programmes and Policy Work and Potential Strategic Work Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Alliance Programmes and Policy Partnerships, International HIV/AIDS Alliance. Country Lessons learned Key population HIV/SRHR integration Five Hearts Service Centre Five Hearts Organisation: of Type provider Main programme type Alliance in China) Alliance 109 109 68 HIV/SRHR integration for key populations 110 110 integration HIV/SRHR Key population programme Main typeof provider Type of Country Open SocietyInstitute) Organisation: Genderresponsiveharmreductionprogrammes(supportedby learned Lessons Making HarmReduction Work forWomen: TheUkrainianExperience,OSI,2010. locations) Ukraine (different • • • • • • • • • (Female) PUD Harm reduction Various appointments inadvance. mobile vansmeanthatwomenwhousedrugsdonothave tomake It isimportanttooffer options forserviceprovision. Forexample, friendly spaces. outreach towomenwhouse drugsandthedevelopmentofwomen- Beyond theprovision ofintegrated services,there isalsoaneedfor health rights. Service provision complementedwithlegalaidandempowermentabout woman andchild’s healthand,asnecessary, providing ART). pregnancy andgivesupportwhentheyhavetheirbabies(monitoringthe pregnancy –tohelpthemaccessANC,provide home visitstosupport Complemented bystrategytoidentifywomenPUDatanearlystageof women tostabilizeandreceive support. the importanceofanuninterruptedsupplyduringpregnancy –enabling acting asa‘bridge’forclients).Provision ofOSTincludespromoting Referrals are totrustedandtrainedservices(withtheprogrammes trauma. Provision ofpeerandsocialsupport,includingforwomenovercoming parenting skillsandmaintaincustodyoftheirchildren). women tomakeinformedchoicesaboutchild-bearing,improve their combined withsupportonmotherhoodandfamilyissues(e.g.helping Programmes havespecificfocusonOSTforpregnant women, improve adherence totreatment. used tolinkharmreduction, SRHRandHIVservicesforindividuals specific information;counsellingandsupport).Casemanagementis (including lowthreshold services);free homepregnancy tests;gender- referral) ofART); andSRHR(including:free condoms;STItesting mobile servicesandrapidHIVtesting);provision (or, ifnotpossible, (including: informationonsafersex;HIVtesting(includinglowthreshold Services provided byprogrammes address: harmreduction; HIV integrating SRHR. Harm reduction andHIVprogrammes forwomenwhousedrugs 110 location Intervention Donor HIV epidemic outreach; mobile community Facility-based; Institute Open Society Concentrated 69 HIV/SRHR integration for key populations Concentrated (general: 0.2%; PUD: 52%) District and local municipalities Facility-based; community mobile outreach; 111 HIV epidemic Donor Intervention type Training Centres’ staff – in service delivery and supportive attitudes to – in service delivery and staff Centres’ Training PUD. NGOs and holding face-to- harm reduction with Building relationships needs. face meetings with PUD to discuss their a facilities and providing space – refurbishing the Centres’ Preparing clinic. separate entrance for the methadone Challenges include that increased uptake of integrated services has Challenges include that increased of guidelines – compounded by a lack the workload of staff increased on integrated services. Government funding means that the initiative is less dependent on than many civil society programmes. external resources committed to leadership understand/are It is vital that an organisation’s integration. – such as FP and services possible, it is important to make core Where for women PUD. for cervical cancer – free screening Community Health Centres (providing 25 primary health care polyclinics 25 primary health care (providing Community Health Centres STI services for SRHR (such as FP, providing in the same centre) ART ANC and MCH), HIV (such as HCT, and management, prevention for PUD (such as needle and reduction and harm and TB screening) Referrals to district screening). syringe exchange, OST and Hepatitis hospital for CD4 and viral load tests. to referred at methadone clinic. Women Male PUD given STI treatment MCH clinic. to the infrastructure but lack in PMTCT, at methadone clinic trained Staff hospital or to the usually referred So women are all four prongs. address NGOs. Steps for integration included: • • • including in and out-patients, Range of service delivery methods used, with a to those free mobile units and health posts. Services are government and minimal costs to others. poverty identification card referrals) and ensure (including Client flow charts used to track progress follow-up. of importance of integration for key recognition Supported by NAC’s populations. • • • • Government Primary health care PUD, SWs and MSM • • • • • • • Indonesia (Puskesmas Indonesia Java) Central Gambir, Linking Sexual and Reproductive Health and HIV: Advocacy Brief on People Who Use Drugs, Indonesia, IPPF East and South Asia and Oceania Region, Linking Sexual and Reproductive Health and HIV: 2011. Lessons learned HIV/SRHR integration Main type of programme Key population Puskesmas – Pusat Kesehatan Masyarakat – Pusat Kesehatan Puskesmas Organisation: Country of Type provider 111 111 70 HIV/SRHR integration for key populations 112 112 integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: SocialAwarenessServiceOrganisation(SASO) learned Lessons Experience), IndiaHIV/AIDS Alliance. Breaking NewGround, SettingNewSignposts:ACommunity-Based CareandSupportModelforInjectingDrugUsers LivingwithHIV • • • • • • • • • Female PUD(plusfemalepartnersofmalePUD) Harm reduction andHIV Civil society India (Imphal,Manipur) environment. SRHR, whileDrop-In Centres needtoensure awomen-friendly Small group sessionsare aneffective waytoengagewomeninHIV/ of menwhousedrugs). complexities oftheneedswomenwhousedrugsor are thepartners mechanisms andprovision ofhands-ontrainingformedicalstaff (onthe Other challengesforintegrationincludetheneedstrong follow-up PUD. and/or infectedwithHepatitisC;andhealthnotbeinga highpriorityfor aggressive stakeholders(e.g. police);highpercentage livingwithHIV include: lackoffamilysupport;incomegenerating opportunities; Challenges forintegratedprogramming forwomenwhousedrugs staff andpeereducatorsare from thecommunityandreceive training. Organisation setupbypeoplewithexperienceofdruguse.Allthe raising amongthepublic). Core AdvocacyGroup, sensitisationofstakeholders andawareness andhealthcaregovernment providers; andactiononstigma(witha service centres ontheneedsofwomenwhousedrugs;advocacyto Service provision complementedby:capacitybuildingoflocal and concealingtheirdrugusefrom healthproviders duetostigma. moneyfordrugs; use (duetolownegotiationpower);sellingsexearn Before programme, womenwhousedrugsreported: verylowcondom Programme hasbeenscaleduptotwomore districts. who usedrugsinManipur. Drop-In Centre andnightshelterare onlyspecificsupportforwomen women whousedrugs(manyofwhomare alsoinvolvedinsexwork). Female doctorprovides free basichealthcare andcheck-upsfor programme]. income generatingactivities.[SeeFigure 20fordiagramofintegrated Also provides recreational activities,vocationaltrainingandloansfor referrals forHCT, ART, PMTCT, MCH,OST, detoxificationandlegalaid. free condomsandnegotiationskillsforcondomuse).Entrypoint/ integrating SRHR(suchasSTIdiagnosisandtreatment, counselling, sessions, abscessmanagement,HepatitisCtestingandtreatment) and management ofopportunisticinfections,care andsupport,group HIV education,prevention counselling,needleandsyringeexchange, Drop-In Centre providing harmreduction andHIVservices(suchas Intervention location Donor HIV epidemic 112 community outreach Facility-based; HIV/AIDS Alliance Foundation /India Elton JohnAIDS Concentrated (ASASO-Alliance 71 HIV/SRHR integration for key populations e vices y (OST) mation t or Therap Oral Substitution and inf Health Ser xification, xual and Reproductiv Se Deto or Children inge & erdose Management f Ov & Abscess Management Educational Suppor (NSEP) t Groups Needle Syr Exchange Programme Suppor Social (SASO) Service Counselling ganisation wareness A Or Self-help Groups & Income Generation Centre (DIC) T Adherence T Clinics & Drop-in , errals or AR k-up and and Linkages aining, Capacity Building, to Community members Counselling & AR Especially f and Sensitisation Sessions Tr FGDs with IDUs Health Chec Diagnosis & Ref Group Sessions & One-to-one Interaction, Framework for integrated harm reduction, HIV and SRHR services for HIV and SRHR harm reduction, for integrated Framework Figure 20: SASO (India) who use drugs, women 2. 73

This review confirmed that there are a growing number of interesting and important experiences in putting HIV/SRHR integration into practice among key populations in a variety of contexts. In many cases, such initiatives are beginning to demonstrate results – such as increasing the range and quality of HIV and SRHR services available to key populations. Often, the successes build upon the established reputations of key population organisations within communities and their ongoing use of creative and evidence-based approaches. The review also demonstrated, however, that, despite the ‘push’ towards HIV/SRH integration for key populations, there remain a number of fundamental challenges [see Figure 21]. These require further acknowledgement and research in India and elsewhere.

Figure 21: ‘Top 10’ challenges in HIV/SRHR integration for key populations 1. Stigma and discrimination related to HIV and key populations. For example, government SRHR clinics being judgmental of sex workers and PLHIV experiencing self-stigma (such as not having the right to have children). 2. Low demand for HIV/SRHR integrated services by key populations. For example with young MSM not being aware of or empowered to demand their SRHR. 3. Lack of rights-based approaches to HIV/SRHR. For example, with programmes focusing on changing sex workers’ risk behaviours, rather than respecting their sexuality and promoting their SRH rights. Legal frameworks that violate sexual and reproductive rights serve as barriers to providing comprehensive services. 4. Low attention to gender inequality in HIV/SRHR integration. For example, with projects not recognizing the very different SRHR needs of male and female PLHIV or SRHR initiatives for people who use drugs not involving men. 5. Missed obvious opportunities for HIV/SRHR integration. For example, with organisations not using regular STI checks for sex workers or post-test counseling for PLHIV as ‘entry points’ for comprehensive contraceptive options. 6. Low understanding of key populations’ specific and diverse HIV/SRH needs. For example, people who use drugs may have very different needs for SRHR (such as depending on if they are male/female, young/old, living with HIV, etc.) 74 HIV/SRHR integration for key populations for keypopulations: identified aboutprinciples,practicesandactionstoincreaseimproveHIV/SRHRintegration Based onthefindingsandconclusionsofreview,anumberkeymessagescanbe not readymayintheshort-runactuallycompromiseoutcomesforkeypopulations. increase reachandimprovequalityofinterventions,integratingservicessystemsthatare scale upSRHR/HIVintegratedprogramming.Whilethisapproachclearlyhasthepotentialto Furthermore, thesechallengesneedtobetakenintoaccountwhennationalresponsesaim 10. 9. 8. 7. or counselorslackingskillstosupporttransgenderpeople. doctors presuming thatanalSTIsare onlyofrelevance tomale(notfemale)sexworkers Presumptions orlackofexpertiseamongserviceproviders. Forexample,with rights. resources availableforadvocacyintegration,lawreform andsexualreproductive environment forscale-upofintegratedservices.Forexample,limitedfinancial Lack ofpolitical,technicalandfinancialsupporttocreate theenabling unsuitable deliverymethodsordoesnotfollowcommunitypriorities. design isnotbasedonneedsassessmentsandthequalityofexistingservices,uses Inappropriate designofHIV/SRHRintegration.Forexample,whenprogramme could leadtoherbeingstigmatized. services. Lackofsensitizationtheserviceprovider towhichasexworkerisprovider may result inlossestofollow-upwhenanindividualisreferred forfurtherspecialized Lack ofastrong referrals systemsforHIV/SRHR.Forexample,weakreferral systems 75 HIV/SRHR integration for key populations of key needs to the unmet to respond an important opportunity presents HIV/SRHR populations. key and increase stigma and discrimination decrease particular, Integration can, in of – rangeboth HIV and SRHR support to a comprehensive populations’ access ‘whole person’ approach. focus on their vulnerability to a rights-based, moving beyond a HIV or SRHR services. the net’ of solely otherwise, ‘fall through Such support might, pose is not a ‘magic bullet’. In practice, it can HIV/SRHR integration However, populations – many of which working with key to organisations significant challenges by the current and challenges. This is exacerbated pressures face significant existing good practice in integration for specific groups. lack of clear technical guidance about long-term goal for some HIV/SRHR integration may be a good Comprehensive too rapid or too large-scale integration that is too premature, However, organisations. – key populations’ access to high quality – rather than enhancing risks compromising HIV and SRHR services. should . Instead, efforts In the short-term, full HIV/SRHR integration is not required priorities for the community and services that are start with the integration of selected of complementarity). entry point and areas easy to implement (with an obvious relatively the . However, HIV/SRHR integration shows potential to enhance cost-efficiency can of key populations mean that such programming specific and often complex needs investment. level of a realistic requires be challenging to take to scale and particularly critical with key populations are Good practice principles for work a human rights-based in HIV/SRHR integration. Examples include gender equality, PLHIV and other key populations. and the meaningful involvement of approach by and for key (particularly those that are Community systems and organisations integration happen. Beyond the critical to making populations themselves) are vital for mobilising demand, ensuring services of HIV/SRHR services, they are provision a continuum of support (for example with follow-up within and providing appropriate are communities). their community organisations cannot achieve HIV/SRHR integration on However, is needed, for example with the ‘buy-in’ of other own. Instead, a partnership approach national governments service providers, and international donors and the development and nationally). at all levels (including organisations of an enabling environment

• • • • • • • • • HIV/SRHR Integration for KPs: Key Messages for KPs: Integration HIV/SRHR © Prashant Panjiar for India HIV/AIDS Alliance 77 HIV/SRHR integration for key populations Global Network of People Living with HIV Global Network of People Living with with HIV International Community of Women Living Use Drugs International Network of People Who Global MSM Forum Network of Sex Worker Projects UN agencies – UNFPA, WHO and UNAIDS www.srhhivlinkages.org online resource pack of Inter Agency Working Group www.hivandsrh.org website of the Centre for Communication Programs, Johns Hopkins University Bloomberg School of Public Health and Constella Group India HIV/AIDS Alliance PATH Government of India The Humsafar Trust Child MAMTA Health Institute for Mother and Social Awareness Service Organisation International HIV/AIDS Alliance International Planned Parenthood Federation Guttmacher Institute Family Health International Engenderhealth Marie Stopes International Interact Worldwide Global network for each key population: • • • • • • • • Sources of information for review of information Sources from the websites of the following this report was predominantly sourced The information for organisations: India: • • • • • • Global: • • • • • • • • Annex 1: List of resources for review for 1: List of resources Annex 78 HIV/SRHR integration for key populations • • • • • • • • • • • • • • • • • • • • Resources relatedtoHIV/SRHRintegrationforkeypopulations(general) This reportisinformedbyareviewofthefollowingresourcesfromIndia: Indian resources includedinreview AIDS Alliance,2010. Learning fromOurRoleinthe HIVResponseinIndia:AnnualReport2009-10,IndiaHIV/ India HIV/AIDSAlliance. Building LinkagesandReferrals: AStepTowards Sustainability:AllianceIndia’s Experiences, Comprehensive ProgrammaticGuideforNGOs(Volume I),IndiaHIV/AIDSAlliance. inResource-PoorSettings:A Setting UpandManagingSexualHealthClinicalServices Policies inAsia,IndiaHIV/AIDSAlliance,2011. Interim NarrativeReport:CommunityActionforSexual andReproductiveHealthRights Application totheEuropeanUnion,IndiaHIV/AIDSAlliance,2008. Community ActionforSexualandReproductiveHealth andRightsPoliciesinAsia:Grant (draft), IndiaHIV/AIDSAlliance. Linking SRHRandHIV–ACommunity-CentredApproach toAchievingUniversalAccess, Groups, NationalAIDSControlOrganisation,October2007. Targeted UnderNACPIII:OperationalGuidelinesVolume Interventions 1:CoreHighRisk Family Welfare,GovernmentofIndia. Annual Report2009-2010,NationalAIDSControlOrganisation,MinistryofHealthand Married Young PeopleinIndia,PopulationCouncil,March2007. Towards MessagesthatMatter:UnderstandingandAddressingHIVSRHRisksamong Targeted forMigrants:OperationalGuidelines,2008. Interventions Red RibbonClubsProgramme(RRCP)OperationalGuidelinesforRRCFunctionaries. Control Programme,MinistryofHealthandFamilyWelfare,GovernmentIndia. NACP III:To HaltandReversetheSpreadofHIVEpidemicinIndia,NationalAIDS Family Welfare,GovernmentofIndia. Annual Report2008-2009,NationalAIDSControlOrganisation,MinistryofHealthand of FamilyWelfare(Volume48),ProfessorVimlaNadkarni,2002. TheFPAIIntegration ofHIV/STI/AIDSinFamilyPlanningServices: Experience,TheJournal 2006. SRH-HIV ConvergenceNewsletter,HIV-SRHProject(India),PATH,April Policy andPracticeUpdate3,HIV-SRHConvergenceProject(India),PATH,April2009. inIndia, Convergence ofSexualandReproductiveHealth(SRH)HIV/AIDSServices (India), PATH,December2009. HIV-SRH Convergence,PolicyandPractice Update4,HIV-SRHConvergenceProject PATH, March2007. What isConvergence?PolicyandPracticeUpdate2,HIV-SRHConvergenceProject(India), 2007. Populations: ALiteratureReview,HIV-SRHConvergenceProject(India),PATH,January inIndia:ImpactsonandImplicationsforKey Convergence ofHIVandSRHServices Pradesh, PATH,June2007. in India:FindingsfromanAssessmentAndhraPradesh,Bihar, Maharashtra,andUttar Options andChallengesforConvergingHIVSexualReproductiveHealthServices 79 HIV/SRHR integration for key populations Stories of Significance: Redefining Change: An Assortment of Community Voices and Community An Assortment of Change: Significance: Redefining Stories of Alliance, 2007. , India HIV/AIDS Articulations India HIV/AIDS Changing Face of the Epidemic in India, and HIV/AIDS: The Women Alliance. (powerpoint presentation), Alliance India Experiences and Review SRHR/HIV Integration: August 2011 India HIV/AIDS Alliance, for MSM and Health (SRH) and HIV Linkages Sexual and Reproductive What Works? Planned Parenthood Federation, 2011. People, (Draft), International Transgender People: Experiences of MSM and Transgender Linking SRH and HIV to Meet the Needs Association India, August 2011. from India, (powerpoint presentation), Family Planning of PLHIV in India, Report Better Sexual and Reproductive Health and Rights Towards Working to the European Union, India HIV/AIDS Alliance, 2011. Programme: 2000-2010, MAMTA Health Institute for Community-Based Care and Support Mother and Child, 2011. of FSWs, MSMs and TGs: Research Report Sexual and Reproductive Health Needs and Piler Sites of Alliance in Andhra Guntakal on Quantitative Findings from Warangal, 2008. Pradesh, SWASTI Health Resource Centre, December Family Planning with STI/HIV ServicesIntegration of SRH Communication and among Alliance, Avahan Initiative and (poster presentation), India HIV/AIDS Female Sex Workers, Mythri. Services for Key Population, (poster presentation), Focused STI Prevention and Treatment and Mythri. India HIV/AIDS Alliance, Avahan Initiative Reproductive Health ServicesStrengthening Access to Sexual and for People with HIV and Integration or Convergence of Research Evidence to Promote for People at Risk of HIV: Sexual and Reproductive Health services into HIV Programmes in India, Policy Brief, HIV- SRH Convergence Project (India), PATH, 2008. Services Who Have for Men Integration of Sexual and Reproductive Health and HIV-Related People in India, (draft), Family Planning Association Sex with Men (MSM) and Transgender of India, 2010 Convergence of HIV and Sexual and Reproductive Health Service for People Living with or for Capacity Building, HIV-SRH Convergence Project (India), A Toolkit Most at Risk of HIV: PATH, December 2009. Adults and Adolescents Including Post- Antiretroviral Therapy Guidelines for HIV-Infected Exposure Prophylaxis, National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, May 2007. of HIV. Guidelines for the Prevention of Mother to Child Transmission Early Infant Diagnosis (EID) Guidelines. Centres, National AIDS Control Organisation, Ministry Operational Guidelines for Link ART of Health and Family Welfare, Government of India, June 2008. • • • key populations to HIV/SRHR integration for specific Resources related • • • • • • • • • • • • • • 80 HIV/SRHR integration for key populations • • • • • • • • • • • • • • • • • Injecting DrugUsersinManipur, PopulationCouncil,2008. Exploring theLinksbetweenDrugUseandSexualVulnerability amongYoung Female AIDS Alliance. Model forInjectingDrugUsersLivingwithHIV(ASASO-Alliance Experience), Breaking NewGround,SettingSignposts:ACommunity-Based CareandSupport presentation), IndiaHIV/AIDSAlliance. Elton JohnAIDSFoundation:ProjectforFemaleInjectingDrugUsers,(powerpoint Chanura KolBaselineStudyonWomen WhoInjectDrugsinManipur,IndiaHIV/AIDSAlliance. Injecting DrugUsersinManipur,India,IndiaHIV/AIDSAlliance,2010. Grant ReportForm:MitigatingtheImpactofInjectingDrugUseandHIV/AIDSonFemale Men andGayMen,NazFoundationIndiaTrust,2001. Training Manual:AnIntroductiontoPromotingSexualHealthforMenWhoHaveSexwith and Transgender Women inChennai,India,November2008. Barriers toFreeAntiretroviralTreatment AccessforMenWhoHaveSexwith(MSM) APCOM andDepartmentofHealthHongKong(China),2010. MenandTransgenderWith PeopleintheAsia-PacificRegion,WHO,UNDP,UNAIDS, intheHealthSectorforMenWhoHave Sex Priority HIVandSexualHealthInterventions India HIV/AIDSAlliance,May2008. Needs,Gapsand Barriers, Sexual andReproductiveHealthofMales-at-RiskinIndia:Service India, FamilyHealthInternational,2010. TheAasthaProjectinMumbai, Integrating HIVPreventionandFamilyPlanningServices: Indian NetworkofPeopleLivingwithHIV,2007. Sexual andReproductiveHealthofPeoplelivingwithHIVinIndia:AMixedMethodsStudy, Programme Brief,IndiaHIV/AIDSAlliance,2007. Spotlight onWomen, Sexual andReproductiveHealthRightsHIV/AIDS: , IndiaHIV/AIDSAlliance,2006. Report BasedonKnowledge,AttitudeandPracticeSurvey Foretelling theCrisis:HIV/AIDS,SexualandReproductiveHealthWomen inIndia:A Alliance. Sexual andReproductiveHealthofWomen LivingwithHIV: AFlipbook,IndiaHIV/AIDS doc8.htm Samarth Project(websiteofUSAIDIndia);http://www.usaid.gov/in/our_work/health/hiv_ Affected byandLivingwithHIV, IndiaHIV/AIDSAlliance. Issue Brief:SexualandReproductiveHealthRights–KeyIssuesforAdolescents IndiaHIV/AIDSAlliance. Widows, Issue Brief:SexualandReproductiveHealthRights–KeyIssuesforHIV-Affected IndiaHIV/ 81 HIV/SRHR integration for key populations

Meeting of the UNAIDS Programme Coordinating Meeting of the UNAIDS Programme

Board, June 2010. or Break?, Friends Africa, Global AIDS Alliance, Mobilizing for RH/HIV Integration: Make Alliance, IPPF and Population International, 2010. Interact Worldwide, International HIV/AIDS and HIV Linkages: A Generic for Sexual and Reproductive Health Rapid Assessment Tool GNP+ and Young Positives, 2009. Guide, IPPF, UNAIDS, UNFPA, WHO, ICW, 2005. A Framework of Priority Linkages, WHO, UNFPA, UNAIDS and IPPF, Services into Reproductive Health Settings and Testing Counselling Integrating HIV Voluntary Planners, Managers and Service– Stepwise Guidelines for Programme Providers, UNFPA & IPPF (2004). Interventions:Linking Family Planning with HIV/AIDS A Systematic Review of the Evidence, C, Almers L, Packel L, Mirjahangir J, Kennedy G, Spaulding AB, Brickley DB, Kennedy 23, pp. S79-88, 2009. Collins L, Osborne K & Mbizvo M, AIDS. Evidence for Delivering Integrated HIV and SRH A Five-year Research Project to Gather services HIV Prevalence Settings, INTEGRA. in High and Medium Health & Rights (SRHR): Report on Existing Integration of HIV and Sexual and Reproductive and Potential Strategic Partnerships, International Alliance Programmes and Policy Work HIV/AIDS Alliance. a Variety Exploring Integrated SRH and HIV Models and Programming Examples from of Settings in Countries/Areas with Concentrated HIV Epidemics, Amitrajit Saha, Anna AIDS Zakowicz, Dawn Averitt Bridge, Jill Gay, Robert Carr, (Presentation at International Conference), July 2010. Health, Rights Good Practice Update: Linkages and Integration of Sexual and Reproductive Approach, International HIV/AIDS Alliance, March 2009. The Alliance and HIV: Health and Intimate Links: A Call to Action on HIV/AIDS and Sexual and Reproductive Rights, Interact Worldwide. Hiding in Plain Sight: The Role of Contraception in Preventing HIV, Susan A Cohen, Guttmacher Policy Review, Volume 11, Number 1, Winter 2008. Despite Consensus and Mounting Evidence, Challenges to Improved HIV–Reproductive Health Linkages Remain, Heather D. Boonstra, Volume 11, Number 4, Guttmacher Policy Review, Fall 2008. Care and Support in Sexual and Models of Care Project: Linking HIV/AIDS Treatment, Reproductive Health Care Settings: Examples in Action, International Planned Parenthood Federation, 2005. Integration of HIV and Sexual and Reproductive Health and Rights: Good Practice Guide, Sexual and Reproductive Health Integration of HIV and International HIV/AIDS Alliance, December 2010. International HIV/AIDS the Design, Implementation and Programming Standards: For Use in Good Practice HIV Alliance, June 2010. Programmes, International HIV/AIDS Evaluation of Alliance Alliance, International HIV/AIDS and Sexuality: Responding to HIV, Approaches to Gender February 2011. Health (SRH) ServicesThematic Segment: Sexual and Reproductive with HIV Interventions in Practice: Background Paper, 26th • • • • • • • • • • • • • This report is also informed by a review of the following resources from around the world: from around the following resources by a review of the is also informed This report (general) HIV/SRHR integration for key populations Resources related • Global resources included in review included resources Global • • • 82 HIV/SRHR integration for key populations • • • • • • • • • • • • • • • • • • • • Council, 2008. Population the IntegrationofFamilyPlanning andOtherReproductiveHealthServices, Assessing IntegrationMethodology (AIM)Toolkit: AHandbookforMeasuringandAssessing APN+, August2009. (MSM), Transgender (TG)andInjectingDrugUsers(IDU):ResearchFindingHighlights, Access toHIV-Related inPositiveWomen, HealthServices MenwhohaveSexwith Recommendations forAction,IPAS,2005. HIV/AIDS andReproductiveHealth:SensitiveNeglected Issues:AReviewofLiterature, Checklist, NGOCodeofGoodPractice. Getting Closer–LinkingHIVandSexualReproductive Health:Self-Assessment Working inHighHIV/STIPrevalenceSettings,PopulationCouncil2008. Providers The BalancedCounsellingStrategyPlus:AtoolkitforFamily PlanningService 2003. Counselling onDualProtection:STD/HIVandPregnancy:AGuideforProjectStaff, Counselling: ATraining Manual,Engenderhealth,2009. Integration ofHIVandSTIPrevention,SexualityDualProtectioninFamilyPlanning Health Settings,IPPF,2002. Programme GuidanceforCounsellingSTI/HIVPreventioninSexualandReproductive , PopulationCouncilandUNFPA,2010. HealthServices Health andPrimary GuidanceforIntegratingFamilyPlanningandSTI/RTIServices withotherReproductive Planning andImplementinganEssentialPackageofSexualReproductiveHealth Youth WorkingGroup,USAID,IATTonHIVandYoungPeopleFHI,2010. Young PeopleMostatRiskofHIV: AMeetingReportandDiscussionPaper, Interagency Recommendations forAction,IPAS,2005. HIV/AIDS andReproductiveHealth:SensitiveNeglectedIssues–AReviewofLiterature, and AccesstoSRHR,InteractWorldwide,2011. Who AreWe Failing?HowMarginalisationandVulnerability AffectAdolescents’Needsfor 2010. and ReproductiveHealthHIVLinkages,UNFPA,WHO,UNAIDSDecember ImplementationoftheRapidAssessmentToolConsultation toDiscussCountry forSexual Worldwide, November2006. AIDS Alliance,InternationalHIV/AIDSPopulationActionandInteract Opportunities andStrategiesfortheGlobalFundtoFightAIDS,TBMalaria,IPPF, Integration betweenSexualandReproductiveHealthHIVAIDSMalaria: WHO Bulletin,Volume87,Number11,805–884,November2009. Special Theme:StrengtheningLinkagesbetweenSexualandReproductiveHealthHIV, International PlannedParenthoodFederationWesternHemisphereRegion,2006. Integrating HIV/AIDSTreatment andCareintoReproductiveHealth Settings,SpotlightNo.4, Recommendations, UCSF,WHO,UNAIDS,UNFPAandIPPF,2009. Sexual andReproductiveHealthHIVLinkages:EvidenceReview In aLife:LinkingHIVandSexualReproductiveHealthinPeople’s Lives,IPPF,July2010. Settings, IPPF,2006. In aLife:LinkingHIVTreatment, CareandSupportinSexual ReproductiveHealthCare In aLife:LinkingHIVandSexualReproductiveHealthinPeople’s Lives,IPPF,2008. PATH, 83 HIV/SRHR integration for key populations Family Health Family Health A Toolkit, with HIV: for Clients Access to Contraception Increasing International, 2008. Guttmacher People Living with HIV, and Reproductive Health Needs of Meeting the Sexual ICW and GNP+, 2006. UNFPA, WHO, EngenderHealth, IPPF, Institute, UNAIDS, Living with HIV – Counselling Tool, and Family Planning for People Reproductive Choices WHO, 2006. Consultation Report, GNP+ and UNAIDS, and Prevention: Technical Positive Health, Dignity 2009. Rights of People Living with HIV: and Reproductive Health and Human Advancing the Sexual UNAIDS, Positives, EngenderHealth, IPPF and GNP+, ICW, Young A Guidance Package, 2009. , IPPF, GNP+, ICW and UNAIDS, 2008. The People Living with HIV Stigma Index Reproductive Health and Rights for People Living with Amsterdam Statement on Sexual and GNP+, December 2007. HIV, Adolescent Girls: Manual for and Women Sexual and Reproductive Health for HIV-Positive Community of and Programme Managers, ENGENDERHEALTH and International Trainers Women Living with HIV, 2006. Therapy ServicesIntegrating Family Planning and Antiretroviral in Uganda, Family Health International, 2010. Services in Kenya, Family Health and Treatment Integrating Family Planning into HIV Care International, 2010. Maternal and Child through Family Planning in HIV Transmission Preventing Mother-to-Child Health Services: and South Africa, Family Health International, 2010. Kenya, Rwanda, Family Health International A Toolkit, for Clients with HIV: Increasing Access to Contraception and Engenderhealth, 2010. as HIV Prevention: Stakeholder Mapping to Identify Increasing Support for Contraception Influential Individuals and Their Perceptions, Family Health International, Plos ONE Volume 5, May 2010. A Five-Country Study of Family Planning and HIV Integrated Services, Family Health International, 2010. Centers in and Testing Counseling Integrating Family Planning Services into Voluntary Kenya: Operations Research Results, Family Health International, 2006. Family Planning–Integrated HIV Services: A Framework for Integrating Family Planning and Antiretroviral Therapy Services, The Acquire Project and USAID, June 2007. How to Strengthen Family Planning and HIV Service Essential Steps: Integration, Family Ten Health International. Living with HIV/AIDS: Guidelines on Care, Sexual and Reproductive Health of Women Living with HIV/AIDS and Their Children in Resource- for Women and Support Treatment Constrained Settings, WHO, 2006. Living with Advancing the Sexual and Reproductive Health and Human Rights of People of HIV Report of Study on the Uptake of Prevention of Mother to Child Transmission HIV, Services by People Living with HIV in Nairobi, Kenya, NEPHAK and GNP+, January 2010. Living with Advancing the Sexual and Reproductive Health and Human Rights of People from Studies in Kenya, Nigeria and Zambia, GNP+, NEPHAK, NZP+ and Key Findings HIV: NEPHAN, April 2010. Resources related to HIV/SRHR integration for people living with HIV for people living integration related to HIV/SRHR Resources • • • • • • • • • • • • • • • • • • • • 84 HIV/SRHR integration for key populations • • • • • Resources relatedtoHIV/SRHRintegrationforsex workers • • • • • • • • • • • • • • • • 2006. HIV andSTIPreventionamong SexWorkers inEastern EuropeandCentralAsia,UNAIDS, Sex Work, Violence andHIV , InternationalHIV/AIDSAlliance, 2008. Associacao BrasileiraInterdisciplinardeAIDS,2010. Sexuality andDevelopment:BrazilianNationalResponse toHIV/AIDSAmongstSexWorkers, with HIV: PolicyBriefing,GNP+andNSWP,May2010. Advancing theSexualandReproductiveHealthHuman RightsofSexWorkers Living presentation), UNFPAAsiaPacificRegionalOffice,August 2011. Advancing SexualandReproductiveHealthRights forSexWorkers, (powerpoint • • • • • Tools inFP/ART-Integrated forFacilitativeSupervision EngenderHealth,2007: Services, Hormonal ImplantsandDualProtectionMessages,PSIZimbabwe. inZimbabwe: Case Study:Zimbabwe,IntegrationofFamilyPlanningandHIVServices Progress andChallengesunderIMPACT 2010,InternationalHIV/AIDSAlliance. Study,Caribbean: Country ofAchievements, Studies:AGlobalSummary AllianceCountry Gateways toIntegration:ACaseStudyfromHaiti,WHO,UNFPA,UNAIDSandIPPF,2008. Gateways toIntegration:ACaseStudyfromKenya,WHO,UNFPA,UNAIDSandIPPF,2008. WHO,USAIDandFamilyHealthInternational,2009. AIDS Policies,Programs,andServices, Strategic ConsiderationsforStrengtheningtheLinkagesbetweenFamilyPlanningandHIV/ 2009. Gateways toIntegration:ACaseStudyfromSerbia,WHO,UNFPA,UNAIDSandIPPF, Zambia: BriefingPaper,InternationalHIV/AIDSAlliance,2011. Needs, ChallengesandOpportunities:AdolescentsYoung PeopleLivingwithHIVin Ukraine, GNP+,HSRCandUniversityoftheWitwatersr,June2009. Study:InsightsfromSouthAfrica,TanzaniaHIV DiscordantCouples:AnExploratory andthe IPAS, September2010. Expanding ReproductiveRightsandKnowledgeAmongHIV-Positive Women andGirls, Becoming PregnantWhenYou’re HIVPositive,TheBody,2010. Healthy, HappyandHot,IPPF,2010. the Ukraine,GNP+,HRSCandUniversityofWitwatersr,2009. Study:InsightsfromSouthAfrica,TanzaniaHIV DiscordantCouples–AnExploratory and Evidence fromBangladesh,DominicanRepublicandEthiopia,IPPF,2011. Piecing ItTogether forWomen andGirls:TheGenderDimensionsofHIV-Related Stigma: Linking FamilyPlanningtoPMTCT: EmpoweringWomen LivingwithHIV, WHO. website ofGuttmacherInstitute),November2006. Meeting theSexualandReproductiveHealthNeedsofPeopleLivingwithHIV, (Articleon Supervisory StyleSelf-AssessmentChecklist. Services Checklist forAssessingPerformanceoftheOn-SiteSupervisor:FP-IntegratedART Services Checklist forAssessingPerformanceoftheOff-SiteSupervisor:FP-IntegratedART Supervision forFP-IntegratedAntiretroviralTherapyServices Essential ElementsofanFP-IntegratedAntiretroviralTreatment(ART)Program 85 HIV/SRHR integration for key populations Development Connections: A Manual for Integrating the Programmes and Services the Programmes A Manual for Integrating Connections: Development of HIV 2009. , UNIFEM Women against and Violence Counselling: A Meeting Report, and in HIV Testing Women against Addressing Violence WHO, 2006. 2005. the Lancet Volume 366, December Michael L Rekart, Harm Reduction, Sex Work , International HIV/ with Sex Workers A Guide for Programmes and HIV: Violence Sex Work, 2008. AIDS Alliance, May Community- the Results of Monitoring and Evaluating Learning from and Sex Work: Violence , India HIV/AIDS in India: Think Piece Female Sex Workers Responses among Led Violence Alliance. NGO Alliance, July , Khmer HIV/AIDS of Activities: Entertainment Workers Standard Package 2008. AIDS Prevention Projects: Case of Integrated Health Linking Reproductive Health to HIV & , Young Power in Social Action, 2008. Centers (IHCs) in Chittagong, Bangladesh The Experience of SRH & HIV/AIDS NGOs and CBOS in Ecuador: Together Working (powerpoint Hourcade Bellocq, LAC Team, Frontiers Prevention Programme, Javier Alliance. presentation), International HIV/AIDS in Asia and the Sexual and Reproductive Health Services for MSM and Transgenders Asia Pacific , (powerpoint presentation), FHI 360 Pacific: Challenges for Future Programming Region, August 2011. Summary and Programme Recommendations: From FHI MSM Report of Key Findings Indonesia and Nepal), Family Health International. Programme Evaluations (Bangladesh, Health and Human Rights of Men Who Have Sex Advancing the Sexual and Reproductive Policy Briefing, GNP+ and MSMGF, May 2010. with Men Living with HIV: Services and Reproductive Health and HIV-Related Advocacy Brief: Integration of Sexual People in India, (draft), Family for Men Who Have Sex with Men (MSM) and Transgender Planning Association of India, 2010. Between Men: HIV/STI Prevention for Men Who Have Sex With, International HIV/AIDS Men Alliance, August 2003. Country Study: Morocco, International HIV/AIDS Alliance. Health Needs of Looking Back, Moving Forward: Understanding the HIV Risk and Sexual Men Who Have Sex With Men: Horizons Studies 2001 to 2008, Horizons, 2010. Health, Welfare Developing Community-Based Organisations Addressing HIV/AIDS, Sexual and Human Rights Issues for Males-Who-Have-Sex-With-Males, Partners and Their Families, NAZ Foundation International. Standard Package of Activities: Men Who Have Sex With Men, Khmer HIV/AIDS NGO Alliance, July 2008. ServicesRegional Consensus Meeting: Developing a Comprehensive Package of to Reduce Populations in Asia and the HIV Among Men Who Have Sex with Men and Transgender Pacific, UNDP, ASEAN, WHO, UNESCO, UNAIDS, USAID, APCOM, 2009. HIV and Men Who Have Sex With Best Practice Men in Asia and the Pacific: UNAIDS Collection, UNAIDS, 2006. • • • • • • • • for men who have sex with men and Resources related to HIV/SRHR integration transgender people • • • • • • • • • • • 86 HIV/SRHR integration for key populations Good practicestandard11 Good practicestandard10 • • • • • • • • • • • Resources relatedtoHIV/SRHRintegrationpeoplewhousedrugs • • • • Making HarmReductionWork forWomen: TheUkrainianExperience,OSI,2010. Standard PackageofActivities:DrugUsers,KhmerHIV/AIDSNGOAlliance,July2008. Response, InternationalHIV/AIDSAlliance. Developing HIV/AIDSWork Assessment and withDrugUsers–AGuidetoParticipatory Report, UNAIDS,ICDDRB,UNODCandWHO,2010. Female DrugUsersandRegularSexPartnersofMaleinBangladesh:A aidsalliance.org; accessed5.4.11) Hidden Women (webpageonwomenwhoinjectdrugsinMalaysia)(pageofwww. Guide, InternationalHIV/AIDSAlliance,2010. HIV andDrugUse:CommunityResponsestoInjectingUseHIV: GoodPractice South EastAsiaandOceaniaRegionIPPF,2011. Linking SRHandHIV: AdvocacyBriefonPeopleWhoUseDrugs,Indonesia,(draft)Eastand 2007. for HIV-Positive InjectingDrugUsers,FamilyHealthInterantional,USAID,ASEANandWHO, Module 11:PsychiatricIllness,PsychosocialCareandSexualHealthTreatment andCare OSI. Women, HarmReductionandHIV,InternationalDevelopmentProgramme, Drugs, Indonesia,IPPFEastandSouthAsiaOceaniaregion,2011. Linking SexualandReproductiveHealthHIV: AdvocacyBriefonPeopleWhoUse Living withHIV: PolicyBriefing,GNP+andINPUD,May2010. Advancing theSexualandReproductiveHealthHumanRightsofInjectingDrugUsers International HIV/AIDSAlliance,UNESCOandPurpleSkyNetwork,2007. with Men:AReferenceManualforPeerandOutreachWorkers, USAID,FHI,PSIAsia, Peer OutreachandEducationforImprovingtheSexualHealthofMenWhoHaveSex Policy Initiative,2008. The Value ofInvestinginMSMProgramtheAsia–PacificRegion:PolicyBrief,Health Transgender People,UNAIDS,2009. Menand UNAIDS ActionFramework:UniversalAccesstoMenWhoHaveSexWith WHO, 2008. menandTransgenderWho HaveSexWith Populations: ReportofaTechnical Consultation, Prevention andTreatment ofHIVandOtherSexuallyTransmitted InfectionsAmongMen 87 HIV/SRHR integration for key populations Increased access to Increased HIV testing, safer sex information and treatment services. Counselling on partner violence integrated into HIV and couples/family counseling. Reduction in stigma and discrimination. and other Access to ART for resources treatment better health. information Comprehensive and services to allow a healthy and satisfying sexual life. Choice about contraception, safe abortion and whether or not to have children. risk of HIV Ability to reduce transmission to children. • • • • • • • What change is needed? Many people do not know that they have Many people do not safer sex and HIV and do not access services. treatment and violence blame Many people suffer status, of their HIV upon disclosure often particularly women, who are diagnosed first at antenatal clinics. Stigma and discrimination can lead to and home; poor children loss of partner, access to services; poor quality care; isolation; and lack of work and housing. to access resources Lack of financial services and commodities. and food with children ART People share and partners. people living of Some people disapprove with HIV engaging in sexual activity and stigma and leading to having children, discrimination. Reluctance of health workers to give living contraceptives to people reliable with HIV because of the fear that they will stop using condoms. may lack knowledge of Health providers safer methods of conception for people living with HIV and on ART. In some parts of the world, it is difficult women to assert their for HIV-positive right to have a safe abortion. Other to have an pressured women are abortion because of their HIV status. risk of STIs, cancers and Increased maternal mortality. • • • • • • • • • • Key SRHR vulnerabilities People living with HIV Group Integration of HIV and Sexual and Reproductive Health and Sexual and Reproductive Health extract from Integration of HIV and The following is an Alliance, 2010: Guide, International HIV/AIDS Rights: Good Practice Annex 2: Key SRHR vulnerabilities for key populations: populations: for key vulnerabilities 2: Key SRHR Annex Guide Good Practice Alliance 88 HIV/SRHR integration for key populations use drugs People who • • • • • Multiple causesofstigma. children takenintocare. Childbearing isdisapproved ofand treatment inpregnancy andlabour. of pooraccesstoopiatesubstitution because offeararrest andbecause Babies maybeabandonedatbirth via injectingomitsSRHneeds. Focus onpreventing HIVtransmission services. partners ofmenwhousedrugslack Women whousedrugsandfemale • • • • reduction services. integrated intoharm services alongsideor STI diagnosisandtreatment exclude activedrugusers. must ensure theydon’t and otherhealthservices reduction services.SRH drug users,linkedtoharm Friendly SRHservicesfor than thepill. implants more acceptable contraceptives suchas may findlongeracting Women whousedrugs safe abortionservices. contraception and protection, emergency contraception, dual Drug user-friendly substitution treatment. PPTCT andopiate who usedrugs,including health servicesforwomen pregnancy andmaternal Drug user-friendly 89 HIV/SRHR integration for key populations Counselling on preferred on preferred Counselling condoms contraceptives, and other safer sex methods (intrauterine increase devices alone may risk of HIV/STI infection). Discussion of the impact of hormonal pills, injections or implants on menstrual bleeding. workers Counselling for sex but who want to conceive that their lover is the ensure father. Counselling on sex work and during pregnancy the risk of STIs reducing and HIV for the mother and foetus. Discuss anti-violence strategies with sex workers, support collectivisation and of safe spaces creation and link up with sex-worker friendly legal, health and support service providers. Support the mother to and attend antenatal care, she will plan for where for costs and care deliver, the baby after it is born. • • • • • • Sex workers experience stigma and Sex workers experience through discrimination demonstrated abuse, and often physical and verbal focus on HIV/STI criminalization The omits other SRH needs such prevention and MNCH. as family planning workers, including The home life of sex is partners and children, their regular ignored. have anti- Only 21% of countries rights the laws that protect discrimination of sex workers. or in moralistic Social attitudes result sex work to stop punitive approaches rather than meet the SRH and HIV needs of sex workers. Emotional, psychological and physical violence is common and is exacerbated underground when sex work is forced unfamiliar hidden, e.g. selling sex in more develop limiting the ability to areas; solidarity with other sex workers to build support and social capital, and negotiate with health and social service providers. the police from Lack of legal protection sex work is even where and judiciary, legal due to societal attitudes or related activities such as soliciting for clients being illegal, making sex workers less likely to make a complaint to the authorities if they have experienced violence. Lack of understanding of sex workers’ rights. Limited participation and prioritisation of sex workers in SRH and HIV responses. of sex workers are proportion A large reach. invisible and difficult to (In addition to the SRHR vulnerabilities of to the SRHR vulnerabilities (In addition all women) • • • • • • • • • Female sex Female sex workers 90 HIV/SRHR integration for key populations sex workers transgender Male and with men have sex Men who • • • • • • • • • • • for menwhohavesexwithmen. delivery ofeffective HIV-related services regulations andpoliciesthathinderthe 41% ofcountriesreported laws, inequality. partners duetostigmaandsocial Difficulty disclosingHIVrisktofemale to femalepartnersandchildren. fertility andpreventing HIVtransmission reproductive health,includingprotecting Lack ofinformationandserviceson STIs. who havesexwithmensuchasanal respond tothespecificneedsofmen Lack ofuser-friendly servicesable to make themsafer. practices, includinganalsex,andhowto Lack ofinformationonarangesexual criminalisation ofsame-sexrelationships. Stigma, discriminationand risk. talk tothemabouttheirworkandHIV partners andchildren finditdifficultto Male sexworkerswhoalsohavefemale SRH response. transgender sexworkersintheHIVand Less attentionisgiventomaleand criminalised inmanycountries. Sex betweenmenandsexworkis HIV needs. rather thanmeetsexworkers’SRHand punitive approaches tostopsexwork Social attitudesresult inmoralisticor and HIVstatus. between men,sexwork,genderidentity Multiple layersofstigmarelated tosex • • • • • • • • • • esteem. tackle issuesaround self- Positive role modelsto PPTCT. partners andchildren, and transmission tofemale to avoidSTIsandHIV including fertility, how reproductive health Information about them safer. practices andhowtomake on therisksofsexual Comprehensive information anal cancer. gonorrhoea, hepatitisand damage, oralandanal related toanusandrectum services; forexample, Specific informationand stigma. self-esteem andreduce Interventions toincrease children, andPPTCT. female partnersand fertility, protection of reproductive health, and counsellingon sessions Learning STIs. Services foranalandoral how toreduce them. of allsexualpracticesand Information ontherisks vital. Work toreduce stigmais doctors. trained, non-judgmental avoid stigma,suchas Discreet servicestohelp 91 HIV/SRHR integration for key populations Health care workers workers Health care treat trained to transgender people (using with respect name, their preferred female allowing the use of toilets and being non- judgmental). Acknowledge geographic and and social isolation potential trauma history. Counselling and learning sessions on accepting being female. of safer Provision alternatives to prosthetic and implant materials. for hepatitis Vaccinations A and B. Information on STIs and timely treatment. Small condoms for neopenises and urgent consultation if condoms slip or break. Lubrication for neo- vaginas. Information on possible interaction between ART and hormones • • • • • • • • • Multiple causes of stigma, discrimination of stigma, discrimination Multiple causes and criminalization. rape and murder. Violence, law and state. Persecution by the Police abuse and imprisonment. and school Rejected by society, into sex work. workplace and forced Poverty. violence and discrimination by Prejudice, health service providers. information and Lack of comprehensive and HIV needs. services to meet SRH and hormone injections. Unsafe surgery Misuse of silicone and oils as implants. Low self-esteem and depression. Use of drugs and alcohol. • • • • • • • • • • • Male to female transgender and transsexual people 92 HIV/SRHR integration for key populations • • • Gender isanimportantfactorinvulnerabilitytoHIV: Gender andvulnerability work effectivelywithwomenwhousedrugs. such asSRHservicesormicro-financingprogrammes,oftenlacktheskillsandexperienceto intimidate women,orsimplynotmeettheirneeds.Alongsidethis,servicestargeting children. Supportgroupsorpeereducationrunbymenwhousedrugscanexclude services, donotofferpregnancyormaternalhealthservicesprogrammesforwomenwith that womenfeellikeoutsidersandtheirneedsarenotmet.Forexample,manydrugs Most servicesforpeoplewhousedrugsaredirectedtowardstheneedsofmen.Thiscanmean Lack of“women-friendly”services transmission ofHIV.Manythembeunawaretheirvulnerability. use drugs,thesewomenandtheirbabieschildrenareveryvulnerabletothesexual drugs, yettheydonotusedrugsthemselves.BecauseofhighratesHIVamongmenwho Large numbersofwomenaremarriedtoorinasexualrelationshipwithmenwhouse multiple vulnerabilities,needsandriskpractices. These different(andnotmutuallyexclusive)socialroles,behavioursandfactorscanleadto • • • • • • use andHIVweinclude: for men,butsomeareverydifferent.Whenwespeakaboutwomen’sneedsinrelationtodrug Women areaffectedbydruguseinmanyways.Someoftheseeffectssimilarorthesame Women Drug UseandHIV: GoodPracticeGuide,InternationalHIV/AIDSAlliance,2010. The followingtextisanextractfrom:HIVandDrugUse:CommunityResponsestoInjecting Alliance GoodPracticeGuide Annex 3:GenderandSRHRissuesforpeoplewhousedrugs: violence andabuse. multiple vulnerabilitiesintermsofHIV–sexwork,marginalisation andincreasedexposureto Men whohavesexwithmen,andtransgenderpeople who usedrugsoftenexperience sub-cultures. Drug use,includinginjectingdrugisinfluencedby gendernormsindifferentculturesor Women haveparticularvulnerabilitiestoHIVrelated injecting druguse. young womenandgirls. women livingwithHIVwhoareusingdrugs pregnant womenwhoareusingdrugs,andmothersdrugs women whousedrugsandsellsex women whoarepartnersofdrugusers,includingwivesandwidows women whousedrugs 93 HIV/SRHR integration for key populations are more likely to be injected by their male partners – being injected by another person or injected by their male partners – being are more likely to be is a predictor of HIV infection being helped to inject equipment the last person to use shared injecting are more likely to be on their sexual partners to obtain drugs, which who inject drugs are often dependent safer sex or safe injecting practices. compromises their ability to negotiate Women and injecting – risks and vulnerabilities injecting – risks Women and women who among the average HIV prevalence show that nine European countries Studies in in China and Kenya also demonstrate than among men who inject. Studies inject is 50% higher amongst women who inject. higher HIV prevalence relationships, and they often borrow injecting drugs in the context of sexual Many women begin Gender inequality in many developing from their male partners. or share injecting equipment that can affect injecting practices. is also reflected in social patterns and transitional countries For example, women: • • • access to services than men who inject drugs. There is Women who inject drugs have lower programmes in Central and Eastern Europe and South- evidence of this among HIV prevention treatment programmes in South Asia. East Asia, and among drug dependence Women, sex work and drug use sex or transactional sex to deal with drug dependency, Many women engage in commercial sex is generally the exchange of sex for money, poverty and homelessness. Commercial informal and involve the exchange of sex for drugs, a whereas transactional sex can be more who use drugs in Imphal, Manipur, exchange sex place to stay or food. For example, women for drugs and for a place to sleep. to take risks in sex work because of their drug habits or Women who use drugs are more likely likely to work in brothels. They are less likely to have access those of their partners, and are less showed that drug-using sex workers were likely to have to or use condoms. A study in China often than non-drug-using sex workers. more clients and use condoms less Pregnancy and motherhood reverse happens and Women who use drugs and are pregnant need extra support. Often the themselves they are marginalised as health care workers, families, partners and the women babies. In fact, drug- assume that their drugs will be causing substantial harm to their unborn problems relating using pregnant women and their unborn babies are more likely to experience use than from illicit to malnutrition, lack of sleep, lack of medical care and tobacco and alcohol pregnancies drug use itself. Because women who use drugs sometimes stop menstruating, as well, the need can go undetected. When pregnant women who use drugs are HIV positive of mother-to- for supportive medical care intensifies, in particular ensuring access to prevention child transmission (PMTCT) programmes. means they give Women who use drugs in maternity wards rarely have access to OST. This giving birth in order birth in states of withdrawal, and need to leave hospital immediately after can be a good to buy drugs. When women who use drugs discover they are pregnant, it and HIV, and opportunity to reassess their drug use and seek treatment for drug dependency of their children. This promote maternal health. Mothers who use drugs may fear losing custody services, for means they become reluctant to use services, including HIV and drug dependency fear that their children will be taken away by the authorities. 94 HIV/SRHR integration for key populations Review thedataasateam and usethatinformationtoimprovetheservicesyouprovide. service dataduringanappropriate timeframe,usingstandardindicatorsandreporting systems. the HIVserviceisresponsibleforreportingdelivery ofintegratedservices.Collectrelevant 10. Monitorandevaluateperformance.Determinewhetherthefamilyplanningserviceor promoting dualprotectionanddual-methoduse. of integratedservices.Makesurethesedocumentsaddress contraceptionandchallengesin monitoring forms,providerjobdescriptions,andchecklists—for consistencywiththeprovision 9. Strengthenskillsforsupportivesupervision.Updatedocuments—supervisionprotocols, monthly follow-upsystemtotrackcompletedreferrals. organizations). Developacontactlistwithphonenumbers ande-mailaddresses.Institutea provided onsite(publicandprivatefacilitiesthoseoperatedbynongovernmental 8. Reinforcereferralsystems.Mapallavailablesourcesofcontraceptivemethodsnot healthy sexualrelationshipsandtobecomepregnantifdesired. are inappropriateforpeoplelivingwithHIV.SupporttherightofHIVtoenjoy neglect othercontraceptivemethods.Correctthefalsebeliefthatsomemethods 7. Challengeproviderbias.Addressthetendencyofproviderstoemphasizecondomsand sexually transmittedinfections. with anothercontraceptivemethod.Stresstheimportanceofpreventingbothpregnancyand male andfemaleclientstousecondomscorrectlyconsistently, 6. Fosterdualprotectionanddual-methoduse.Developcounselingstrategiestoencourage records. and currentcontraceptiveuse.Screenclientsatregularintervalsupdateinformationintheir and allmenshouldbeaskedabouttheirsexualactivity,desireforpregnancyinthenearfuture, 5. Screenallclientsforanunmetneedcontraception.Allwomenofchild-bearingage Internet, organizein-housestudygroups,andusepeer-to-peersupport. criteria forcontraceptiveusebypeoplelivingwithHIV.Accessfreetrainingmaterialsonthe cadres andcommunityhealthworkers.LearntheWorldHealthOrganization’smedicaleligibility 4. Trainproviders.Provideinformationandtraininginbasiccounselingskillstolowerlevel network andwithinthefacility. contraceptives andHIVsupplies.Developaplanforreliablesupplysystemwithinthelocal 3. Ensurecommoditysecurity.Registeryourfacilitywiththeappropriateauthoritiestoreceive and clientcosts. rearranging moveablefixtures.Determinehowservicescanbechangedtoreducewaitingtime available space;reducecostsbyofferingservicesindifferentrooms,modifyingwaitingareas,or 2. Organizeservices.Learnhowyourclientsmovethroughthefacility.Drawadiagramof groups totellothers. brochures, andleaflets.Encouragecommunityhealthworkers,volunteers,localsupport 1. Generatedemandforintegratedservices.Advertizetoyourclientsusingposters, and HIVserviceintegration(FamilyHealthInternational) Annex 4:Tenessentialstepstostrengthenfamilyplanning [Reference: Ten Integration,FamilyHealthInternational] EssentialSteps:HowtoStrengthenFamilyPlanningandHIVService

India HIV/AIDS Alliance Kushal House, Third Floor 39 Nehru Place New Delhi – 110019 +91-11-4163-3081 [email protected]