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A Self-Study and Reference Manual Reducing the Burden of HIV on Men who have Sex with Men and Transgender People in Asia A self-study and reference manual for outreach workers, case workers and other HIV service providers FINAL FULLY UPDATED AND REVISED DRAFT – APRIL 2016 ACKNOWLEDGEMENTS FOR THE 2007 VERSION: The initial draft of this manual was compiled by Jan W de Lind van Wijngaarden, consultant to Family Health International/Asia Regional Program (FHI/ARP), and MSM and HIV advisor to the United Nations Educational, Scientific, and Cultural Organization (UNESCO). Important comments and suggestions for improvement were provided by Graham Neilsen, Celine Daly and Philippe Girault (FHI/Asia Pacific Regional Office), Harry Walsh (International HIV/AIDS Alliance), Clive Wing and Simon Baker (UNESCO) and Prof Louis Gooren of the Free University of Amsterdam (Unit on transgender health). Elden Chamberlain (International HIV/AIDS Alliance), Rakdaow Pritchard (Population Services International (PSI)), Clifton Cortez (United States Agency for International Development/RDMA), Dr Rutt Chuachuwong (Centers for Disease Control / Thailand–US Collaboration (CDC/TUC)) and Xavier Alterescu (Pact) helped facilitate the regional workshop at which this manual was finalized, and provided important inputs and suggestions for improvement. Srisuman Sartsara and Marisa of UNESCO, Chutima Chomsookprakit of FHI, Edmund Settle of UNDP China and Jack Arayawongchai of the Purple Sky Network helped in the logistics and organization of the workshop. Renata Zanetti of UNESCO is thanked for meticulously recording all suggested changes and providing invaluable editorial support to the draft. Dr Rutt Chuachuwong (CDC/TUC) has been an important source for verification and clarification of medical information in this document during the workshop. Last but not least, all peer and outreach workers who so enthusiastically and thoroughly went through the entire document and suggested many improvements that were incorporated in this version must be deeply thanked – without them this document would not be as user-friendly and comprehensive as it is. A list with their names is included in Annex 5. ACKNOWLEDGEMENTS FOR THE UPDATED 2015 version: This entirely updated version of the manual was again prepared by Jan W. de Lind van Wijngaarden, PhD, this time as a consultant to UNAIDS Regional Support Team in Bangkok, Thailand. Matt Avery of FHI 360 re-wrote Unit 1 and he and Justine Sass of UNESCO Bangkok provided helpful comments and suggestions for improvement of the entire manual. Dr. Graham Neilsen (Australia, formerly FHI 360 in Bangkok) reviewed the STI sections (Unit 10 and Annex 2); several people, including Rob Oostvogels (Netherlands) and Jamie Uhrich (Thailand) advised on the section on testing and counselling. Prempreeda Pramoj Na Ayudhya (UNESCO Bangkok) reviewed the section on transgender health. Matthew Vaughan (APCOM), Laurindo Garcia (B-Change Group) reviewed the new section on internet dating and social media. Dr Bas van Loon (Amsterdam) provided advice on a section on rectal health. 2 Table of Contents Abbreviations ................................................................................................... 4 Introduction – what is this reference manual about? ................................... 5 Unit 1: Outreach and the HIV Cascade .......................................................... 6 Unit 2: Basic information about HIV ............................................................. 12 Unit 3: HIV and its transmission ................................................................... 16 Unit 4: The prevention of HIV infection ........................................................ 24 Unit 5: Basic information about condoms and lubricants ......................... 27 Unit 6: Pre-exposure and Post-exposure Prophylaxis to prevent HIV infection .......................................................................................................... 35 Unit 7: Sexual risk reduction and principles and practice of behavior change ............................................................................................................ 40 Unit 8: Dealing with accidental exposure to HIV ......................................... 47 Unit 9: HIV Counselling and Testing (HCT) ................................................. 50 Unit 10: Sexually Transmitted Infections and how they can or cannot be transmitted ..................................................................................................... 57 Unit 11: Supporting people who are living with HIV stay healthy and happy .............................................................................................................. 61 Unit 12: Sexuality and sexual identities ....................................................... 70 Unit 13: Basic health issues for transgender people ................................. 75 Unit 14: Dealing with love, sex and friendship ............................................ 77 Unit 15: Dealing with the family, marriage, girlfriends, etc ........................ 81 Unit 16: Dealing with drugs and addiction .................................................. 84 Unit 17: Tips for handling stigma and harassment in everyday life ......... 86 Unit 18: Using social media and the internet for outreach ........................ 89 Unit 19: ’Syndemic conditions’: Understanding the context of HIV transmission ................................................................................................... 94 ANNEX 1: A referral list to available health- and social support services 96 ANNEX 2: OVERVIEW of common STIs among men who have sex with men and transgender people ........................................................................ 97 ANNEX 3: List of drugs that may be used by some men who have sex with men and transgender people .............................................................. 112 ANNEX 4: Useful websites, hotlines and other resources for MSM and TG ....................................................................................................................... 115 3 Abbreviations AIDS Acquired Immune Deficiency Syndrome ART Anti-Retroviral Therapy CBC Complete Blood Count CD4 Cluster of Deviation 4 (marker on white blood cells) CCR5 Chemokine Receptor 5 (used by HIV to enter target cells) DNA Deoxyribonucleic acid - a nucleic acid molecule (genetic material in cells) ELISA Enzyme Linked ImmunoSorbent Assay (Diagnostic Medical Tool) FHI Family Health International HIV Human Immunodeficiency Virus HPV Human Papillomavirus HSV 1-2 Herpes, types 1 and 2 HCT HIV Counselling and Testing IEC Information, Education and Communication KY KY™ Jelly (water-based lubricant) MSM Men who have sex with men OI Opportunistic Infection PCR Polymerase Chain Reaction PEP Post Exposure Prophylaxis PrEP Pre-Exposure Prophylaxis RTI Reverse Transcriptase Inhibitor STI Sexually Transmitted Infection T-Cell Sub-group of White Blood Cells TG Transgender 4 Introduction – what is this reference manual about? What is this reference manual about and what are its aims? This manual helps people who work in HIV service organizations, including peer educators and outreach workers, who are working with men who have sex with men and transgender people1 sustain and update their knowledge about HIV/STI and sexual health issues. It provides detailed information about everything an HIV service worker or outreach worker may be asked about during their work. It aims to improve the scope and accuracy of information that peer and outreach workers provide to their target audience. How should this manual be used? The manual consists of different parts, which can be put in or taken out of the ring binder, allowing each user to choose the materials he needs. In addition, updates will be provided when needed, for example when new HIV prevention technologies (i.e. vaccines, circumcision, and microbicides) or treatments become available (see e-mail address and website below). Users of this manual can access a website to discuss its use, ask additional questions on a web-board or provide feedback – please contact the author at [email protected] The information in this manual is presented in a Question and Answer format, to enable users to find answers to questions asked in the field. Where does the information in this manual come from? Information was collected from existing documents used by Family Health International, the HIV alliance and other organizations, as well as scientific information and the internet, with many entries adapted from: www.cdc.gov www.thebody.com www.wikipedia.com www.engenderhealth.com Other sources are mentioned throughout the text; see also Annex 4. A draft of the 2007 version of this manual was reviewed by experts from different international organizations, and was reviewed by English speaking peer and outreach workers from Thailand, Lao PDR, China, Viet Nam, Cambodia and Myanmar at a regional workshop in Chiang Mai, Thailand in June 2007. The new version of the manual was reviewed using an online peer-review process. 1 In this manual the focus is mainly on transgender people who cross more or less permanently from the male into the female gender. 5 Unit 1: Outreach and the HIV Cascade What is the role of the peer worker? In every major Asian city, men who have sex with men and transgender women are disproportionately affected by the human immunodeficiency virus (HIV). This is mainly because HIV is transmitted much easier via anal sex than it is via vaginal sex. In addition,
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