JANUARY 2016 Issue 5

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Drugs, Data, Deliberations: Putting it Into Perspective People who inject drugs continue to be disproportionately affected by HIV because of limited investment in — and access to — proven interventions. Even when effective services are available, severe stigma and punitive laws create barriers to their use, compounding people’s risk of acquiring HIV and hepatitis infection through unsterile injection equipment.

Discrimination against drug users and criminalization of drug use also make it difficult to collect accurate data about people who inject drugs. Estimates of HIV prevalence among people who inject drugs; the size of drug-using populations; and their use of HIV prevention, care, and treatment services are incomplete, as is understanding of their needs and risk behaviors, because many people are unwilling to identify themselves as users of illicit drugs.

All over the world, successful responses Photo Credit: © Malaysian AIDS Council / International HIV/AIDS Alliance to the HIV epidemic have been driven in large part by two key factors: Personal experiences inspired Amran Ismail to establish the first community- political commitment and agency of the based organization in Kuala on the east coast of Malaysia, CAKNA, which constituency group. For people who supports people who inject drugs. inject drugs, neither of these pillars has been given sufficient attention The Link, our guest authors write about of people who inject drugs are often and dedicated focus. In this issue of innovative efforts to strengthen both. gender-neutral or heavily skewed toward the men. Although women who In this issue On page 4, Judy Chang writes about inject drugs are even more hidden than Afghani women who use drugs—a 1 | Drugs, Data, Deliberations their male counterparts, they account 3 | HISTORIES OF COMMUNITY ACTION group who, traditionally, has had about for about one-third of all people who 4 | OUT OF THE SHADOWS as little agency as it’s possible to have. inject drugs.1 5 | DATA AND HUMAN RIGHTS Chang explains how gaps in the data 6 | WHAT WORKS FOR WHOM AND WHERE on these particular women—but also Estimates of those receiving evidence- 7 | in Focus: LINKAGES IN INDIA for all women who inject drugs—are informed and rights-based HIV 8 | The People @ LINKAGES particularly pronounced. National and and harm reduction services are 9 | new resources international research and surveillance article continued on page 2 Drugs, Data, Deliberations: Putting it Into Perspective continued from page 1

also problematic, but coverage is HIV. In addition to more comprehensive to guide the programs that serve undoubtedly poor. Fewer than eight data, he writes, we need a better them. Implementing Comprehensive in 100 people who inject drugs have understanding of how to promote HIV and STI Programmes with People access to opioid substitution therapy application of the data we have. Who Inject Drugs: Practical Guidance (OST), and only an average of two sterile for Collaborative Interventions, to be needles are distributed per month per However, a number of promising published in 2016, will be a welcome person who injects drugs.2 HIV-positive developments suggest a potential trend resource for improving programs. people who inject drugs appear to toward more evidence-based policies have lower rates of HIV treatment and and greater political commitment. In It’s true that more information is viral suppression compared to other April 2016, The UN General Assembly needed to better understand the most key populations, in part because many will hold a Special Session (UNGASS) effective way to provide services for people do not report their drug use on drugs. This Special Session will offer people who inject drugs and to retain when they seek these services.3 member states the opportunity to them in the HIV care cascade. But, put deliberate on the thorny issues related into perspective, data are just one part Estimating coverage may be to drug law reform. For over a year, of a bigger picture. In the absence of challenging, but the evidence base for organizations led by people who inject perfect data, governments must be comprehensive HIV and harm reduction drugs as well as other stakeholders determined to move from deliberation services for people who inject drugs have been participating in pre-UNGASS to action. The history of response to the AIDS epidemic was built through this combination of data and resolve and Fewer than eight in 100 people who inject drugs have based on the fundamental principles of access to opioid substitution therapy (OST), and only an people-centered approaches. average of two sterile needles are distributed per month 1. Degenhardt L, Whiteford HA, Ferrari AJ, et al. Global burden of disease attributable per person who injects drugs. to illicit drug use and dependence: find- ings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1564- is strong. Distributing free or low-cost consultations to share their practical 74. Available from: http://www.thelancet. com/journals/lancet/article/PIIS0140- sterile needles reduces HIV transmission expertise and experiences. 6736(13)61530-5/abstract. http://www. among people who inject drugs without thelancet.com/pdfs/journals/lancet/ increasing drug use, and it is most Most recently, the U.S. Congress PIIS0140-6736(13)61530-5.pdf. effectively lifted a decades-long ban on effective when combined with access to 2. UNAIDS. People who inject drugs. In: needle and syringe programs. Malaysia OST and HIV counseling and treatment. The gap report. Geneva, Switzerland: OST reduces high-risk injection has transformed eight compulsory UNAIDS; 2014. Available from: http:// behaviors and drug-related deaths while detention centers into voluntary care www.unaids.org/en/resources/cam- improving adherence to antiretroviral clinics and has expanded OST provision paigns/2014/2014gapreport/gapreport. regimens among HIV-positive people in prisons. Tanzania has established the 3. Pierce R, Hegle J, Sabin K, et al. Strategic who inject drugs.4 first community-based OST program in information is everyone’s business: per- East Africa. spectives from an international stake- holder meeting to enhance strategic Despite the strength of this evidence, information data along the HIV cascade Such community action has been most countries continue to emphasize for people who inject drugs. Harm Re- criminalization over harm reduction. instrumental in the development of duct J. 2015;12:41. Available from: http:// Drug use is illegal in all but a handful of harm reduction, writes Andy Guise on harmreductionjournal.biomedcentral. countries, and few offer harm reduction page 3. His call for research on how to com/articles/10.1186/s12954-015-0073-y. services in prisons. In many countries, support community action and a study 4. WHO, UNODC. UNAIDS technical guide people who inject drugs experience exploring how to support integrated for countries to set targets for universal involuntary drug testing and compulsory OST and HIV care in Kenya (see access to HIV prevention, treatment and care for injecting drug users – 2012 revi- page 6) are examples of a much-needed detention, or “rehabilitation,” which sion. Geneva, Switzerland: WHO; 2012. rarely includes OST. implementation science approach Available from: http://www.who.int/hiv/ to adapting proven interventions for pub/idu/targets_universal_access/en/. Lack of commitment is one cause of the people who inject drugs in different Photofailure Credit: to heed © evidence,Steve Lambert as Ralf Jürgens settings. notes in his article on page 5. This, rather than the scarcity or quality of data, is A central theme of this issue of The the main reason why people who inject Link is the importance of engaging drugs are left behind in the response to people who inject drugs in research 2 LEARNING FROM HISTORIES OF COMMUNITY ACTION

In New York in the late 1970s and early research and development of biomedical Community action, and how to support it, 1980s, before the public health and med- methods of HIV prevention, and just 1% is then a key priority for global health re- ical authorities had recognized HIV and of that is oriented toward their social and search in the response to HIV for, and with, taken action, people who were injecting behavioral dimensions.5 New HIV research people who use drugs. Among the many drugs responded to the new challenge priorities from within the NIH’s Office of issues to learn about: facing them. Even hostile policing couldn’t AIDS Research also focus almost exclu- • The various roles people who use drugs 6 stop the emergence of a market in sterile sively on cure and treatment efforts. can play in facilitating access to care needles and syringes among the drug us- Biomedical interventions for people who within clinics ing community to replace the home-made use drugs are, of course, essential. PrEP, • How community action can foster new and frequently shared injecting equipment vaccines, and microbicides should all form norms that support preventive action that was being linked to HIV.1 part of a comprehensive HIV strategy, and that allow for the uptake of new This is just one vignette, from a specific alongside ART, opioid substitution thera- biomedical interventions time and place, but stories like this one pies, and needle and syringe programs. • How people who use drugs, and their have occurred many, many times around Community mobilization is in turn networks, are instrumental in altering the world. People who use drugs have been essential to ensure the relevance of these the structural environment and over- 7 central to the development of HIV and interventions and their accessibility. coming barriers, such as police brutality, harm reduction services, in settings from And yet, community mobilization, espe- that create vulnerability to HIV 1, 2 Africa and Asia to Europe and America. cially among people who use drugs, is Self-organized community action in Networks in countries across the world, and little understood.8 The cause of this lack of the 1970s and 1980s in New York likely globally in partnership through the Interna- knowledge is partly methodological: com- stopped HIV prevalence among people tional Network of People who Use Drugs, munity mobilization deals with complex who inject drugs from reaching 70%.1 We push for wide-ranging policy reform. relationships and shifting norms, which need to learn more from these experi- are not easily identified and monitored However, community action and mobiliza- ences and the ongoing work of drug user (a randomized controlled trial of organic tion is often marginalized in research. Our networks to foster communities’ ability to processes like network formation is not evidence and understanding of community protect human rights, and prevent, treat, easy, or necessarily desirable).8 But a ne- organization and action by people who use and care for HIV. drugs is limited,3 reflecting an overall gap glect of community action by people who in research of the grounded experience of use drugs in research is also partly political By Andy Guise, IAS-NIDA Research Fellow, those who must confront HIV.4 and economic: criminalization and hostility University of California San Diego toward people who use drugs flow from [email protected] The context for this gap is an HIV research all sectors of society, and public health Many thanks to Professor Steffanie agenda focused on biomedical inter- structures are often more interested in top Strathdee for comments and support. ventions. About $1.25 billion is spent on down, biomedical interventions. 1. Friedman SR, de Jong W, Rossi D, Touzé G, Rockwell R, Des Jarlais DC, et al. Harm reduction theory: Users’ culture, micro-social indigenous harm reduction, and the self-organization and outside-organizing of users’ groups. International Journal of Drug Policy. 2007;18(2):107-17. 2. Marshall Z, Dechman MK, Minichiello A, Alcock L, Harris GE. Peering into the literature: A systematic review of the roles of people who inject drugs in harm reduction initiatives. Drug and Alcohol Dependence. 2015;151:1-14. 3. Friedman SR, Schneider E, Latkin C. What We Do Not Know About Organizations of People Who Use Drugs. Substance Use & Misuse. 2012;47(5):568-72. 4. Adam BD. Epistemic fault lines in biomedical and social approaches to HIV prevention. Journal of the International AIDS Society. 2011;14(Suppl 2):S2-S. 5. HIV Vaccines and Microbicides Resource Tracking Working Group. HIV Prevention Research and Development, Funding trends, 2000-2014; investing in innovation in an evolving global health and development landscape. AVAC, International AIDS Vaccine Initiative, Joint United Nations Programme on HIV/AIDS 2015. 6. NIH. FY 2016 Trans-NIH Plan for HIV-related research. US National Institutes for Heath 2015. 7. Alliance USA. Communities Deliver, the critical role of communities in reaching global targets to end the AIDS epidemic. Geneva: UNAIDS, 2015. 8. Cornish F, Priego-Hernandez J, Campbell C, Mburu G, McLean S. The impact of Community Mobilisation on HIV Prevention in Middle and Photo Credit: © Nell Freeman for the Alliance Low Income Countries: A Systematic Review and Critique. AIDS and Behavior. 2014;18(11):2110-34. An outreach worker talks with injecting drug users ‘Niko’ and ‘Omar’ in Mombasa, Kenya. 3 OUT OF THE SHADOWS: REACHING AND ENGAGING WOMEN WHO USE DRUGS

Critical gaps in data and strategic informa- The challenge that presented itself was tion, which threaten to hamper effective how to mount an effective HIV response in HIV responses, are severely pronounced such a highly complex and high-risk setting, COMPREHENSIVE when it comes to women who use drugs. and among one of the most marginalized ALLIANCE-BUILDING National and international research and and vulnerable populations in the world. surveillance of people who inject drugs Coact is an international technical are often gender-neutral or heavily Coact was commissioned by the NACP to support agency that specializes skewed toward the male population. This carry out a community consultation, as in HIV and drug use, with a means that the specific challenges and part of its mission to involve and consult team of consultants made up needs of women in this key population re- people who use drugs in the national of current and former drug HIV response. This three-way innovative main unaccounted for. Coupled with the users. Bridge Hope and Health lack of reliable population size estimates partnership among Bridge, NACP, and Organisation is the first drug-user- of women who use drugs, significant Coact combined community know-how led organization in Afghanistan hurdles are present in designing appropri- and expertise, national government plan- ate, tailored, and effective HIV prevention, ning, and international technical support and its mission is to provide peer care, and treatment responses. grounded in community-based princi- outreach harm reduction services. ples to bridge the gaps in HIV and harm In August 2015, Coact and Bridge Hope reduction responses. and Health Organisation worked together Our findings revealed that: with the Afghan National AIDS Control To ensure that women who use drugs • Many women were not aware of avail- Program (NACP) to collect strategic were not left behind, the community able services. information on women who use drugs. consultation had a specific component on Afghanistan is one of the lowest ranking women who use drugs and other at-risk • Some important information gaps are countries on the Human Development woman, who were sex workers and wives best bridged by peer-based interventions. Index and a country of chronic instability of PWID. Our community-based approach • Participants feel a strong need to at- and conflict. Gender inequality is deep- capitalized on community connectedness tract and retain female clients through rooted and profound. Afghani women and trust among people who use drugs the provision of child care facilities, have few legal rights, and they experience to engage peers, and we were able to gender-segregated services, and voca- low literacy rates—21% among women include 36 women in our consultation, tional training. compared to 51% among men—low including hard-to-reach women from • Barriers and challenges include lack of participation rates in public life, and a high the open air drug scene of Kabul. Focus investment in services, extreme levels prevalence of gender-based violence. The group discussions were structured to of stigma and discrimination com- last Bio-Behavioural Surveillance study collect information on levels of HIV knowl- pounded by gender inequality, lack of that included women was conducted in edge; access to services related to HIV, personal resources, and gender-based 2009 and estimated there to be 110,000 harm reduction, and women’s health; and violence. women who use drugs in Afghanistan. the barriers and challenges to this access. Finally, the women were asked to identify the most important factor in successfully reaching women who use drugs. They all agreed that the best way to gather data and information and to promote essential HIV, harm reduction, and health services among the community is through other drug users. Peer-led, community-based HIV responses provide a vital link among government, services, and community. These lessons will prove valuable to work among women who use drugs all over the world, not just in Afghanistan. By bringing women who use drugs out of the shadows, hidden populations become visible; easier to engage, count, and account for; and em- powered through appropriately designed HIV, health, and social interventions. Photo Credit: © Mat Southwell By Judy Chang, MIntDev, Coact Coact training session for women. [email protected] 4 DATA AND HUMAN RIGHTS: MAINTAINING THIS IMPORTANT DUAL FOCUS

In countries around the world, people vulnerable populations, (b) strengthening Most importantly, perhaps, there is a who inject drugs and other marginalized data systems for health and countries’ need to shift from simply calling for more and often criminalized populations are capacities for analysis and use of data; data and for undertaking more research, not benefitting equally from the scale-up and (c) promotion and protection of to developing a better understanding of of HIV prevention and care, treatment, human rights. Attention to all three when data are most useful for decision and support programs. Even where topics is welcome and needed to making and how we can increase uptake services are being provided, they are ensure greater attention to the needs of of data. This will require a different often not accessible to people who use people who use drugs and, ultimately, drugs because of multiple human rights to increase the impact of Global Fund barriers, including ill-treatment and grants. ...while there is no doubt discrimination in health care settings, we need more data to One of the most frequently mentioned violence or interference by police, and be able to provide better the lack of services in prisons and other reasons for not including (more) places of detention. services for people who use drugs in services... lack of data is applications for Global Fund grants rarely, if ever, the main At its meeting in November 2015, the is lack of data about how many reason people who inject Board of the Global Fund to Fight AIDS, people who use drugs live in a certain Tuberculosis and Malaria (the Global country, where they live, what their risk drugs are left behind in the Fund) adopted the framework of its behaviors are, and how prevalent HIV response to HIV and TB. upcoming new strategy for 2017–2022. and other infections are among them. Not surprisingly, the framework has Collecting data about these and other a strong emphasis on (a) key and factors in a way that helps people who way of working, across disciplines and use drugs, rather than exposing them communities of researchers, involving to further risk of violence and abuse, is activists and people who use drugs. therefore a priority. It won’t be easy because there are many vested interests and also a lot of However, while there is no doubt that mistrust, but it is a challenge we all need we need more data to be able to provide to live up to if we are truly committed to better services to people who use drugs ending the epidemics for everyone. and to other marginalized populations, we also need to acknowledge a number By Ralf Jürgens, Senior Human Rights of other issues. First and foremost, Coordinator in the Community, Rights and lack of data is rarely, if ever, the main Gender Department of the Global Fund to reason why people who use drugs are Fight AIDS, Tuberculosis and Malaria left behind in the response against HIV [email protected] and TB. Often, some data have been available for years, but action has not been taken because decision makers are not committed to devoting greater attention and resources to marginalized and criminalized members of society. Secondly, when research is undertaken, it sometimes fails to sufficiently involve people who use drugs. Not involving people who inject drugs can create risks of further human rights abuses against them and can result in flawed research. Without the meaningful engagement of people who inject drugs, research either fails to answer questions that are most relevant to their health, safety, and security, or it answers questions that Photo Credit: © International Network of could have been easily answered by the People Who Use Drugs community itself. 5 WHAT WORKS FOR WHOM AND WHERE: THE VALUE OF IMPLEMENTATION SCIENCE FOR PWID PROGRAMS

In addition to its well established role What is the best role for community clinic with comprehensive support will for the treatment of opiate dependence, outreach workers and nongovernmental suit the needs of many. For others, travel, medication-assisted treatment (MAT) such programs, who often have developed family commitments, and fear will prevent as methadone has been shown to support relationships of several years with their this, and more community-focused models 10 people who inject drugs in accessing and clients? How will communities react to and of delivery may be optimal. Our broader 7 adhering to antiretroviral treatment (ART), use methadone? challenge is then also in developing a more local, client-centered evidence base for leading to positive HIV-related outcomes.1-3 The need to understand how an ev- what works. Debates on whether methadone should be idence-based intervention works in available reflect politics and ideology, not particular contexts represents our growing By Andy Guise, Frederick Owiti, Steffanie human rights and public health. recognition of the value of an “implemen- Strathdee, Tim Rhodes, James Ndimbii, tation science” approach.8 As interven- Emmy Iganyo Methadone works, and there is long tions are introduced in particular settings Correspondence: [email protected] experience of its delivery in North America, they respond and evolve in response to We thank the National AIDS and STIs Europe and, increasingly, Asia. Methadone political, economic, social, and cultural Control Programme and National AIDS is now being introduced in settings across contexts. The era of evidence-based policy Control Council in Kenya for their support Africa in response to the rising role of is evolving from “what works,” to focus on and guidance in the research. The injecting drug use in HIV epidemics, like in “what works for whom and where.” 9 What research is funded by the Centre for AIDS Kenya. But there is little understanding on works in one social, political, economic, Research at the University of California. how to best deliver MAT and integrate it and cultural context may be very different 1. Wolfe D, Carrieri MP, Shepard D. Treatment and with HIV care in ways that are acceptable from what works in another. care for injecting drug users With HIV infection: A review of barriers and ways forward. Lancet. for people using these services. 2010;376:355-66. Research ongoing in Kenya through the 2. Uhlmann S, Milloy MJ, Kerr T, Zhang R, Guillemi S, University of Nairobi, Kenya AIDS NGOs Marsh D, et al. Methadone maintenance therapy promotes initiation of antiretroviral therapy among Consortium, University of California San injection drug users. Addiction. 2010;105(5):907-13. Diego, and London School of Hygiene and 3. Reddon H, Milloy MJ, Simo A, Montaner J, Wood Tropical Medicine is adopting an imple- E, Kerr T. Methadone Maintenance Therapy Decreases the Rate of Antiretroviral Therapy mentation science approach to under- Discontinuation Among HIV-Positive Illicit Drug stand community experiences of MAT and Users. AIDS and Behavior. 2014;18(4):740-6. HIV care. 4. Bruce RD, Lambdin B, Chang O, Masao F, Mbwambo J, Mteza I, et al. Lessons from Tanzania on the integration of HIV and tuberculosis treatments In Nairobi, the model of care focuses on into methadone assisted treatment. International hospital-focused delivery and integrated Journal of Drug Policy. 2014;25(1):22-5. MAT and HIV care. Clients are often eu- 5. Lambdin B, Bruce RD, Chang O, Nyandindi C, Sabuni N, Zamudio-Haas S, et al. Identifying phoric in their praise for the program, with programmatic gaps: inequities in harm reduction the initiation of methadone equated to service utilisation among male and female drug Photo Credit: © Josh Estey/DFAT users in Dar es Salaam, Tanzania. PLOSOne feeling “reborn.” The ease of getting ART at 2013;8(6). the same site is welcomed. 6. Lambdin BH, Masao F, Chang O, Kaduri P, Mbwambo J, Magimba A, et al. Methadone Treatment for HIV Prevention—Feasibility, Findings from Tanzania show that an inte- However, lingering concerns remain for Retention, and Predictors of Attrition in Dar es some about the visibility of taking HIV Salaam, Tanzania: A Retrospective Cohort Study. grated hospital-focused model is feasible Clinical Infectious Diseases. 2014;59(5):735-42. medication. Stigma is persistent. For and acceptable, although women find 7. Rhodes T, Guise A, Ndimbii J, Strathdee S, Ngugi E, access to be difficult.4-6 Integrated care can, others, travel time to access the meth- Platt L, et al. Is the promise of methadone Kenya’s adone clinic—which can take several solution to managing HIV and addiction? A mixed- however, take a range of forms, and so method mathematical modelling and qualitative many questions still remain in understand- hours—limits the potential for integrated study. BMJ open. 2015;5(3). ing how to best support care in settings care. If a daily visit to the clinic can’t be 8. Lambdin BH, Cheng B, Peter T, Mbwambo J, Apollo managed, then both daily doses of meth- T, Dunbar M, et al. Implementing Implementation like Kenya: does hospital-focused care— Science: An Approach for HIV Prevention, Care adone and HIV care are missed unless and Treatment Programs. Current HIV Research. with directly observed treatment and carry-home doses can be permitted. 2015;13(3):244-9. intensive support—prove acceptable in Women in particular seem to face disad- 9. Cornish F, Priego-Hernandez J, Campbell C, Kenya also? Or will women also experience Mburu G, McLean S. The impact of Community vantages in accessing methadone. Mobilisation on HIV Prevention in Middle and challenges to access? Is primary clinic-level Low Income Countries: A Systematic Review and Critique. AIDS and Behavior. 2014;18(11):2110-3 care, integrated with HIV care, a way to What works for whom and where? The 10. Guise A, Ndimbii J, Ayon S, Rhodes T, editors. mitigate stigma? Is community distribution challenge for integrated methadone and Community based outreach in Kenya; successes, of methadone possible and desirable, even HIV care in settings like Kenya is likely to challenges and potential for the delivery of HIV treatment and methadone International Harm if it means health care professionals are focus on developing multiple entry points Reduction Conference; 2015; Malaysia. less directly involved in providing support? to respond to varying needs. A fixed site 6 IN FOCUS: LINKAGES STRATEGIES AND TECHNICAL SUPPORT IN INDIA

In India, the HIV prevalence among sites and unreached populations. services and increase the probability people who inject drugs is 10.9%. Female sex workers, men who have sex of retention and outcome success Targeted interventions for people who with men, and transgender people who along the cascade.1 LINKAGES will form inject drugs include needle and syringe are also people who inject drugs will support groups for young people who programs, free condoms, peer outreach, be identified and provided appropriate inject drugs and for family members abscess management and STI services services to address their dual risks. to help enhance access to OST and other harm reduction services. Peer provided by nongovernmental and • Assessing the feasibility for secondary navigators will be trained and placed community-based organizations (NGOs distribution of needles and syringes. in the HIV testing and ART centers and CBOs); and referrals to government To improve access to and coverage to facilitate referrals and provide hospitals for opioid substitution therapy of needle and syringe programs, adherence support to HIV-positive (OST), HIV testing services and antiret- LINKAGES will explore the feasibility people who inject drugs. roviral therapy (ART) for those found of secondary distribution through positive. preferred health care providers, • Strengthening links to testing and government primary health care treatment. Community-based HIV LINKAGES will be providing technical centers, nontraditional outlets, and screening services will be established assistance to NGOs and CBOs peer volunteers. at sites where HIV testing coverage is implementing targeted interventions low. LINKAGES will strengthen referral • Improving OST coverage. To improve such as these in five districts of two high- services to government HIV testing coverage of OST services, LINKAGES HIV-prevalence states—Guntur, Krishna, centers for confirmation of diagnosis will explore lower threshold strategies and East Godavari in Andhra Pradesh and to ART centers for treatment. and Mumbai and Pune in Maharashtra. such as take-home dosing and task • Develop referrals for hepatitis The estimated number of key population shifting of OST program management B/C and tuberculosis (TB). Referral members in the districts is 108,234 of to nurses once a patient’s dose has linkages will be established with whom 2,732 are people who inject drugs. been stabilized. government hospitals for screening of • Mobilizing the community and LINKAGES’ technical assistance will focus hepatitis B and C. All people who inject generating demand. Engaging and on the following: drugs, regardless of HIV status, will working with both the community of be verbally screened for TB at regular • Addressing dual risk. LINKAGES will people who inject drugs and other intervals. Those suspected of having conduct an exercise to revalidate key community organizations that support TB will be referred to diagnostic population estimates and map new them will strengthen linkages to centers, and confirmed TB cases will be linked to the nearest provider of directly observed treatment short course for treatment.

HIV prevalence among people who inject drugs in India is high with previously unknown pockets of infection emerging from new areas. However interventions are currently available to only a small proportion of people who inject drugs in India.1 Particularly because of stigma and discrimination, greater attention will be needed to avoid losses at every step of the HIV cascade. LINKAGES India will be working to identify the cause of these losses and address these issues to help achieve the UNAIDS goal of 90:90:90.

By Anjana Das, FHI 360

1. Mastro T, George B, Osborne K. The evolving HIV epidemic among people who inject drugs in India and the need for a heightened response. AIDS Photo Credit: FHI 360 2015;29:629-31.

Community outreach among people who inject drugs in India. 7 The People @ LINKAGES: GREGORIO SORIANO URBAEZ

Gregorio Soriano Urbaez moved to What are your responsibilities for Life Facts Honduras in September 2015 to serve LINKAGES Honduras? as the country representative for Expertise: Nutrition, monitoring I provide overall vision and leadership LINKAGES. The move coincided with and evaluation, HIV, family planning, for the project in Honduras and manage the launch of LINKAGES Honduras last reproductive health, and mother and its implementation and monitoring. November and was closely followed in child health Among other tasks, I oversee work December by the birth of Gregorio’s Number of years working on HIV plans, budgets, technical assistance in son, Sebastián Elías. The new country programs: 8 program operations, project reports, representative (and father) finds quality control, and the efforts of the Professional achievements: Supported himself with the exciting challenges project’s staff. I also act as liaison the day-to-day health, nutrition, and of “parenting” two very different between LINKAGES, USAID Honduras, HIV policy in Dominican Republic, newborns. He recently took time from the Government of Honduras, Paraguay, and El Salvador; updated his new roles to answer some questions stakeholders, donors, and all other the protocols and treatment guidelines about the first few months of life for relevant players and client country in HIV for the Dominican Republic; LINKAGES in Honduras. partners. supported the Government of the Dominican Republic to reduce the What challenges have you prevalence of HIV transmission from encountered? mother to child by improving the There is still a lot of stigma associated health system services. with HIV testing and HIV-positive Country experience: Paraguay, diagnoses in Honduras, even among Nicaragua, El Salvador, Dominican health care workers. As a result, key Republic, and Honduras populations do not seek HIV testing Languages: Spanish, English, and soon and treatment services. Hard-to-reach to take up Portuguese and French populations are also not accessing these services, so very few new HIV-positive Family: Married with five children individuals are being identified. (three girls and two boys) Leisure Activities: Walking, playing What is your wish for key populations? dominoes, reading health sciences My greatest desire is to integrate key literature, and watching television and populations into a strong health care action movies network that will provide access to high-quality, stigma-free HIV treatment and practices needed to reduce spread and prevention services. This will ensure Photo Credit: Fernando Neda, FHI 360 of HIV and the stigma that surrounds it. that key populations groups have a better quality of life and, for those I am also pleased to help local and members who are HIV positive, attain What is LINKAGES doing in Honduras national constituent-led organizations an undetectable viral load by being with key populations? become empowered so they can secure, retained in the HIV cascade. promote, and defend their rights within We are working with the Honduran the public sphere through peer-support I believe that key populations, who have Ministry of Health, plus local and networks and public policies. When been so marginalized and stigmatized, international partners, to improve key populations achieve full inclusion can strengthen the organizations that the delivery of HIV services to key and equality, the entire nation will represent them. They deserve a solid populations, specifically men who have benefit as we’ll become a more just and social platform that will enable them to sex with men, transgender people, sex understanding society. workers, and those key populations secure their interests, have their voices among the Garifuna population. We heard, and defend their rights in the By Michael Szpir, FHI 360 assist these organizations with the challenging society they live in. use of evidence-based interventions, the collection and use of strategic What excites you most about your information, and the documentation of work? best practices. Our objective is to save I am absolutely thrilled to be part of a (and prolong) lives by increasing HIV community of change agents working to detection, reducing transmission, and ensure that our key population groups retaining individuals in treatment. have the scientifically based information 88 new Resources: Research, reports, and websites

TRANSGENDER WOMEN AND PRE-EXPOSURE PROPHYLAXIS: WHAT WE KNOW AND WHAT WE STILL NEED TO KNOW

https://careacttarget.org/library/transgender-women-and-pre-exposure-prophylaxis- what-we-know-and-what-we-still-need-know

Published by the National Center for Innovation in HIV Care, this report includes a discussion of the research on the safety of pre-exposure prophylaxis (PrEP) use among transgender women, guidance for clinicians on prescribing PrEP to trans women, and recommendations for more research on HIV prevention technologies for this population.

SERVICES UNDER SIEGE: THE IMPACT OF ANTI-LGBT VIOLENCE ON HIV PROGRAMS

http://msmgf.org/high-levels-of-violence-against-lgbt-people-stymie-hiv-prevention-and- treatment-worldwide/

This new report from the Global Forum on MSM and HIV (MSMGF) examines levels of violence against lesbian, gay, bisexual, and transgender (LGBT) people around the world. The report indicates that activists and HIV service providers are especially vulnerable, with attacks against community leaders resulting in interruptions to life-saving HIV services. The report underscores the urgent need for real, institutionalized protections for marginalized communities.

RESPECT, PROTECT, FULFILL: BEST PRACTICES GUIDANCE IN CONDUCTING HIV RESEARCH WITH GAY, BISEXUAL, AND OTHER MEN WHO HAVE SEX WITH MEN (MSM) IN RIGHTS-CONSTRAINED ENVIRONMENTS http://www.amfar.org/uploadedFiles/_amfarorg/Articles/Around_The_World/GMT/2015/ RespectProtectFulfill-MSM-ResearchGuidance-Rev2015-English.pdf

These recently revised guidelines were developed for researchers, community-based organizations, and governmental agencies that engage in research in rights-constrained environments. The guidance is intended to help these stakeholders to better design and conduct meaningful research on HIV among MSM in challenging social, political, and human rights contexts; to help protect the rights and safety of MSM participants and communities involved in research; and to offer lessons learned through case studies of research and community partnerships. 9 new Resources: Research, reports, and websites continued from page 9

SEX WORKERS WHO USE DRUGS: ENSURING A JOINT APPROACH

http://www.clac.cab/portfolio-item/sex-workers-who-use-drugs This briefing paper by The Global Network of Sex Projects and The International Network of People who Use Drugs addresses the lack of recognition of the intersections between two key population communities. The document provides an overview of some of the most endemic and substantive ways in which sex workers who use drugs face double criminalization, compounded marginalization and social exclusion, and heightened harassment from health care workers and other service providers. Case studies highlight efforts to meet the needs, and advocate for the rights, of sex workers who use drugs.

COMMUNITY LEADERSHIP AND ACTION COLLABORATIVE (CLAC) http://www.clac.cab/

The MSMGF and LINKAGES recently announced the launch of a redesigned website for the CLAC, which features a resource library for key-population-related policy and research. The site will serve as an online hub for information and resources on HIV among sex workers, men who have sex with men, people who inject drugs, and transgender people. The library serves a range of audiences including policymakers, advocates, program planners and implementers, health care workers, and peer educators. The site links beneficiaries with tools and resources that build and strengthen communities with a focus on organizational and technical capacity.

LINKAGES Advisory Board LINKAGES, a five-year cooperative agreement funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Eliot Albers, International Network of People Who Use Drugs U.S. Agency for International Development (USAID), is the largest George Ayala, The Global Forum on MSM & HIV global projected dedicated to key populations. The project is led Solange Baptiste, International Treatment Preparedness Coalition by FHI 360 in partnership with IntraHealth International, Pact, Jennifer Bushee, Global Network of People Living with HIV (GNP+) and the University of North Carolina at Chapel Hill. Chris Collins, UNAIDS Clifton Cortez, United Nations Development Programme The contents of The LINK do not necessarily reflect the views of Gina Dallabetta, The Bill and Melinda Gates Foundation PEPFAR, USAID, or the United States Government. JoAnne Keatley, International Reference Group/Center for Excellence for Transgender Health ©2016 by FHI 360 Ron MacInnis, Palladium Eni Martin, U.S. Agency for International Development (USAID) Send feedback to [email protected] Flavian Rhode, International AIDS Alliance Kevin Osborne, FHI 360 Thank you to the following for submitting photos for the Billy Pick, USAID LINKAGES banner: FHI 360’s Asia-Pacific Regional Office Ruth Morgan Thomas, Global Network of Sex Work Projects (Ian Taylor and Mr. Naysokhim); Global Forum on MSM & HIV; Kate Thompson, The Global Fund to Fight AIDS, Tuberculosis and Malaria Global Network of Sex Work Projects; and the International Annette Verster, World Health Organization Network of People who Use Drugs. Tisha Wheeler, USAID David Wilson, World Bank Cameron Wolf, USAID

n LINKAGES Project Director — Kevin Osborne, FHI 360 n Director of Research Utilization and LINKAGES Knowledge Management — Rose Wilcher, FHI 360 10 n Managing Editor — Suzanne Fischer, FHI 360 n Design — Lucy Harber, FHI 360 n E-Newsletter and Dissemination — Jesse Hastings, FHI 360