HIV/SRHR Integration for Key Populations A review of experiences and lessons learned in 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 šPeople living with HIV populations – describing issues to consider within integrated HIV/ šSex workers SRHR support, sharing key strategies and providing examples of šMen who have sex with men integration in action. šTransgender people šPeople 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 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/SRHRintegrationasaneffectiveapproachimprove A numberofcriticalquestionsremainoutstanding.Theseinclude: compromise outcomesforkeypopulations. interventions, integratingservicesandsystemsthatarenotreadymayintheshort-runactually While thisapproachclearlyhasthepotentialtoincreasereachandimprovequalityof into accountwhennationalresponsesaimtoscaleupSRHR/HIVintegratedprogramming. recommendations forSRHR/HIVintegratedprogrammes.Thesechallengesneedtobetaken access toservicesforkeypopulations.Thisreviewidentifiesanumberofchallengesand of programmesandsystemsthatarenotreadycould,infact, However, whileintegrationisadesirablegoalinthelong-run,concernsremainthatjoining different contextsandmodels the HIV/SRHRcomponentsintegrated,lessonslearned, etc.)tofacilitatecomparisonacross a templatewasusedtorecordthedetailsofprogrammes (suchasthetypeofpopulation, mappings, toolkits,policybriefingsandreports.Where adequateinformationwasavailable, agencies andUN[see websites ofselectednationalandinternationalorganisations, includingNGOs,technicalsupport The methodologyforthereviewfocusedonassessing over 160resourcesavailableonthe groups. populations ordetailed,technicalguidanceonthe‘howto’ofintegratedprogrammingforsuch It alsodidnotaimtoprovidecomprehensivedocumentationoftheSRHRneedskey The reviewdidnotaimtoserveasasystematicormeta-analysisofallrelevantdocumentation. 3. 2. 1.

contexts ofkeypopulations. such programmesarebasedongoodpracticeandrespondtothespecificneeds integrated programmesbyIndiaHIV/AIDSAlliance To informthefuturedevelopment,implementationandevaluationof overall andinrelationtothefiveprioritygroupsforIndiaHIV/AIDSAlliance. lessons learned From thatdocumentation,to HIV/SRHR integrationforkeypopulationsinIndiaandinternationally. To identifyandreviewa from HIV/SRHRintegratedprogrammingforkeypopulations–both Annex 1 selection ofexistingdocumentation identify andanalysesuccessfulapproaches for alist].Theresourcesincludedcasestudies, compromise – inparticularensuringthat Do wehavestrongevidence both onprogrammingfor SRHRandHIV the qualityofand HIV/SRHR 3

2. Overview of HIV/ © Prashant Panjiar for India HIV/AIDS Alliance SRHR integration for key populations

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: SRHR services to demand opportunities capacity or Weaker

Factors thataffectkeypopulationsinthecontextofSRHR For example,compared toothercommunitymembers… š š š š š š š š š š š š š š š š š 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 How HIV/SRHR integration “Linkages and integration enable enable integration and “Linkages people, more reach to programmes more respond to populations, key especially HIV both reach to and needs their to fully Linkages effectively. more goals SRH and the address to programmes strengthen including ill-health, SRH of causes root also HIV and SRH between Linkages HIV. that issues structural and social the address ill-health SRH to vulnerable people make stigma poverty, inequality, gender – HIV and and violations rights discrimination, and legal issues.” Good Practice HIV Programming International Standards, HIV/AIDS Alliance Figure 4: strengthens programming UCSF, WHO, UNAIDS, UNFPA and IPPF, 2009; ]. , International HIV/AIDS Alliance, June 2010. This . Rapid Assessment Tool for Sexual and Reproductive Health Rapid Assessment Tool International HIV/AIDS Alliance, 2010. Figure 4 International HIV/AIDS Alliance, 2010. Figure 5 , International HIV/AIDS Alliance, June 2010. . It can, for ]. These needs often ‘fall through the net’ often ‘fall through ]. These needs 7 [see 2

and Programming 3 4 ’s access to a wider Figure 3 , as well as leaders in the field 6 Good Practice HIV Programming Standards [see in Manipur found that: individual one or more components of in Andhra Pradesh found that: , IPPF, UNFPA, UNAIDS and WHO, 2005; and Good Practice HIV Programming Standards , IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives, 2009. Examples of key populations’ unmet SRHR needs, India populations’ unmet SRHR needs, Examples of key female sex workers women who use drugs of the International HIV/AIDS Alliance. [See 5 A Framework for Priority Linkages Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations, to guide the design, implementation and evaluation of Alliance programmes in seven areas, with each including a number of agreed standards to guide the design, implementation and evaluation of Alliance programmes in seven areas, with each including a number

Good Practice Guide: Integration of HIV and Sexual and Reproductive Health and Rights, 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. Many concealed their drug use from 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 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 and India HIV/AIDS Alliance (150 women who use drugs, aged 18-49 years in 3 sites in Manipur) India HIV/AIDS Alliance. Understanding 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, Standards (measurable and evidence-based benchmarks of quality). For example: and HIV Linkages: A Generic Guide For example: 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 Based on description of Standard 4.1 in š š š A study of š š Figure 3: A study of š š š

significant unmet needs for SRHR unmet needs for significant 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 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) 3 4 5 6 7 2 includes referrals from one service to another, with the overall includes referrals from one service aim of providing more comprehensive support 2.2. What is HIV/SRHR integration? In this review, integration refers to into (or ‘joined with’) one SRHR programming being integrated or vice versa or more components of HIV programming; There is increasing evidence and recognition that HIV/SRHR integration brings multiple benefits at multiple levels of integration in India, notably PATH India. 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 HIV/SRHR integration for key populations 6 protection from are particularlyevidentintheuptakeofkey‘cross-over’services,suchascondoms(fordual including the2011UN HIV/SRHR integrationhasbeenincreasinglyrecognizedinkeyglobalpolicycommitments– and 6(combatHIV,malariaotherdiseases). seen ascriticaltoachieving 10 9 8 resources; andahealth range of

11 10 9 8 7 6 5 4 3 2 1 International HIV/AIDSAlliance Figure 5:

PoliticalDeclarationon HIV/AIDS:IntensifyingourEffortstoEliminate HIV/AIDS SexualandReproductive HealthandHIVLinkages:EvidenceReview andRecommendations, A FrameworkforPriority Linkages, 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, both Good practiceprogrammingstandardsforHIV/SRHRintegration, HIVandSRHRsupport;a both HIVandunwantedpregnancy) WHO,UNFPA,UNAIDS andIPPF,2005. Political DeclarationonHIV/AIDS system both ’s collaborativeplanningandmanagement MillenniumDevelopmentGoals5(improvematernalhealth) service ’s efficientuseofhumanandfinancial , UNGeneralAssembly, June2011. 9 . UCSF, WHO,UNAIDS, UNFPAandIPPF,2009. 10 – andnationalframeworks.Itis 8 . Thebenefits 7 HIV/SRHR integration for key populations , , 26th Meeting of the – increasing key – increasing – by enabling them to GNP+, ICW, Young Positives, – increasing key populations’ key populations’ – increasing . However, on the whole, 13 – going beyond a focus on ‘disease , for example by reducing the the , for example by reducing support

related to HIV and/or key populations HIV and SRHR

Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations . This is because – beyond the generic benefits to all . This is because – both 11 for , IPPF, UNFPA, UNAIDS and WHO, 2005.

. ]. 12 Potential benefits of HIV/SRHR integration for key populations Potential benefits of HIV/SRHR integration Thematic Segment: Sexual and Reproductive Health Services with HIV Interventions in Practice: Background Paper A Framework for Priority Linkages Figure 6 be ‘tailor made’ to the specific and sometimes complex needs of key populations. be ‘tailor made’ to the specific and sometimes for key populations 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 Promotes a rights-based and ‘whole person’ approach 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, Reduces stigma and discrimination issues and needs. populations’ access to services by ‘normalising’ of HIV and SRHR services Increases the quality and appropriateness Provides a ‘one stop shop’ and continuous support. access to and uptake of comprehensive EngenderHealth, IPPF and UNAIDS, 2009. Adapted from: UNAIDS Programme Coordinating Board, June 2010; and WHO, UNFPA, IPPF, UNAIDS and UCSF, 2008 A Guidance Package, Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV:

š š š š š Figure 6: š integrated programming. 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, to reduce stigma and discrimination and increase the quality and relevance of SRHR services and relevance of SRHR services discrimination and increase the quality to reduce stigma and [see 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 11 For example: 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 populations? 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 practice. 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 HIV/SRHR integration for key populations 8 strategies forHIV/SRHRintegrationkeypopulations: The reviewidentifiedthattherearearangeofexamplesinterestingand/orsuccessful for keypopulations? 2.4. WhatstrategiesarebeingusedforHIV/SRHRintegration Sex workers People livingwithHIV HIV programme Figure 7: (especially HCT) components or selectedHIV Comprehensive (plus widerHIV) HIV prevention services forSWs specific, key HCT orother HIV prevention Advocacy onHIV PMTCT andART) services, e.g. followed byother HCT (often for PLHIV General services and support) PMTCT orcare HCT (alsooften care andsupport) ART (alsooften HIV) HCT (andbroader

Examples ofstrategiesforHIV/SRHRintegrationkeypopulations Integration SRHR programme 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 violence) Case studiesinthisreport š š š š š š š š š š š š š š š š š š š š š š š š š 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, 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 Humsafar Trust, India Humsafar Trust, India SAATHII, Malaysia DICP, Korsang, Cambodia OSI, SASO, India Five Hearts Service Centre, PKBI, 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, North Africa Regional InternationalProgramme, HIV/AIDS Alliance Espace Confiance, Cote D’Ivoire š š š š š š š š š š š š š š š š š š š condoms and STIs and often specifically including women’s health) SRHR or Broad primary health care Advocacy on SRHR SRHR (especially 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) HIV and harm reduction Advocacy on HIV HIV General HIV services Selected components of HCT (and other HIV services) 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 š š key populations: 1. Promote goodpracticeprinciplesthroughout HIV/SRHRintegrationfor findings highlightthatitisimportantto: communities thataremarginalisedandvulnerableinthecontextofHIV/SRHR.Thereview’s specific tointegration,manyserveasareminderofgoodpracticefor important lessonsaboutHIV/SRHRprogrammingforallkeypopulations.Whilesomeare Based onthecasestudiesdescribedinfollowingsections,reviewidentifiedmany integration forkeypopulations? 2.5. WhatlessonshavebeenlearnedaboutHIV/SRHR 19 18 17 16 15 14 š there’, gatheringevidenceandidentifyingkeyentrypoints: 2. PlanandgetstartedonHIV/SRHRintegration bybuildingon‘what’s š š

India, August2011. Linking SRHAndHIVTo MeetTheNeedsOfMSM&Transgender People:ExperiencesfromIndia, Positively Caring 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 increase insafersexpractices provision ofclinicalserviceswithraisingawarenesssexworkers’rights–leadingtoan For example:theFamilyPlanningAssociationofTrinidadandTobagocomplements including tosexuality,havechildrenandmakechoicesabouttheirownSRHR. Use arights-basedapproachthatrecognizeskeypopulations’individualrights, harm reductionNGOtobemulti-disciplinaryratherthan recruitspecialistSRHRstaff.Only become ‘sexworkerfriendly’ratherthansetupaseparate clinic;ortrainexistingstaffata than startingfromscratch. Develop integratedprogrammesthatbuildon‘what’s there’forHIVandSRHR,rather discrimination) access toservices;andaddresscriticalbarriersforkeypopulations(suchasstigma gather evidenceoftherealHIV/SRHRneedskeypopulations;facilitatepopulations’ groups –especiallythosethatare HIV/SRHR integration. Recognise thecentralityofcommunityorganisationsandsystemsforhighquality training tothestaffoftheirSRHRclinic and PROFAMILIA,Colombia,employedmenwhohavesexwithtodesigndeliver relevant support) to thestigmaassociatedwiththeirparents,mayalsoexperiencechallengesinaccessing male partnersoffemalesexworkersortheMSM)andchildren(who,due learned thatthisincludeslookingattheHIV/SRHRneedsofpeople’spartners(suchas populations, butthosearoundthem. Take afamily-centredapproachthatsupportsnotonlytheHIV/SRHRneedsofkey as community-basedvolunteersandmembersofitsManagementAdvisoryBoards Options KenyainvolvesPLHIVthroughoutthecycleofitsintegratedprogramme,including populations atallstagesofintegratedprogramming. Ensure theprincipleofgreaterinvolvementPLHIV(GIPA)andotherkey transgender peopletoimprovefamilyacceptanceand understanding oftheirneeds (powerpointpresentation), InternationalHIV/AIDSAlliance,March2011. 14 . 18 . FPAIfounditimportanttoworkwiththefamilymembersofMSMand For example,theIndiaHIV/AIDSAlliancehasseenthatcommunity For example,wherepossible:supportalocalSRHRclinic to 15 . by , (powerpointpresentationatICAAP2011),India HIV/AIDSAlliance,2011. and 17 For example,theInternationalHIV/AIDSAlliancehas . for keypopulations–areinauniquepositionto: For example:FamilyHealth (powerpointpresentation), FamilyPlanningAssociationof any typeofworkwith

2010 . 19 International International . 16 ;

11 HIV/SRHR integration for key populations . 29 ; 26 Family key within International HIV AID Alliance in India. GNP+, ICW, Young Positives, , International HIV/AIDS Alliance, 2011. ; and a study of sex workers . 24 25 ; and Bandhu Social Welfare 22 ; ensuring attention to taboo taboo to attention ensuring ; 28 . 20 . 23 For example: a sex worker might also be a migrant or use For example: a sex worker might also . 21 These will vary according to the context, but can be identified by to the context, but can be identified These will vary according For example: an India HIV/AIDS Alliance study found that young For example: an India HIV/AIDS Alliance , International HIV/AIDS Alliance, 2010. For example, some women living with HIV may be able to access women living with HIV may be able For example, some . For example, this might involve: integrating SRHR services such as safe safe as such services SRHR integrating involve: might this example, For . r example, women who use drugs may have significantly different SRHR r example, women who use drugs may , SWASTI Health Resource Centre, December 2008. , SWASTI Health Resource Centre, December 2008. 27 Consider factors such as: Fo For example Alliance Zambia found that young people living with HIV had intensive For example Alliance Zambia found , International HIV/AIDS Alliance. , International HIV/AIDS Alliance. , International HIV/AIDS Alliance. married women living with HIV face pressures to become pregnant and have children married women living with HIV face pressures Relationship status. 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. Other status or behaviours. with HIV. drugs; or an MSM might also be living needs to men who use drugs. Age. due to their age SRHR needs, but less access to services, Gender. š subjects, such as anal STIs for sex workers; and addressing the SRHR needs that often ‘fall ‘fall often that needs SRHR the addressing and workers; sex for STIs anal as such subjects, combining HIV- through the net’, such as of women who use drugs who require a package programming, syringe and needle treatment, substitution opiate as (such interventions related services MNCH and SRHR key with prevention) overdose and injecting safe about education š š Identify, understand and respond to the diversity of HIV/SRHR needs Identify, understand and respond populations. š Identify and start with the most needed and obvious ‘entry points’ for integrating with the most needed and obvious Identify and start 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 require specialised services require specialised 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 specific context. who are sex workers – may services, while others – such as those mainstream SRHR 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 MNCH for sex workers or women who use drugs sex workers or women MNCH for 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 Use comprehensive definitions of HIV and SRHR that go beyond the ‘usual suspects’ suspects’ ‘usual the beyond go that SRHR and HIV of definitions comprehensive Use for integration abortion that – while still not commonly integrated with HIV for the general public – can be be can – public general the for HIV with integrated commonly not still while – that abortion 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, Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: EngenderHealth, IPPF and UNAIDS, 2009. HIV and Drug Use: Good Practice Guide Health International. People Living with HIV in Zambia: Briefing Paper 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 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 and Potential Strategic Work Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Alliance Programmes and Policy Partnerships 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 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 Summary Report of Key Findings and Programme Recommendations: From FHI MSM Programme Evaluations (Bangladesh, Indonesia and Nepal),

š š š 29 24 25 26 27 28 20 21 22 23 3. Ensure comprehensive HIV/SRHR integrated programming for key HIV/SRHR integrated programming comprehensive 3. Ensure populations: š 12 HIV/SRHR integration for key populations š š š for keypopulations: 4. Ensure effective andcreative servicedeliveryforHIV/SRHRintegration 36 35 34 33 32 31 30 š š š

Exploring theLinksbetweenDrugUseandSexual Vulnerability amongYoung FemaleInjecting DrugUsersinManipur August 2011. AdvancingSexualand Reproductive HealthandRightsforSexWorkers, HIVandDrugUse:Community ResponsestoInjectingDrugUseand HIV: GoodPracticeGuide, IntegrationofHIVandSexual andReproductiveHealthRights:Good PracticeGuide, in India, AdvocacyBrief:IntegrationofSexualandReproductive HealthandHIV-Related forMenWho HaveSexwithMen(MSM)andTransgender Services People GatewaystoIntegration:ACaseStudyfromSerbia Zakowicz, DawnAverittBridge,JillGay,Robert Carr,(PresentationatInternationalAIDSConference),July SRH andHIVModelsProgrammingExamples fromaVariety ofSettingsinCountries/Areaswith ConcentratedHIVEpidemics, PATH, India:HIV-SRH Convergence, PolicyandPracticeUpdate4, self-esteem – leading to greater health seeking behaviour Andhra Pradesh,India,foundthatpeereducatorshelpedMSMtobuildself-confidenceand especially foraddressingsensitiveorcomplexissues. Recognise peereducationasacriticalstrategyinHIV/SRHRforkeypopulations, use drugsisalwaysdeliveredbyfemaleworkers of Korsang,Cambodia,areallcurrentorformerdrugsusers,whilesupportforwomenwho mobile supportat‘hotspots’ reaches sexworkersthroughcombiningcentre-basedservices,communityoutreachand Offer flexibleservicedelivery previously beentargetedforHIVpreventionandisolatedfromSRHRsupport. (such asaccompanimentbyvolunteers)toaccessservices;andsexworkersmayhaveonly PLHIV maynotknowthattheyhavetherighttoSRHorneedactiveencouragement Create demandaswellsupplyforHIV/SRHRintegratedservices. those withanSRHRproblemsoughtsupportatafacility also sexworkers,only20%usedcondomswiththeirregularboyfriendsandhalfof study among15-34yearoldwomenwhousedrugsinManipur,India,foundthatmanywere different typesandlevelsofvulnerabilityinter-relate. Within thedevelopmentofintegratedprogrammes,addresshowkeypopulations’ to integratedservices PATH’s trainingonstigmaforhealthprovidersandsexworkersledtoanincreaseinaccess populations) asafundamentalbarriertointegratedprogrammes. Proactively addressstigmaanddiscrimination(relatedtobothHIVkey service providersanddecision-makers a partnershipbetweensexworkersandserviceproviders,aswellwithotherHIV/SRHR stakeholders. Work inpartnershipbothwithinaprojectandwiththecommunityother government clinic referral toin-houseservicesatanNGO,aCommunityPreferredPrivatePractitioneror Programme-III inIndia,programmesforMSMtoprovideSTIsupportcandosothrough (draft),FamilyPlanningAssociationofIndia,2010. For example, in countries such as Myanmar, UNFPA has found it vital to build 33 . 31 . 32 , WHO,UNFPA,UNAIDSandIPPF,2009. ; and,intargetedinterventionsfortheNationalAIDSControl . Forexample:theInstituteforStudentsHealth,Serbia, 36 HIV-SRHConvergenceProject,PATH,December 2009;and . (powerpoint presentation atICAAP2011),UNFPAAsiaPacificRegional Office, 35 . InternationalHIV/AIDS Alliance,December2010. 30 Forexample,aPopulationCouncil InternationalHIV/AIDS Alliance,2010. 34 . ; and the staff and peer educators For example:Mythriclinicsin

2010. , PopulationCouncil,2008. Forexample,inIndia, Forexample: Exploring Integrated Amitrajit Saha,Anna 13 HIV/SRHR integration for key populations . . 41 40 staff all ; and For Examples 37 For example, ensure that This includes: targeting (powerpoint presentation at ICAAP 2011), Family For example, where possible, Indonesia, IPPF East and South Asia and Oceania Region, laws that criminalise same-sex acts . For example, programmes to support . For example, programmes

(powerpoint presentation at ICAAP 2011), UNFPA Asia Pacific Regional Office, , Open Society Institute, 2010. For example, Puskesmas, Indonesia, needed to refurbish some facilities and For example, Puskesmas, Indonesia, . . 38 39 attitudes towards key populations; and being led by or, at least, actively involving attitudes towards key populations; and (draft), Family Planning Association of India, 2010. 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 Ensure that training to support integrated programming for key populations is Ensure that training to support integrated and high quality. 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 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) advocating to legal authorities for recourse in instances of violence against 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’. individuals, demonstrate to donors the cost-efficiency of integrated programmes – for services and health systems. Complement the provision of integrated services with local/national advocacy on Complement the provision of integrated services with local/national 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 people; and between consenting adults or do not recognise the identity of transgender example, FPAI found it vital to take proactive 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 Build a multi-level approach to HIV/SRHR integration for key populations that Build a multi-level approach to HIV/SRHR of joint services. 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. Build an organisation’s knowledge If integration involves referrals, ensure the quality, confidentiality and ‘key population- referrals, ensure the quality, If integration involves systems and services 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 provide a separate entrance for a methadone clinic within its primary health care services provide a separate entrance for a methadone If necessary, reconfigure an organisation’s physical space to provide integrated If necessary, reconfigure an organisation’s programmes. August 2011. Making Harm Reduction Work for Women: The Ukrainian Experience 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, People: Experiences from India, Meet The Needs Of MSM & Transgender Linking SRH And HIV To Planning Association of India, August 2011. Advocacy Brief on People Who Use Drugs, Linking Sexual and Reproductive Health and HIV: 2011. Advancing Sexual and Reproductive Health and Rights for Sex Workers,

š 37 38 39 40 41 š š 7. Address the political, legislative and funding context of HIV/SRHR the political, legislative and 7. Address integration for key populations: š š 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 populations, including through high quality and systematic referrals: and systematic high quality through including populations, š 5. Ensure a strong ‘chain’ of HIV/SRHR integrated services for key services for key integrated of HIV/SRHR ‘chain’ a strong 5. Ensure š 14 HIV/SRHR integration for key populations organisational ‘pitfalls’,suchas International (FHI)–see Essential StepstoStrengthenFamilyPlanningandHIVServiceIntegrationbyHealth step approach[see SRHR integrationforkeypopulations.Theseincludethatitisvitaltotakeasteady,step-by- The reviewparticularlyhighlightedlessonslearnedaboutgoodpracticeininitiatingHIV/ integration forkeypopulations? 2.6. Howdoorganisations‘getstarted’withHIV/SRHR 42 så så så så så så så så så

IPPF, UCSF,UNAIDS, UNFPA andWHO,2008. Informed bymultipledocuments andadaptedfromthegeneric‘helps’ and‘hindrances’identifiedin Simply ‘doingmore’withoutconsideringthemosteffectivewaystodointegration. wants Doing integrationbecauseit’s‘therightthingtodo’ratherthansomethingtheorganisation 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. todo. Figure 8 Annex 4 , informedbyarangeofpublications,forexampleincludingTen 42 : ]. Thelessonsalsoincludethatitisimportanttoavoid Linkages:EvidenceReview andRecommendations, 15 HIV/SRHR integration for key populations

For example, to other facilities. referral identified in the needs such as combining: with indicators for integrated of services or among all key stakeholders both: among all key stakeholders including ensuring that referral facilities are facilities are including ensuring that referral including to track clients ‘journey’ within the provision of HIV and SRHR information, services and of HIV and SRHR information, services to identify the key population’s specific needs and population’s to identify the key For example, integrating supply management to deal with additional challenges or processes related related to deal with additional challenges or processes of integration Consider issues such as: involved in the programme, as well as referral sites. as well as referral involved in the programme, These might include: concept to identify ‘what’s already there’ for HIV and SRHR in terms of for HIV there’ already to identify ‘what’s For example, ensure that: an HIV organisation understands/ that: an HIV organisation For example, ensure for integrated programming and/or renegotiating funding with existing and/or renegotiating for integrated programming

– including among the wider health community and leaders of key populations. the wider health community and leaders – including among – particularly among the organisation’s management and governance. management the organisation’s – particularly among Ten key steps to developing an HIV/SRHR integrated programme for integrated programme an HIV/SRHR steps to developing Ten key

integrated programme, including referrals to other organisations. to other organisations. including referrals integrated programme, Strengthening the monitoring and evaluation system, programming. Developing protocols and guidelines for integrated programming. Strengthening project management to integrated programming. As necessary, building a strong referral system, technical expertise. ‘key population friendly’ and have relevant Strengthening systems for patient monitoring, Developing specific strategies to respond to barriers to services Developing specific strategies to respond assessment, such as stigma and discrimination. 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. systems. The extent to which integration will involve The extent to which integration will involve Securing resources donors. Providing training to all staff What HIV or SRHR components are already available and accessible to community members. community to accessible and available already are components SRHR or HIV What – 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). existing data, services, infrastructure, funding, types of providers, accessibility, cost, etc. accessibility, funding, types of providers, existing data, services, infrastructure, Externally assessment A participatory community barriers to services. issues such as and explore to HIV and SRHR relation in desires An environment mapping Internally addresses the changes needed to provide SRHR services; or an SRHR organisation 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. š throughout 7. Build a ‘key population-friendly’ and ‘HIV/SRHR-friendly’ environment integrated programming. š š š š š š š š been agreed, plan and implement a series of key steps 6. When the type of integration has to ‘make integration happen’. š š strategy for HIV/SRHR integration. š š š 4. Based on the assessment and technical guidance (such as National AIDS Programme 4. Based on the assessment and technical 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 š to gather evidence and assess needs, 3. Start with steps š š key populations for HIV/SRHR integrated population community to create demand 1. Mobilise the key services. for the 2. Secure the ‘buy-in’ š Figure 8: 16 HIV/SRHR integration for key populations authorities. example betweenserviceproviders andcommunitymembersbetweenanNGOhealth 10. Planon-goingopportunitiesfordialoguetoenhanceknowledgeandrespect, before integratingmore complexoptions(suchasART). For example, an SRHR programme might start with ‘easy fit’ options (such as HCT and PMTCT) 9. IntegrateHIVorSRHRcomponentsovertime,buildinguptoafullerrangeofintegrated. improve themodelbeforescalingup. 8. Startwithapilotproject(perhapsfocusingonsome‘easywins’forintegration),then for 17

3. HIV/SRHR integration © Prashant Panjiar for India HIV/AIDS Alliance for people living with HIV

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: š Psycho-social support, including focused on sexuality and sexual health (e.g. sexual desires, safer sex) for both men and women. š FP (e.g. counselling on safe ways to become pregnant and access to a full range of contraceptive options, including long-lasting ones). š Interactions between different drugs, such as ART, hormonal contraceptives and methadone. š Pregnancy and birth, including PMTCT, ANC, delivery and PNC. š MNCH, including infant feeding and treatment. š Positive health, dignity and prevention (e.g. information on ‘positive prevention’, support for voluntary disclosure). š Empowerment on sexual and reproductive health rights. š Full range of treatment, including second/third line ARVs and for opportunistic infections. š Full range of STIs (e.g. rapid testing, treatment). š Male and female condoms (e.g. supplies, support for negotiation skills) for dual protection. š Sexual dysfunction (e.g. low libido related to ART). š (Where legal) safe and confidential abortion and (in all contexts) post-abortion care. š Sexual and intimate partner violence (e.g. support after rape or gender-based violence following disclosure of HIV status), including PEP. š Sero-discordant couples (e.g. information on safer sex, counselling on disclosure, biomedical prevention services). š 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 š seen intheliteratureanddemonstratedcasestudiesbelow,examplesinclude: on someofthemosteffectivestrategiesforHIV/SRHRintegrationpeoplelivingwithHIV.As The reviewidentifiedthat,comparedtootherkeypopulations,thereisemergingconsensus integration forpeoplelivingwithHIV? 3.2. WhataresomecommonstrategiesforHIV/SRHR 45 44 š 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: Advocacy onHIV ART) e.g. PMTCTand by otherservices, HCT (oftenfollowed PLHIV General servicesfor support) PMTCT orcare and HCT (alsooften and support) ART (alsooftencare Issue Brief:Sexualand ReproductiveHealthandRights–KeyIssues forHV-Affected Widows StudyofFamilyPlanningand HIVIntegratedServices A Five-Country Republic andEthiopiafound thatwomenlivingwithHIVweremorelikelythanmen tohave: programmes. Address thegenderdimensions ofHIV/SRHRandtheimplicationsforintegrated stigma) many womenlivingwithHIVwereactuallynotsexually active (duetoissuessuchasself- although a study by FHI in five countries found little unmet need for FP, this was because Not makepresumptionsabouttheSRHRneedsor desires ofPLHIV Andhra Pradeshfoundthat widows livingwithHIV risk (suchasrelatedtoviolence andsexwork)haveunmetneedsforSRHRservices 44 . Meanwhile, an Alliance India study in Maharashtra, Manipur, Tamil Nadu and Examples ofstrategiesforHIV/SRHRintegrationpeopleliving Forexample,anIPPFstudy ofstigmainBangladesh,theDominican Integration

SRHR programme Selected components Advocacy onSRHR SRHR) FP (alsooftenbroad violence) or gender-based related toSTIs of SRHR(e.g.support SRHR) FP (alsooftenbroad and/or broad SRHR) FP (alsooftenSTIs , FamilyHealthInternational, 2010. are sexually active, experience heightened , InternationalHIVAIDAlliance inIndia. Examples incasestudies š š š š š š š š š š š š š MAMTA, India transgender people) Section 5onMSMand SAATHII, India[see FHOK, Kenya Republic PROFAMILIA, Dominican ABEF, Rwanda Uganda Alliance inUganda, HIV/AIDS International Gheskio, Haiti PSI, Zimbabwe HCT Centres, Ethiopia HCT Centres, Kenya POZ, Haiti Ministry ofHealth,Keny TASO, Uganda . For example,

45 . 19 HIV/SRHR integration for key populations , ]. This 49 Amsterdam Statement on For of choice regarding 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. People living with HIV have the freedom People living with HIV have the freedom Figure 10 š š Figure 10: SRHR for people living with HIV š [see , GNP+, HRSC and University of Witwatersr, 2009. GNP+, December 2007. , International HIV AID Alliance in India, May 2008. GNP+ and UNAIDS, April 2009. . 50 . 47 [see Figure 11]. Such approaches involve integrating integrating involve approaches Such . 48 . A report by the International Community of Women Living with HIV found Living with Community of Women by the International . A report 46 How integration avoids ‘missed opportunities’ How integration avoids ‘missed the rights and responsibilities of people living with HIV, including to confidentiality, the rights and responsibilities of people both 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. to the HIV/SRHR needs of Pay particular attention couples said that their sexual study in 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 sterilisation 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 PNC and, if required, safe abortion and post-abortion care. care. post-abortion and abortion safe required, if and, PNC confined to their HIV status to, HIV for developed services supportive and safe the on Build needs pregnancy-related of range full the address particular, in of women living with HIV. ANC, counselling/testing/screening, pregnancy FP, as such services Use integrated programme as a means to look at the full, Use integrated programme as a means needs the than rather HIV, with living people of needs holistic Positive Health, Dignity and Prevention: Technical Consultation Report, Positive Health, Dignity and Prevention: Technical 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 Sexual and Reproductive Health of Males-at-Risk in India: Service Needs, Gaps and Barriers and the Ukraine HIV Discordant Couples – An Exploratory Study: Insights from South Africa, Tanzania Amsterdam Statement on Sexual and Reproductive Health and Rights for People Living with HIV,

the discomfort that many clients and health workers feel about about feel workers health and clients many that discomfort the discussing these issues.” and Women Health for HIV-Positive Sexual and Reproductive Managers, and Programme Adolescent Girls: Manual for Trainers Engenderhealth and ICW or addressed by a service provider. By not addressing those those addressing not By provider. service a by addressed or improve to opportunities key miss may workers health needs, opportunities missed of problem This status. health overall clients’ potentially the given services, SRH in serious particularly is AIDS, and STIs pregnancies, of consequences life-threatening and AIDS and HIV with associated stigma social the both and “Clients typically seek SRH services for one particular need or or need particular one for services SRH seek typically “Clients post-abortion and legal) (where abortion STI, an FP, e.g. – problem workers health and – care health maternal of aspect some or care, However, problem. or need particular one that to respond typically that concerns or needs other have may HIV with living people identified never are that but problem, primary their to contribute Figure 11: to address critical needs of PLHIV š š š 50 46 47 48 49 includes ensuring that positive health dignity and prevention (‘positive prevention’) programmes includes ensuring that positive health respect informed consent and voluntary disclosure Recognise the centrality of sexual rights for people living with HIV Recognise the centrality of sexual 20 HIV/SRHR integration for key populations with HIV 3.4. CasestudiesofHIV/SRHRintegrationforpeopleliving 51 51 integration HIV/SRHR Key population type Programme Provider type Country Organisation: learned Lessons Integrating Family Planning and Antiretroviral Therapy Services inUganda IntegratingFamilyPlanning andAntiretroviralTherapyServices The AIDSSupportOrganisation(TASO) š š š š š š š š PLHIV (individualsandcouples) HIV Civil society Uganda (Mbale) š š š services forcouples,etc.). in project design,developingmaterialsinlocallanguages, providing Demand hastobebuiltforservices(e.g.byinvolvingthe community and mobilizingvolunteers. organization, training It iscriticaltoinvestinpeople–delineatingFPtasksfor 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 š š 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 HIV services (including ART) integrating practices andneeds–tounderstandthecontextbuildownership. Doing aparticipatoryneedsassessmentofclients’FPknowledge, capacity (human,physical,financial,technical)foraddingservices. Using aframework(developedbyACQUIRE)toassessorganization’s all levelsofstaff, buildingthe skillsofsupervisors , FamilyHealthInternational, 2010. Intervention type Donor HIV epidemic 51

(supported byFHI) community outreach Facility-based; USAID Generalised everyone inthe 21 HIV/SRHR integration for key populations , PSI Zimbabwe. 52 Generalised Government of the Netherlands Facility-based; mobile negative) and reaching over 35,000 over negative) and reaching or HIV epidemic Donor Intervention type Marketing and distribution of contraceptives, including implants, Marketing and distribution of contraceptives, contraceptive pills. injectables and emergency clients per month. Referrals to FP service providers (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 ‘New Start’ network of 19 static and 23 mobile HCT units integrating ‘New Start’ network of 19 static and FP (for people testing positive 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. š 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, communication is vital for enabling individual PLHIV Inter-personal and make and couples to understand the benefits of dual protection š emphasises: Programme š š 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 š š š š š š Civil society HIV couples discordant women) and sero PLHIV (particularly š š Zimbabwe Population Services International (PSI)/Zimbabwe Services International Population Case Study: Zimbabwe, Integration of Family Planning and HIV Services in Zimbabwe: Hormonal Implants and Dual Protection Messages Lessons learned type Key population HIV/SRHR integration Organisation: Organisation: Country type Provider Programme 52 52 22 HIV/SRHR integration for key populations 53 53 53 integration HIV/SRHR Key population type Programme Provider type Country Opportunistes (GHESKIO) Organisation: Gateways toIntegration: ACaseStudyfromHaiti Groupe Haïtiend’ÉtudeduSarcomedeKaposietdesInfections š š š š š š š š š š š š PLHIV (includingsero-discordant couples) HIV Civil society de Dieu) neighbourhoods ofCite Haiti (two 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 24% inthecatchmentpopulation. Results includethatcontraceptiveprevalence increased from 6%to adapted to22publicandprivatehealthcentres. Model hasbeenscaledupandinfluencednational practice –being providing confidentialcounseling rooms. Clinics were re-arranged toprovide integratedservices,including 53 , WHO,UNFPA,UNAIDS andIPPF,2008. Intervention type Donor HIV epidemic Facility-based Generalised 23 HIV/SRHR integration for key populations Generalised USAID Facility-based (supported by FHI) 54 “Women, if they are HIV-positive, may be may if they are HIV-positive, “Women, HIV epidemic Donor Intervention location , Family Health International, 2010. Ministry of Health and FHI carrying out supportive supervision visits. developing its own plan for Centre Care Each Comprehensive integration. 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. š š in the use of modernResults included a significant increase contraceptives by PLHIV. 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 š š š barriers to access are removed.” Stigma and discrimination – not just in relation to HIV, but issues 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 stated that: 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 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 š š HIV PLHIV š š Kenya (Coast and Rift Provinces) Valley Government š š š š š Ministry of Health, Goverment of Kenya Ministry of Health, Goverment of Integrating Family Planning into HIV Care and Treatment Services in Kenya Integrating Family Planning into HIV Care and Treatment Lessons learned Key population HIV/SRHR integration Type of Type provider Main programme type Organisation: Country learned Lessons Lessons 54 54 24 HIV/SRHR integration for key populations 55 55 IPPF) integration HIV/SRHR Key population type Programme Provider type Country Organisation: learned Lessons Planned ParenthoodFederation, 2005. ModelsofCareProject: LinkingHIV/AIDSTreatment, Association pourleBien-EtreFamilial(ABEF) Rwanda (Kigaliand š š š š š š š š š š PLHIV SRHR Civil society Butare) 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 š š š š 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. C are andSupportinSexual andReproductiveHealthCareSettings:Examples inAction, Intervention type Donor HIV epidemic 55 (supportedby community outreach Facility-based; Generalised International 25 HIV/SRHR integration for key populations

56 , Interntional GTZ community Facility-based; outreach HIV epidemic Donor Intervention type “I feel like any other person in the waiting room. We sit in the same room. We “I feel like any other person in the waiting PROFAMILIA staff now bring their own relatives 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. 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). 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, Started with a pilot project 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 said: 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 ART, to adherence care, clinical providing – Team Care Model a Developed family/partner education, etc. emotional support, safer sex counselling, š š š š š š š š š š š (Santo Domingo and (Santo Domingo and Santiago) Civil society SRHR PLHIV š š Dominican Republic Dominican Republic Asociación Dominicana Pro-Bienestar de la Familia (PROFAMILIA) Pro-Bienestar de Dominicana Asociación 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 integration Provider type Provider Programme type Key population HIV/SRHR Organisation: Organisation: Country (supported by IPPF) (supported 56 56 26 HIV/SRHR integration for key populations 57 57 integration HIV/SRHR Key population type programme Main provider Type of Country Organisation learned Lessons Community-Based Care andSupportProgramme:2000-2010 MAMTA HealthInstituteforMotherandChild India (districtsofDelhi) š š š š š š š š š PLHIV (includingchildren) Child health Civil society ART immunisation, nutrition and followup.Itisaboutbreastfeeding, Executive Director ofMAMTA says: 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 development was a great learning forthe organisation.” learning development wasagreat ofchildhealthand and variousotheraspects.Thiscomprehension , MAMTAHealthInstitute forMotherandChild,2011. location Intervention Donor HIV epidemic “Child healthisjustnotabout community outreach Facility-based; Abbott FundUSA Concentrated 57 27 HIV/SRHR integration for key populations

, Interntional Generalised GTZ Facility-based; community outreach HIV affects almost every area of “ (supported by IPPF) (supported 58 HIV epidemic Donor Intervention type Delivering integrated services. and involving PLHIV. demand for services Creating and monitoring and evaluation. Carrying out research Building FPAK’s capacity. Building FPAK’s etc.) and requires SRHR organisations to have sustainable resources. SRHR organisations etc.) and requires 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 opportunistic infections is integrated into regular medical care, 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: As a member of clinic staff other staff. avoid dealing with it.” sexual and reproductive health work, so you can’t providing programme, the to central are PLHIV) (including volunteers Community 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 š š š 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 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 š š š š š š š š š š š š š Civil society SRHR (clients of SWs) PLHIV and truckers š š Kenya Family Health Options Kenya (FHOK) Options Kenya Family Health 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 Organisation Country type Provider Programme type 58 58 28 HIV/SRHR integration for key populations 60 59 59

60 Provider type Country Organisation: learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: learned Lessons integration HIV/SRHR Key population type Programme HIV/AIDS Alliance) Integrating Family Planning Services intoVoluntary IntegratingFamilyPlanning Services CounselingandTesting CentersinKenya:OperationsResearch Results HIV/AIDS Alliance(accessed 13.4.11);http://www.aidsalliance.org/linkingorganisationdetails.aspx?id=31 GoodPracticeGuide:Integration ofHIVandSexualReproductive HealthandRights Promoteurs d’ObjectifZerosida(POZ) HIV CounsellingandTestingCentres š HIV Kenya š š š š PLHIV HIV Civil Society Haiti š š š of integratedprogrammes. Record keepingandcommodity supplyare criticalforeffective scale-up STIs andevenlesssopregnancy. predominantly spoketoclients aboutcondomspreventing HIV, lessso integrated programming. For exampleresearch foundthatproviders There isaneedtomonitor theperformanceofstaff indelivering Training giventoserviceproviders onintegration. š š š š 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, As in‘1’,plusinjectablecontraceptives. information onFP, STIsandHIV; andprovision ofpillsandcondoms. Risk assessmentofpregnancy, STIsandHIV; counsellingand Provision offullrangeFP methods. As in‘2’,plusintrauterinecontraceptivedevices. 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 , FamilyHealthInternational, 2006. 29 HIV/SRHR integration for key populations Good , International HIV/AIDS Alliance, Generalised Facility-based Generalised Community-based , International HIV/AIDS Alliance, December 2010; and 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 mobilize PLHIV to use existing services and refer 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 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 š š HIV testing those including clients, HCT specific for protocols Developed to FP. positive, and modified counsellors’ logbooks to include information relating in the discussion of SRHR issues (such as Results included dramatic increase contraception, fertility options and condoms) in HCT sessions. 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: 61 š š š Civil society HIV PLHIV š š Uganda š š š Ethiopia (4 focus regions) Civil society and government HIV PLHIV š š HIV Counselling and Treatment Centres (supported by Pathfinder HIV Counselling and Treatment International HIV/AIDS Alliance in Uganda (supported by International (supported by in Uganda HIV/AIDS Alliance International March 2009. Integration of HIV and Sexual and Reproductive Health and Rights: Good Practice Guide The Alliance Approach Practice Update: Linkages and Integration of Sexual and Reproductive Health, Rights and HIV: learned Lessons Key population HIV/SRHR integration Type of Type provider Main type of programme Organisation: International) Country Lessons learned Main type of programme Key population HIV/SRHR integration Organisation: Organisation: Alliance) HIV/AIDS Country of Type provider 61 61 30 HIV/SRHR integration for key populations 62 62 by IPPF) learned Lessons integration HIV/SRHR Key population programme Main typeof provider Type of Country Organisation: Reproductive Healthin People’s Lives InaLife:LinkingHIVTreatment, CareandSupportinSexualReproductive HealthCareSettings Reproductive HealthAssociationofCambodia(RHAC) Cambodia (Kurn Potproh)Cambodia (Kurn š š š š 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: 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 , IPPF,2008;and In aLife:LinkingHIVand SexualandReproductiveHealthinPeople’s Lives Intervention location Donor HIV epidemic “‘I amHIV-positive, butmywife isn’t. , IPPF,2006; In aLife:LinkingHIVand Sexualand community outreach Facility-based; Concentrated 62 , IPPF,July2010. (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: š ‘Tailor made’ HIV prevention and behaviour change communication. š Male and female condoms and lubricant (e.g. negotiation skills, regular supplies for dual protection). š Safer sex negotiation skills, counselling and risk-reduction (including for anal sex). š Full range of FP support and contraceptive options (to, for example, prevent pregnancy from clients and plan a family with a partner). š Sexual violence (e.g. prevention strategies, counselling). š Emergency PEP for rape or sexual assault. š Full range of STIs, including attention to anal infections and re-occurring infections. š Pregnancy and birth, including supportive and non-judgemental ANC, PMTCT, delivery, PNC and MNCH. š Empowerment on sexual and health rights. š Negotiation skills to deal with stigma and criminalised status (e.g. sexual harassment by police). š (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 š to: section 2.5]applytosexworkers.Inaddition,somespecificlessonsincludethatitisimportant The genericlessonslearnedforHIV/SRHRintegratedprogrammingkeypopulations[see HIV/SRHR integrationforsexworkers? 4.3. Whatlessonshavebeenlearnedaboutgoodpractice HIV programme Figure 12: (especially HCT) components or selectedHIV Comprehensive wider HIV) HIV prevention (plus for SWs specific, key services HCT orother HIV prevention HIV) HCT (andbroader GoodPracticeGuide:Integration ofHIVandSexualReproductive HealthandRights Alliance inAndhraPradesh, SWASTIHealthResourceCentre,December 2008. SexualandReproductive HealthNeedsofFSWs,MSMsandTGs:Research ReportonQuantitativeFindingsfrom Warangal,GuntakalandPilerSitesof and 6%inbrothels–affectingboththeirneedsaccess toservices found that35%werestreet-based,27%home-based, 26%basedinsecret,7%lodges of sexworkers. Identify, understandandrespondtothedifferentSRHR/HIV needsofdifferenttypes male ortransgender experience differentlevelsofvulnerabilityandneedsaccording towhethertheyarefemale, integration forsexworkers? WhataresomecommonstrategiesforHIV/SRHR Examples ofstrategiesforHIV/SRHRintegrationsexworkers Forexample,astudyamongsexworkersinGutakal,Andhra Pradesh 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 š š š š š š š š š š š š 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 Policy Briefing, GNP+

SRHR needs of sex Meanwhile,

. 66 , GNP+, ICW, Young Positives, Interact Worldwide, 2011. Figure 13: 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 Living with HIV: and NSWP . 67 , IPPF, 2006. that address the holistic needs the holistic needs that address For example, Alliance partners in For example, Alliance

. 70 For example, within integrated , International HIV/AIDS Alliance, 2008. , rather than treating them as ‘transmitters’ of infection to clients. infection to clients. ‘transmitters’ of treating them as , rather than , SWASTI Health Resource Centre, December 2008. For example, Community Support Concern and HMAP in Pakistan found For example, Community Support Concern . Meanwhile, a study in Guntakal, Andhra . For example, in Nepal, the Family Planning For example, in Nepal, the Family Planning 71 . 69 72 , India HIV/AIDS Alliance. with the procedure sometimes taking place in their own homes Pradesh, found that some sex workers were forced to have abortions by their caretakers/family members, district, Kolkata, India) to design integrated SRHR/HIV district, Kolkata, India) to design integrated services for young girls and women being trafficked for sex work treatment services for anal STIs or support during treatment services for anal STIs or support pregnancy. for sex Address the wider socio-political context workers. Mahila Samanwaya Association partnered with the Durbar in Sonagachi Committee (a sex workers’ cooperative Not make assumptions about sexual ‘norms’ and Not make assumptions about sexual needs of sex workers. diagnosis and programmes, sex workers may need 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 Provide comprehensive integrated services integrated Provide comprehensive Pay specific attention to the SRHR needs of sex workers who are living with HIV to the SRHR needs of sex workers Pay specific attention PMTCT, MNCH services access to a non-discriminatory contraception, including providing Figure 13]. and abortion [see issue of violence. 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 that it was critical to engage pimps in the development of that it was critical to engage pimps in integrated programming Advocate on the benefits of integration to gatekeepers within sex workers’ Advocate on the benefits of integration communities. Alliance in Andhra Pradesh Maharashtra, and Uttar Pradesh, PATH, June 2007. A Guidance Package Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: EngenderHealth, IPPF and UNAIDS, 2009. and HIV 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 Affect Adolescents’ Needs for and Access to SRHR, Failing? How Marginalisation and Vulnerability Who Are We Care and Support in Sexual and Reproductive Health Care Settings In a Life: Linking HIV Treatment, Guntakal and Piler Sites of Sexual and Reproductive Health Needs of FSWs, MSMs and TGs: Research Report on Quantitative Findings from Warangal, Options and Challenges for Converging HIV and Sexual and Reproductive Health Services in India: Findings from an Assessment in Andhra Pradesh

š š š š š 67 68 69 70 71 72 66 š 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: Treatment forKeyPopulation Services amongFemaleSexWorkersSTI/HIV Services Questionnaire –Scaling upSRHR/HIVIntegration:Avahan Programme IntegrationofHIVandSexual andReproductiveHealthRights:Good PracticeGuide Avahan, India š š š š š š drugs SWs (andtheirclients),MSM,transgenderpeople,PLHIV, peoplewhouse HIV/STI prevention Civil society;government Andhra Pradesh) Telengana Districts, India (Rayaleemaand š š Key integrationstrategieshaveincluded: services, HCT(byreferral) andSTItesting/treatment onsite. in accordance with NACO guidelines). Support will involve one-to-one outreach workers from outside of community (focusing on monitoring role, Outreach was by SWs and other key population peers. In Phase 2, is by Facility services complemented by outreach work, including at ‘hotspots’. specifically focusesonSTItreatment, withreferrals tootherservices. Phase 2 (2009-13) involves transition to government and community and 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 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 š š Having anemphasisondualprotection andwomen-centricFPmethods. management. presumptive treatment, monthly check-ups, counselling and partner SWs and other key populations. STI services include management, At the Mythri clinics, providing a range of appropriate services for clinics. to-one support,group sessions andmobilisationtoaccesstheMythri Building acommunity-drivenapproach [seeabove],combiningone- issues suchasANC,PNC,FP, PAP smearsandmenstrualhygiene. Training outreach workers, medical officers and counsellors, covering , (posterpresentation), India HIV/AIDSAlliance,AvahanInitiativeand Mythri. , (posterpresentation), India HIV/AIDSAlliance,AvahanInitiativeand Mythri;and 73 , IndiaHIV/AIDSAlliance; location Intervention Donor HIV epidemic , InternationalHIV/AIDS Alliance,December2010;and Integration ofSRHCommunication andFamilyPlanningwith community outreach Facility-based; ofIndia Government Foundation, then Bill &MelindaGates Concentrated Focused STIPrevention and Mapping 73 35 HIV/SRHR integration for key populations Challenges include limited access to some governmentChallenges include limited access to services for living with HIV needing support some populations, such as for women for delivery or abortion. going assessment 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 exit regular 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 It may be better to mainstream services into government initiatives from into government services from initiatives better to mainstream It may be points and set up specific service rather than a programme, the start of among community members. raise expectations support on- a baseline situation analysis to It is important to conduct š š š š š š learned Lessons Lessons 36 HIV/SRHR integration for key populations 74 74 integration HIV/SRHR Key population programme Main typeof provider Type of Country Organisation: learned Lessons Alliance) LinkingSRHRandHIV – ACommunity-CentredApproachtoAchieving UniversalAccess Child SurvivalIndia(CSI) India (HolumiKalan š š š š š š SWs andPLHIV SRHR andHIV Civil society Delhi) Phase 1,NorthWest š š 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 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 š š š š š 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 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 location Intervention establishment of support group for SWs living with HIV; increased 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 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. management, PAP smears for cervical cancer, screening for breast 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 to SWs’ needs. flexible – to respond are Opening hours of centre services per day; Results include: up to 300 SWs accessing 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, š š š š š š š š š Civil society HIV SWs and their clients Kenya Kenya AIDS NGO Consortium (KANCO) NGO Consortium Kenya AIDS Good Practice Guide: Integration of HIV and Sexual and Reproductive Health and Rights Lessons learned integration Main programme type Key population HIV/SRHR Organisation: Organisation: HIV/AIDS Alliance) International Country of Type provider 75 75 38 HIV/SRHR integration for key populations 76 76 (supported byInternationalHIV/AIDSAlliance) learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country Organisation:

AIDS Alliance. Study, Caribbean:Country ofAchievements, ProgressandChallengesunder IMPACT Studies:AGlobal Summary AllianceCountry 2010 Eastern CaribbeanCommunityActionProject(ECCAP) Caribbean (Antiguaand SWs HIV Civil society Nevis) Barbuda, StKittsand š š š š 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

, InternationalHIV/ 39 HIV/SRHR integration for key populations , Amitrajit Saha, Anna Exploring Integrated Concentrated DfID; Hewlett and Foundations Packard community Facility-based; outreach HIV epidemic Donor Intervention location , HIV-SRH Convergence Project, PATH, December 2009; and “The women who have never visited a hospital before 77 Creating demand (by raising awareness and creating interest 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. In Andhra Pradesh, used face-to-face 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: Muzaffarpur have started going now.” complemented by national advocacy and stakeholder Service provision meetings. 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 š š 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. 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. š š š š š š š š š Muzaffarpur, Bihar) Muzaffarpur, Government and private sector HIV and SRHR SWs and PLHIV š š India (Srikakulan, Andhra India (Srikakulan, and Pradesh and Patna PATH India ATH, India: HIV-SRH Convergence, Policy and Practice Update 4 India: HIV-SRH ATH, Zakowicz, Dawn Averitt Bridge, Jill Gay, Robert Carr, (Presentation at International AIDS Conference), July 2010. P Countries/Areas with Concentrated HIV Epidemics of Settings in SRH and HIV Models and Programming Examples from a Variety Lessons learned integration provider provider Main type of programme Key population HIV/SRHR Organisation: Organisation: Country of Type 77 77 40 HIV/SRHR integration for key populations 78 78 learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: IPPF) InaLife:LinkingHIVand SexualandReproductiveHealthinPeople’s Lives Family PlanningAssociationofMalawi(FPAM) Malawi š š š š š SWs SRHR Civil society confidence condoms, etc)with 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

to

look aftertheirownsexualhealth.

providing sexworkerswiththeinformationand , IPPF,July2010. Intervention location Donor HIV epidemic 78 (supportedby community outreach Facility-based; Generalised 41 HIV/SRHR integration for key populations Concentrated Facility-based; community outreach , Interact Worldwide, 2011. (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 officials. 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 š š š Civil society SRHR and HIV MSM and transgender people (Adolescent) SWs, Pakistan (Punjab) š Community Support Concern and HMAP Support Concern Community Who Are We Failing? How Marginalisation and Vulnerability Affect Adolescents’ Needs for and Access to SRHR Failing? How Marginalisation and Vulnerability Who Are We Worldwide) Lessons learned Main type of programme Key population HIV/SRHR integration Organisation: Organisation: Country of Type provider 79 79 42 HIV/SRHR integration for key populations 80 80 learned Lessons integration HIV/SRHR Key population type Programme Provider type Country Organisation: GatewaystoIntegration: ACaseStudyfromSerbia Institute forStudents’Health(ISH) SWs, MSMandPUD Serbia (Belgrade) š š š š š HIV andSRHR Civil society the policewhooftenharassSWsduetotheirillegalstatus). It isimportanttorespond toachallengingenvironment (e.g.bytraining populations. Staff trainingiscriticaltoresponding toprejudices aboutkey populations, forexampleproviding HCTclinicsintheevening. It isimportanttohaveaflexibleapproach toserviceprovision forkey š š š š š š 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. , WHO,UNFPA,UNAIDS andIPPF,2009. Intervention type Donor HIV epidemic 80 outreach; mobile community Facility-based; Concentrated 43 HIV/SRHR integration for key populations , Young Power in Social in Power Young , Concentrated Facility-based; community outreach Bangladesh 81 HIV epidemic Donor Intervention location Integration provides an opportunity 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. Condom promotion focuses on dual protection and targets 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. 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 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. š š š š š š š š š Civil society SRHR and HIV SW and PUD š Bangladesh (Chittagong) Bangladesh Young Power in Social Action (YPSA) in Social Action Young Power Linking Reproductive Health to HIV & AIDS Prevention Projects: Case of Integrated Health Centers (IHCs) in Chittagong, in (IHCs) Centers Health Integrated of Case Projects: Prevention AIDS & HIV to Health Reproductive Linking Action, 2008. Lessons learned programme programme type Key population HIV/SRHR integration Organisation: Organisation: Country of Type provider Main 81 81 44 HIV/SRHR integration for key populations 82 82 learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: Kimirina –LinkingOrganisationofInternationalHIV/AIDSAlliance) Programme Partnerships IntegrationofHIVandSexual andReproductiveHealth&Rights(SRHR): ReportonExistingAllianceProgrammes andPolicyWork andPotential Strategic , JavierHourcadeBellocq, LACTeam,(powerpointpresentation),International HIV/AIDSAlliance. , InternationalHIV/AIDS Alliance;and Frontiers PreventionProgramme,CEMOPLAF Ecuador š š š š š š š š 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 Working Together SRH&HIV/AIDSNGOsand CBOSinEcuador:TheExperienceofFrontiers Prevention 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 “The concerns of a , Family Health International, 2010. (supported by FHI) (supported 83 HIV epidemic Donor location Intervention Revising counselling and training modules 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 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). Project 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: 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 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. Steps for integrated programming included: Steps for integrated programming š š š š š 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. risk of unintended pregnancy, etc.); strategic behaviour communication (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: š š 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 India š š š š š š š š š š HIV and transgender) SWs (female, MSM š Civil society Aastha (‘To Care About’) Project Care About’) Aastha (‘To Integrating HIV Prevention and Family Planning Services: The Aastha Project in Mumbai, India

Country learned Lessons programme programme type Key population HIV/SRHR integration Organisation: Organisation: of Type provider Main 83 83 46 HIV/SRHR integration for key populations 84 84 learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: Figure 14: AdvancingSexualand Reproductive HealthandRightsforSexWorkers 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 Integrated approachtoHIVpreventionandSRHR,TOP(Myanmar) VCCT each activities ials distr TOP vices Myanmar š š š š š š 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 , (powerpointpresentation), UNFPAAsiaPacificRegionalOffice,August 2011. 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. HIV/SRHR integration © Prashant Panjiar for India HIV/AIDS Alliance for men who have sex with men

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: š ‘Tailor made’ HIV prevention and behaviour change communication. š Sexuality and sexual health (e.g. counselling on sexual identity, risk-reduction strategies). š 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). š STIs (including diagnosis and treatment for anal and oral STIs for male and female partners). š Negotiation within sexual relationships (e.g. between kothi and panthis in India). š Hepatitis information and vaccination. š Sexual violence, including PEP after rape/assault. š Screening, vaccination and support in relation to HPV and anal cancer (at high levels among MSM, especially those living with HIV). š Sexual dysfunction (e.g. related to ART). š 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 š š š š programme HIV sex withmenandtransgenderpeople Figure 15: HIV components of Selected services General HIV HIV services) HCT (andother HIV Advocacy on 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 Examples ofstrategiesforHIV/SRHRintegrationmenwhohave Integration

SRHR programme Advocacy onSRHR SRHR Selected componentsof STIs SRHR, especiallySTIs especially STIs) FP (andbroader SRHR, Examples incasestudies š š š š š š š š š š š š 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 – who , while . 88 87 . 89 For example, ]. For example, in India, kothis and For example, in India, Figure 16 [see For example, a study by India HIV/AIDS Alliance found For example, a study by India HIV/AIDS especially married couples. Responses can include providing especially married couples. Responses and, in turn, their different HIV/SRHR needs. and, in turn, their

(draft), Family Planning Association of India, 2010. (draft), Family Planning Association of India, 2010. Welfare Society, Bangladesh refers female partners to mainstream SRHR services Welfare Society, Bangladesh refers female Emphasise the rights of sexual minorities and of men who have sex with men and Emphasise the rights of sexual minorities with HIV transgender people who are living partners of men who have sex with men Provide specific support to the female from services. For example, Bandhu Social may be especially stigmatised and marginalised 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 intensive training to SRHR staff or identifying non-government (often NGO) facilities to refer intensive training to SRHR staff or identifying people. men who have sex with men and transgender Recognise and address the fact that most SRHR services are designed for Recognise and address the fact that heterosexual people, that men who have sex who are married may want to have children and need FP that men who have sex who are married Recognise the specific vulnerability and needs of transgender people. 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 with men and transgender people. Understand the different types of men who have sex with men and transgender types of men who have sex Understand the different people 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 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, Summary Report of Key Findings and Programme Recommendations: From FHI MSM Programme Evaluations (Bangladesh, Indonesia and Nepal), 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

š š š 87 in India, 88 89 š š š integration for men who have sex with men and transgender and transgender sex with men who have for men integration people? 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 50 HIV/SRHR integration for key populations MSMGF, May2010. Reference: AdvancingtheSexualandReproductiveHealthHumanRightsofMenWhoHaveSexwithLivingHIV:PolicyBriefing,GNP+ support theHIV/SRHRrightsofMSMlivingwithHIV Figure 16: 3. 2. 1. 4. 4. Voluntary andaffordable STIandHIVprevention, care, treatment andsupportservices confidentiality, andthespecificchallengesfacingyoungMSM. the specificneedsandprioritiesofMSMlivingwithHIV, includingstigmareduction, Healthserviceproviders andadvocatesshouldreceive sensitivitytrainingrelated to psychosocial supportservices. including STIscreening andtreatment, hepatitisimmunisation,mentalhealthandother transgender) shouldhaveaccesstoafullandcomprehensive rangeofSRHservices AllMSMlivingwithHIV, includingyoungMSMandtheirsexpartners(male,female,or with HIV. favour oflawsthatguaranteetherightsgaymenandotherMSM,includingMSMliving in NationallawscriminalisinghomosexualityandHIVtransmissionshouldbeoverturned and unethicalpublichealthpractice. testing isscaledup–casefindingwithoutappropriate servicesconstitutessubstandard with disproportionately highnumbersofMSMlivingwithHIVatthesametimethat SystemsforHIVprevention, care, treatment andsupportmustbestrengthened todeal HIV –basedonconfidentiality, informedconsentandcounseling. must beexpandedandtailored tomeetthespecificneedsandprioritiesofMSMlivingwith Recommendations forprogrammemanagersandpolicy-makersto 51 HIV/SRHR integration for key populations , International Concentrated (general 0.4%; MSM 18%) GTZ Facility-based HIV epidemic Donor location Intervention 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 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 š š MSM, female partners of MSM and women living with HIV MSM, female partners of MSM and women š š š š š Colombia Civil society (IPPF affiliate) SRHR Asociacion Pro-Bienestar de la Familia Colombiana de la Familia Colombiana Asociacion Pro-Bienestar 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 integration programme programme type Key population HIV/SRHR Type of Type provider Main Organisation: (PROFAMILIA) Country 90 90 sex with men and transgender people transgender men and sex with 5.4. Case studies of HIV/SRHR integration for men who have for men who integration of HIV/SRHR studies 5.4. Case 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: Key population type programme Main provider Type of Country Organisation: in India AdvocacyBrief:Integration ofSexualandReproductiveHealthHIV-Related forMenWhoHaveSexwith (MSM)andTransgender Services People Health International. ReportofKeyFindingsandProgramme Recommendations:FromFHIMSM Programme Evaluations(Bangladesh,Indonesia andNepal) Summary , (draft),FamilyPlanning AssociationofIndia,2010. Bandhu SocialWelfareSociety Family PlanningAssociation(FPA)ofIndia Bangladesh (6cities) MSM, femalepartnersofMSMandtransgenderpeople SRHR Civil society Kolkata andKohima) India (Mumbai,Chennai, š š š š š š 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 MSM and their partners to services; and provided 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 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 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. 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 their confidentiality: couple to be referred options to protect clinic day; for a non-drop-in clinics; couple to make an appointment FPA š 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 HCT – rapid tests, pre and post-test counselling; 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 š š 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); š š š š š š š š Lessons learned integration HIV/SRHR HIV/SRHR 54 HIV/SRHR integration for key populations 94 93 93

94 Key population programme Main typeof provider Type of Country Organisation: integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: learned Lessons integration HIV/SRHR InaLife:LinkingHIVTreatment, CareandSupportinSexual ReproductiveHealthCareSettings in India AdvocacyBrief:IntegrationofSexualandReproductive HealthandHIV-Related forMenWho HaveSexwithMen(MSM)andTransgender Services People , (draft),FamilyPlanningAssociationofIndia, 2010. Tamil NaduStateAIDSControlSociety,APACandTAI Reproductive HealthAssociationofCambodia(RHAC) India (Tamil Nadu) š š š š MSM SRHR andHIV Civil society Cambodia (SiemReap) š š š š 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 location Intervention HIV epidemic Donor location Intervention 96 provides videos, training and social events. provides is supported by social marketing of condoms. Programme 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 involvement of key populations in programmes. 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 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 (supported by Interact Worldwide) (supported š š š MSM sexual health MSM and (female) SWs š š š š š Nepal (Kathmandu) Civil society Civil society SRHR and HIV partners), PUD and PLHIV MSM, SWs (and their š š Pakistan (Sindh) 95 Blue Diamond Society Pakistan Voluntary Health and Nutrition Association (PAVNHA) and Association (PAVNHA) and Nutrition Voluntary Health Pakistan 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 programme programme Key population HIV/SRHR integration Organisation: Country of Type provider Main type of Lessons learned integration Main programme type Key population HIV/SRHR Organisation: 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: learned Lessons integration HIV/SRHR Key population type programme Main provider Type of Country AIDS Alliance) Organisation: integration HIV/SRHR type programme Main provider Type of Country Key population Partnerships I Partnerships IntegrationofHIVandSexual andReproductiveHealth&Rights(SRHR): ReportonExistingAllianceProgrammes andPolicyWork andPotential Strategic ntegration ofHIVandSexual andReproductiveHealth&Rights(SRHR): ReportonExistingAllianceProgrammes and PolicyWork andPotential Strategic , InternationalHIV/AIDS Alliance. , InternationalHIV/AIDS Alliance. North AfricaRegionalProgramme(supportedbyInternationalHIV/ Espace Confiance(supportedbyAllianceNationalecontreleSIDA 97 98 Algeria, Lebanon, š š š š š MSM MSM Health andsupportfor Civil society Morocco, Tunisia MSM HIV andSRHR Civil society Cote D’Ivoire š š 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 on peer education and support. Also on involvement of MSM and supportservices. condoms andlubricantinformationmaterials).Referralstomedical Organisations provide a range of HIV and SRHR services (including HCT, š š š š 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 location Intervention 99 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 Started with a mapping of MSM, then 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 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 HIV-related care and support (including at home, supported by 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). 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); š š š š š š š š š Civil society Health for sexual minorities people MSM and transgender š India (Mumbai) Humsafar Trust Humsafar , (draft), Family Planning Association of India, 2010. in India 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 Lessons learned programme programme Key population HIV/SRHR integration Organisation: Organisation: Country of Type provider Main type of 99 99 58 HIV/SRHR integration for key populations ser ser related related MSM, HumsafarTrust(India) Figure 17: SRH- Y Y Y HIV ear ear vices vices ear - Drop-in centreandsupportgroupsaddressingHIV Drop-in centreandsupportgroupsaddressingsexualitygenderissues 1994 1994 1994 Timeline ofintegrationHIVandSRHRservicesintosupportfor 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 partners ofMSMto Referrals ofwomen general SRHclinics

2010 2010 2010 59 HIV/SRHR integration for key populations 100 sexual Concentrated (MSM 7%; transgender 18- 41%; general 0.7%) and (Provincial national advocacy) The coalitions’ , (Draft), International Planned Parenthood Implemented/planned activities HIV epidemic Donor location Intervention and stigma and discrimination. Supporting policy-level advocacy. 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: for sexual on issues providers activities include sensitizing healthcare and advocating for technical training for service minorities and PLHIV; providers. coalitions, with the work strengthened through 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 focused on issues such as access to services minorities and PLHIV, 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 š š š Key steps towards HIV/SRHR integration included: HIV/SRHR Key steps towards š š š NGO for key populations coordinating advocacy coalitions on SRHR NGO for key populations coordinating and HIV. SAATHII complements its advocacy by supporting over 40 agencies 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 š Civil society Support to key populations and PLHIV networks MSM and transgender organisations š India (West Bengal and India (West Orissa branch) Solidarity and Action Against the HIV Infection in India (SAATHII) in India the HIV Infection and Action Against Solidarity Federation, 2011. What Works? Sexual and Reproductive Health (SRH) and HIV Linkages for MSM and Transgender People Sexual and Reproductive Health (SRH) and HIV Linkages for MSM and Transgender What Works? Key population HIV/SRHR integration Type of Type provider Main programme type Country Organisation: Organisation: 100 100 60 HIV/SRHR integration for key populations 1. learned Lessons

š š š š š 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. 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

Only a 61

6. HIV/SRHR integration © Prashant Panjiar for India HIV/AIDS Alliance for people who use drugs

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: š Full range of options to prevent HIV, STIs and unwanted pregnancy, including (but also going beyond) condoms. š Interactions between different types of drugs (e.g. methadone, ART, contraceptives). š Safer sex practices while under the influence of different types of drugs (e.g. risk reduction, skills to improve condom efficacy). š Specific SRHR issues for people who use drugs (e.g. sexual dysfunction for men, impact on menstruation and fertility for women). š 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. š Empowerment on sexual and health rights. š 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. š Sexual violence, including PEP in relation to rape or sexual assault. š Sexual counselling (e.g. on the relationship between sexual drive, performance and drug use). š Family welfare services, to support people who use drugs to maintain custody of their children. š 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 6.3. WhatlessonshavebeenlearnedaboutHIV/SRHR seen intheliteratureanddemonstratedcasestudiesbelow,examplesinclude: effective HIV/SRHRintegrationstrategiesspecificallyforpeoplewhousedrugs.However,as The reviewindicatedthat,asyet,thereappearstobelittleclearconsensusonthemost integration forpeoplewhousedrugs? 6.2. WhataresomecommonstrategiesforHIV/SRHR 102 š š important to: section 2.5]applytopeoplewhousedrugs.Inaddition,somespecificlessonsincludethatitis The genericlessonslearnedforHIV/SRHRintegratedprogrammingkeypopulations[see integration forpeoplewhousedrugs? š š programme HIV drugs Figure 18: reduction HIV andharm reduction HIV andharm

needs forsupportandservices having sexualrelationswithwomen,menandhijras–all associatedwithdifferentissuesand drugs. Not makepresumptionsabouttheHIV/SRHRbehaviours orneedsofpeoplewhouse other. and medicines(suchasmethadone,hormonalcontraceptives andART)interactwitheach people whousedrugsinrelationtosexualpleasureand risktakingandhowdifferentdrugs reduction, HIVandSRHR 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, Sexual andReproductive HealthofMales-at-RiskinIndia:Service Forexample,anIndiaHIV/AIDSAlliancestudyfoundthat maledrugusersmaybe

Examples ofstrategiesforHIV/SRHRintegrationpeoplewhouse Integration , suchashowdrugusecanaffectthechoicesordecisionsof 102 SRHR programme women’s health) specifically including and STIsoften SRHR (especiallycondoms health care Broad SRHRorprimary . India HIV/AIDSAlliance, May2008. Examples incasestudies š š š š š š š SASO, India OSI, Ukraine Korsang, Cambodia DICP, Malaysia Puskesmas, Indonesia PKBI, Indonesia Centre, China Five HeartsService 63 HIV/SRHR integration for key populations

GNP+ and INPUD , Supporting the SRHR Supporting the SRHR ]. Meanwhile, the International HIV/AIDS Alliance, 2010. Figure 19 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 Figure 19: 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, National AIDS Control Organisation, October 2007. ; and GNP+ emphasises the need ; and GNP+ emphasises 103 . . 104 105

, OSI, 2010. HIV and Drug Use: International HIV/AIDS for extract from HIV and Drug Use: Community Responses to Injecting Drug Use and HIV: Good Practice Guide, HIV and Drug Use: Community Responses to Injecting Drug Use and HIV: Annex 3 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 Women who use drugs of drug users, Women who are partners widows including wives and Targeted Interventions Under NACP III: Operational Guidelines Volume 1: Core High Risk Groups, Interventions III: Operational Guidelines Volume Under NACP Targeted Making Harm Reduction Work for Women: The Ukrainian Experience for Women: Making Harm Reduction Work š š š š to support women who use drugs who are living with HIV [see who use drugs who are living with HIV to support women is paid to: Alliance recommend that attention International HIV/AIDS š š – 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 accompanied referrals to other SRHR services accompanied referrals to other SRHR For example, NACO in India recommends 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 Community Responses to Injecting Drug Use and Community Responses to Injecting Drug Good Practice Guide, HIV: Alliance]. of integrated Provide a comprehensive package use drugs. HIV/SRHR support for people who [See

Definition from:

š 105 103 104 š 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: learned Lessons

2011. LinkingSexualandReproductive HealthandHIV: Advocacy BriefonPeopleWhoUseDrugs,Indonesia Perkumpulan KeluargaBerencanaIndonesia(PKBI) š š š š š š š PUD, SWs,MSMandtransgenderpeople SRHR affiliate) Civil society(IPPF Jakarta) Indonesia (Pisangan, š 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, š š š 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 , IPPFEastandSouth Asia andOceaniaregion, 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 location Intervention community outreach to PUD 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 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 š š š Malaysia (Pahang) Civil society HIV PUD and SWs (Women) š Drug Intervention Community Pahang (DICP) Community Drug Intervention (web page on women who inject drugs in Malaysia) (page of www.aidsalliance.org; accessed 5.4.11). Hidden Women 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 Organisation: Organisation: provider Main programme type Key population Country of Type 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: learned Lessons HIVandDrugUse:Community ResponsestoInjectingDrugUseand HIV: GoodPracticeGuide Korsang š š š š š š š PUD (includingwomen) Harm reduction Civil society Cambodia (PhnomPenh) š 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: 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 “We a24hourprogramme.Alot are , InternationalHIV/AIDS Alliance,2010. 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 Programme supported by PUD 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 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. China (Sichuan Province) š š š š š š š Civil society; government HIV and harm reduction PUD š Five Hearts Service Centre Five Hearts , International HIV/AIDS Alliance. Partnerships 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

Country learned Lessons integration Main programme type Key population HIV/SRHR Organisation: Organisation: of Type provider 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: learned Lessons MakingHarmReduction Work forWomen: TheUkrainianExperience Gender responsiveharmreductionprogrammes(supportedby Ukraine (different š š š š š š š š š (Female) PUD Harm reduction Various locations) 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 appointments inadvance. mobile vansmeanthatwomenwhousedrugsdonothave tomake It isimportanttooffer options forserviceprovision. Forexample, friendly spaces. outreach towomenwhouse drugsandthedevelopmentofwomen- Beyond theprovision ofintegrated services,there isalsoaneedfor 110 , OSI,2010. 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 , Indonesia, IPPF East and South Asia and Oceania Region, HIV epidemic Donor Intervention type face meetings with PUD to discuss their needs. face meetings with PUD to discuss their a facilities and providing space – refurbishing the Centres’ Preparing clinic. separate entrance for the methadone 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 increased the workload of staff – compounded by a lack 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 š 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 and ensure (including referrals) Client flow charts used to track progress follow-up. of importance of integration for key recognition Supported by NAC’s populations. uptake of integrated services has Challenges include that increased and TB screening) and harm reduction 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: š š 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 š š š š š š š š š š Government Primary health care PUD, SWs and MSM š Indonesia (Puskesmas Indonesia Java) Central Gambir, Puskesmas – Pusat Kesehatan Masyarakat – Pusat Kesehatan Puskesmas 2011. Linking Sexual and Reproductive Health and HIV: Advocacy Brief on People Who Use Drugs Linking Sexual and Reproductive Health and HIV: Lessons learned HIV/SRHR integration provider Main type of programme Key population Organisation: Organisation: Country of Type 111 111 70 HIV/SRHR integration for key populations 112 112 integration HIV/SRHR Key population type programme Main provider Type of Country Organisation: learned Lessons Experience), IndiaHIV/AIDS Alliance. BreakingNewGround, SettingNewSignposts:ACommunity-Based CareandSupportModelforInjectingDrugUsers LivingwithHIV Social AwarenessServiceOrganisation(SASO) š š š š š š š Female PUD(plusfemalepartnersofmalePUD) Harm reduction andHIV Civil society India (Imphal,Manipur) š š 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 Framework for integrated harm reduction, HIV and SRHR services for HIV and SRHR harm reduction, for integrated Framework

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, women who use drugs, SASO (India) who use drugs, women Figure 20: 2. 73

7. Conclusions and © Nell Freeman for the Alliance key messages

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. rights. resources availableforadvocacyintegration,lawreform andsexualreproductive environment forscale-upofintegratedservices. Lack ofpolitical,technicalandfinancialsupporttocreate theenabling unsuitable deliverymethodsordoesnotfollowcommunitypriorities. design isnotbasedonneedsassessmentsandthequalityofexistingservices,uses Inappropriate designofHIV/SRHRintegration. could leadtoherbeingstigmatized. services. Lackofsensitizationtheserviceprovider towhichasexworkerisprovider may result inlossestofollow-upwhenanindividualisreferred forfurtherspecialized Lack ofastrong referrals systemsforHIV/SRHR. For example,whenprogramme For example,limitedfinancial For example,weakreferral systems Forexample,with 75 HIV/SRHR integration for key populations of key for some increase key increase Beyond the . However, the . However, and . Instead, efforts should . Instead, efforts . In practice, it can pose . In practice, it can HIV and SRHR support – HIV and SRHR support both opportunity to respond to the unmet needs to the unmet to respond opportunity potential to enhance cost-efficiency decrease stigma and discrimination decrease Examples include gender equality, a human rights-based Examples include gender equality, to a comprehensive range of range to a comprehensive full HIV/SRHR integration is not required HIV/SRHR integration may be a good long-term goal HIV/SRHR integration may be a good community organisations cannot achieve HIV/SRHR integration on their community organisations cannot achieve HIV/SRHR integration on HIV/SRHR integration is not a ‘magic bullet’ HIV/SRHR integration Instead, a partnership approach is needed, for example with the ‘buy-in’ of other Instead, a partnership approach own. national governments service providers, and international donors and the development and nationally). at all levels (including organisations of an enabling environment populations themselves) are critical to making integration happen. 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). However, be challenging to take to scale and requires a realistic level of investment. level of a realistic requires be challenging to take to scale and particularly critical with key populations are Good practice principles for work in HIV/SRHR integration. PLHIV and other key populations. and the meaningful involvement of approach by and for key (particularly those that are Community systems and organisations In the short-term, 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 HIV/SRHR integration shows can key populations mean that such programming specific and often complex needs of Comprehensive 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. moving beyond a focus on their vulnerability to a rights-based, ‘whole person’ approach. ‘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, 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 HIV/SRHR presents an important presents HIV/SRHR populations. particular, Integration can, in populations’ access

š š š š š š š š š 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 online resource pack of Inter Agency Working Group website of the Centre for Communication Programs, Johns Hopkins International Network of People Who Use Drugs International Network of People Who Global MSM Forum Network of Sex Worker Projects Global Network of People Living with HIV Global Network of People Living with with HIV International Community of Women Living www.hivandsrh.org University Bloomberg School of Public Health and Constella Group UN agencies – UNFPA, WHO and UNAIDS www.srhhivlinkages.org Marie Stopes International Interact Worldwide Global network for each key population: International HIV/AIDS Alliance International Planned Parenthood Federation Guttmacher Institute Family Health International Engenderhealth The Humsafar Trust Child MAMTA Health Institute for Mother and Social Awareness Service Organisation India HIV/AIDS Alliance PATH Government of India š š š š š så så så så så så så så så så så så så så Global: India: så så så Sources of information for review of information Sources from the websites of the following this report was predominantly sourced The information for organisations: Annex 1: List of resources for review for 1: List of resources Annex 78 HIV/SRHR integration for key populations så så så så så så så så så så så Resources relatedtoHIV/SRHRintegrationforkeypopulations(general) This reportisinformedbyareviewofthefollowingresourcesfromIndia: Indian resources includedinreview så så så så så så så så så ( Linking SRHRandHIV–ACommunity-CentredApproach toAchievingUniversalAccess, Groups, Targeted UnderNACPIII:OperationalGuidelinesVolume Interventions 1:CoreHighRisk Family Welfare,GovernmentofIndia. Annual Report2009-2010 Married Young PeopleinIndia Towards MessagesthatMatter:UnderstandingandAddressingHIVSRHRisksamong Targeted forMigrants:OperationalGuidelines Interventions Red RibbonClubsProgramme(RRCP)OperationalGuidelinesforRRCFunctionaries. Control Programme,MinistryofHealthandFamilyWelfare,GovernmentIndia. NACP III:To HaltandReversetheSpreadofHIVEpidemicinIndia, Family Welfare,GovernmentofIndia. Annual Report2008-2009, of FamilyWelfare(Volume48),ProfessorVimlaNadkarni,2002. TheFPAIIntegration ofHIV/STI/AIDSinFamilyPlanningServices: Experience, 2006. SRH-HIV ConvergenceNewsletter Policy andPracticeUpdate3, inIndia, Convergence ofSexualandReproductiveHealth(SRH)HIV/AIDSServices (India), PATH,December2009. HIV-SRH Convergence,PolicyandPractice Update4, PATH, March2007. What is Convergence? 2007. Populations: ALiteratureReview inIndia:ImpactsonandImplicationsforKey Convergence ofHIVandSRHServices Pradesh, in India:FindingsfromanAssessmentAndhraPradesh,Bihar, Maharashtra,andUttar Options andChallengesforConvergingHIVSexualReproductiveHealthServices AIDS Alliance,2010. Learning fromOurRoleinthe HIVResponseinIndia:AnnualReport2009-10, India HIV/AIDSAlliance. Building Linkages and Referrals: A Step Towards Sustainability: Alliance India’s Experiences Comprehensive ProgrammaticGuideforNGOs(Volume I), inResource-PoorSettings:A Setting UpandManagingSexualHealthClinicalServices Policies inAsia, Interim NarrativeReport:CommunityActionforSexual andReproductiveHealthRights Application totheEuropeanUnion, Community ActionforSexualandReproductiveHealth andRightsPoliciesinAsia:Grant draft), IndiaHIV/AIDSAlliance. NationalAIDSControlOrganisation,October2007. PATH, June2007. IndiaHIV/AIDSAlliance,2011. Policy and Practice Update 2, HIV-SRH Convergence Project (India), , NationalAIDSControlOrganisation,MinistryofHealthand NationalAIDSControlOrganisation,MinistryofHealthand HIV-SRHConvergenceProject(India),PATH,April2009. , PopulationCouncil,March2007. , HIV-SRHConvergenceProject(India),PATH,January , HIV-SRHConvergenceProject(India),PATH,April IndiaHIV/AIDSAlliance,2008. HIV-SRHConvergenceProject IndiaHIV/AIDSAlliance. , 2008. NationalAIDS TheJournal IndiaHIV/ , 79 HIV/SRHR integration for key populations Ministry Policy Brief, HIV- (poster presentation), India HIV/AIDS MAMTA Health Institute for (powerpoint presentation), (powerpoint presentation), (draft), Family Planning Association HIV-SRH Convergence Project (India), for Link ART Centres, National AIDS Control Organisation, for Link ART , India HIV/AIDS Alliance, 2011.

(poster presentation), India HIV/AIDS Alliance, Avahan Initiative and (poster presentation), India HIV/AIDS , National AIDS Control Organisation, Ministry of Health and Family (Draft), International Planned Parenthood Federation, 2011. (Draft), International , India HIV/AIDS Alliance, 2007. , India HIV/AIDS (powerpoint presentation), Family Planning Association India, August 2011. (powerpoint presentation), Family Planning , SWASTI Health Resource Centre, December 2008. , SWASTI Health Resource Centre, December Operational Guidelines of Health and Family Welfare, Government of India, June 2008. Antiretroviral Therapy Guidelines for HIV-Infected Adults and Adolescents Including Post- Antiretroviral Therapy Guidelines for HIV-Infected Exposure Prophylaxis Welfare, Government of India, May 2007. of HIV. Guidelines for the Prevention of Mother to Child Transmission Early Infant Diagnosis (EID) Guidelines. of India, 2010 Convergence of HIV and Sexual and Reproductive Health Service for People Living with or for Capacity Building, A Toolkit Most at Risk of HIV: PATH, December 2009. Strengthening Access to Sexual and 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, SRH Convergence Project (India), PATH, 2008. Services Who Have for Men Integration of Sexual and Reproductive Health and HIV-Related People in India, Sex with Men (MSM) and Transgender Female Sex Workers, Female Sex Workers, Mythri. Services for Key Population, Focused STI Prevention and Treatment and Mythri. India HIV/AIDS Alliance, Avahan Initiative 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, Pradesh Family Planning with STI/HIV ServicesIntegration of SRH Communication and among from India, Report India, in PLHIV of Rights and Health Reproductive and Sexual Better Towards Working to the European Union Programme: 2000-2010, Community-Based Care and Support What Works? Sexual and Reproductive Health (SRH) and HIV Linkages for MSM and Health (SRH) and HIV Linkages Sexual and Reproductive What Works? People, Transgender People: Experiences of MSM and Transgender Linking SRH and HIV to Meet the Needs Articulations Changing Face of the Epidemic in India, and HIV/AIDS: The Women Alliance. Alliance India Experiences and Review SRHR/HIV Integration: August 2011 India HIV/AIDS Alliance, Stories of Significance: Redefining Change: An Assortment of Community Voices and Voices Assortment of Community Change: An Significance: Redefining Stories of så så så så så så så så så så så så Resources related to HIV/SRHR integration for specific key populations to HIV/SRHR integration for specific Resources related så så så så så 80 HIV/SRHR integration for key populations så så så så så så så så så så så så så så så så så Injecting DrugUsersinManipur, Exploring theLinksbetweenDrugUseandSexualVulnerability amongYoung Female AIDS Alliance. Model forInjectingDrugUsersLivingwithHIV(ASASO-Alliance Experience), Breaking NewGround,SettingSignposts:ACommunity-Based CareandSupport presentation), IndiaHIV/AIDSAlliance. Elton JohnAIDSFoundation:ProjectforFemaleInjectingDrugUsers, Chanura Kol Baseline Study on Women Who Inject Drugs in Manipur Injecting DrugUsersinManipur Female on HIV/AIDS and Use Drug Injecting of Impact the Mitigating Form: Report Grant Men andGayMen, Training Manual:AnIntroductiontoPromotingSexualHealthforMenWhoHaveSexwith and Transgender Women inChennai Barriers toFreeAntiretroviralTreatment AccessforMenWhoHaveSexwith(MSM) APCOM andDepartmentofHealthHongKong(China),2010. MenandTransgenderWith PeopleintheAsia-PacificRegion intheHealthSectorforMenWhoHave Sex Priority HIVandSexualHealthInterventions India HIV/AIDSAlliance,May2008. Sexual and Reproductive Health of Males-at-Risk in India: Service Needs, Gaps and Barriers, India, TheAasthaProjectinMumbai, Integrating HIVPreventionandFamilyPlanningServices: Indian NetworkofPeopleLivingwithHIV,2007. Sexual andReproductiveHealthofPeoplelivingwithHIVinIndia:AMixedMethodsStudy, Programme Brief, Spotlight onWomen, Sexual andReproductiveHealthRightsHIV/AIDS: Report BasedonKnowledge,AttitudeandPracticeSurvey Foretelling theCrisis:HIV/AIDS,SexualandReproductiveHealthWomen inIndia:A Alliance. Sexual andReproductiveHealthofWomen LivingwithHIV: AFlipbook doc8.htm Samarth Project Affected byandLivingwithHIV, Issue Brief:SexualandReproductiveHealthRights–KeyIssuesforAdolescents Widows, Issue Brief:SexualandReproductiveHealthRights–KeyIssuesforHIV-Affected FamilyHealthInternational,2010. India HIV/AIDSAlliance. (websiteofUSAIDIndia); IndiaHIV/AIDSAlliance,2007. Naz FoundationIndiaTrust,2001. , India,IndiaHIV/AIDSAlliance,2010. PopulationCouncil,2008. India HIV/AIDSAlliance. , India,November2008. http://www.usaid.gov/in/our_work/health/hiv_ , IndiaHIV/AIDSAlliance,2006. , WHO,UNDP,UNAIDS, , India HIV/AIDS Alliance. (powerpoint , IndiaHIV/AIDS IndiaHIV/

81 HIV/SRHR integration for key populations

UNFPA & , International Amitrajit Saha, Anna , Susan A Cohen, International HIV/AIDS Alliance, International HIV/AIDS International Planned Parenthood , INTEGRA. Friends Africa, Global AIDS Alliance, Meeting of the UNAIDS Programme Coordinating Meeting of the UNAIDS Programme

International HIV/AIDS Alliance, June 2010. International HIV/AIDS , WHO, UNFPA, UNAIDS and IPPF, 2005. , WHO, UNFPA, UNAIDS and IPPF, , International HIV/AIDS Alliance, March 2009. , 26th , Heather D. Boonstra, Volume 11, Number 4, Guttmacher Policy . 2010

Interact Worldwide. IPPF, UNAIDS, UNFPA, WHO, ICW, GNP+ and Young Positives, 2009. IPPF, UNAIDS, UNFPA, WHO, ICW, Models of Care Project: Linking HIV/AIDS Treatment, Care and Support in Sexual and Models of Care Project: Linking HIV/AIDS Treatment, Reproductive Health Care Settings: Examples in Action, Federation, 2005. Rights, Hiding in Plain Sight: The Role of Contraception in Preventing HIV Guttmacher Policy Review, Volume 11, Number 1, Winter 2008. Despite Consensus and Mounting Evidence, Challenges to Improved HIV–Reproductive Health Linkages Remain Review, Fall 2008. Zakowicz, Dawn Averitt Bridge, Jill Gay, Robert Carr, (Presentation at International AIDS Zakowicz, Dawn Averitt Bridge, Jill Gay, Robert Carr, (Presentation at International Conference), July Health, Rights Good Practice Update: Linkages and Integration of Sexual and Reproductive Approach The Alliance and HIV: Health and Intimate Links: A Call to Action on HIV/AIDS and Sexual and Reproductive Integration of HIV and Sexual and Reproductive Health & Rights (SRHR): Report on Existing Integration of HIV and Sexual and Reproductive and Potential Strategic Partnerships 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, Linking Family Planning with HIV/AIDS 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 in High and Medium Guide, A Framework of Priority Linkages Services into Reproductive Health Settings and Testing Counselling Integrating HIV Voluntary Planners, Managers and Service– Stepwise Guidelines for Programme Providers, IPPF (2004). Board, June 2010. or Break?, 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 in Practice: Background Paper Good Practice HIV Programming Standards: For Use in the Design, Implementation and Programming Standards: For Use in Good Practice HIV Programmes, Evaluation of Alliance and Sexuality: Responding to HIV, Approaches to Gender February 2011. Health (SRH) ServicesThematic Segment: Sexual and Reproductive with HIV Interventions Integration of HIV and Sexual and Reproductive Health and Rights: Good Practice Guide, Sexual and Reproductive Health Integration of HIV and Alliance, December 2010. International HIV/AIDS så så så så så så så så så så så så så så så så 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 så Global resources included in review included resources Global 82 HIV/SRHR integration for key populations så så så så så så så så så så så så så så så så så så så så Health and Primary HealthServices Health andPrimary GuidanceforIntegratingFamilyPlanningandSTI/RTIServices withotherReproductive Planning andImplementinganEssentialPackageofSexualReproductiveHealth Youth WorkingGroup,USAID,IATTonHIVandYoungPeopleFHI,2010. Young PeopleMostatRiskofHIV: AMeetingReportandDiscussionPaper, Recommendations forAction, HIV/AIDS andReproductiveHealth:SensitiveNeglectedIssues–AReviewofLiterature, and AccesstoSRHR, Who AreWe Failing?HowMarginalisationandVulnerability AffectAdolescents’Needsfor 2010. and ReproductiveHealthHIVLinkages, ImplementationoftheRapidAssessmentToolConsultation toDiscussCountry forSexual Worldwide, November2006. AIDS Alliance,InternationalHIV/AIDSPopulationActionandInteract Opportunities and Strategies for the Global Fund to Fight AIDS, TB and Malaria Integration betweenSexualandReproductiveHealthHIVAIDSMalaria: WHO Bulletin,Volume87,Number11,805–884,November2009. Special Theme:StrengtheningLinkagesbetweenSexualandReproductiveHealthHIV, International PlannedParenthoodFederationWesternHemisphereRegion,2006. Integrating HIV/AIDSTreatment andCareintoReproductiveHealth Settings, Recommendations, Sexual andReproductiveHealthHIVLinkages:EvidenceReview In aLife:LinkingHIVandSexualReproductiveHealthinPeople’s Lives, Settings In aLife:LinkingHIVTreatment, CareandSupportinSexual ReproductiveHealthCare In aLife:LinkingHIVandSexualReproductiveHealthinPeople’s Lives Council, 2008. the IntegrationofFamilyPlanning andOtherReproductiveHealthServices, Assessing IntegrationMethodology (AIM)Toolkit: AHandbookforMeasuringandAssessing APN+, (MSM), Transgender (TG)andInjectingDrugUsers(IDU):ResearchFindingHighlights, Access toHIV-Related inPositiveWomen, HealthServices MenwhohaveSexwith Recommendations forAction HIV/AIDS andReproductiveHealth:SensitiveNeglected Issues:AReviewofLiterature, Checklist Getting Closer–LinkingHIVandSexualReproductive Health:Self-Assessment Working inHighHIV/STIPrevalenceSettings Providers The BalancedCounsellingStrategyPlus:AtoolkitforFamily PlanningService 2003. Counselling onDualProtection:STD/HIVandPregnancy:AGuideforProjectStaff, Counselling: ATraining Manual Integration ofHIVandSTIPrevention,SexualityDualProtectioninFamilyPlanning Health Settings Programme GuidanceforCounsellingSTI/HIVPreventioninSexualandReproductive August2009. , IPPF,2006. , NGOCodeofGoodPractice. , IPPF,2002. UCSF, WHO,UNAIDS,UNFPAandIPPF,2009. Interact Worldwide,2011. , IPAS,2005. IPAS,2005. , Engenderhealth,2009. , PopulationCouncilandUNFPA,2010. UNFPA,WHO,UNAIDSandDecember , PopulationCouncil2008. , IPPF,2008. Population IPPF,July2010. SpotlightNo.4, Interagency , IPPF, Global PATH,

83 HIV/SRHR integration for key populations

Family Guttmacher Family Health Family Health GNP+ and UNAIDS, GNP+ and UNAIDS, Family Health Family Health Family Health Family Health International Health Family GNP+, NEPHAK, NZP+ and NEPHAK and GNP+, January 2010. , Family Health International, 2010. Family Health International, Plos ONE Volume 5, , IPPF, GNP+, ICW and UNAIDS, 2008. Family Health International, 2006. , ENGENDERHEALTH and International Community of , ENGENDERHEALTH and International The Acquire Project and USAID, June 2007. GNP+, ICW, Young Positives, EngenderHealth, IPPF and UNAIDS, Positives, EngenderHealth, IPPF and GNP+, ICW, Young WHO, 2006. GNP+, December 2007. HIV, Report of Study on the Uptake of Prevention of Mother to Child Transmission 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, Living with Advancing the Sexual and Reproductive Health and Human Rights of People from Studies in Kenya, Nigeria and Zambia, Key Findings HIV: NEPHAN, April 2010. 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, Living with Advancing the Sexual and Reproductive Health and Human Rights of People Integrating Family Planning Services into Voluntary Counseling and Testing Centers in and Testing Counseling Integrating Family Planning Services into Voluntary Kenya: Operations Research Results, Family Planning–Integrated HIV Services: A Framework for Integrating Family Planning and Antiretroviral Therapy Services, How to Strengthen Family Planning and HIV Service Essential Steps: Integration, Ten Increasing Support for Contraception as HIV Prevention: Stakeholder Mapping to Identify Increasing Support for Contraception Influential Individuals and Their Perceptions, May 2010. A Five-Country Study of Family Planning and HIV Integrated Services, International, 2010. International, 2010. Maternal and Child through Family Planning in HIV Transmission Preventing Mother-to-Child Health Services: and South Africa Kenya, Rwanda, Toolkit, A HIV: with Clients for Contraception to Access Increasing and Engenderhealth, 2010. Trainers and Programme Managers Trainers Women Living with HIV, 2006. Therapy ServicesIntegrating Family Planning and Antiretroviral in Uganda, International, 2010. Services in Kenya, and Treatment Integrating Family Planning into HIV Care 2009. The People Living with HIV Stigma Index Reproductive Health and Rights for People Living with Amsterdam Statement on Sexual and HIV, Adolescent Girls: Manual for and Women Sexual and Reproductive Health for HIV-Positive WHO, 2006. Consultation Report, and Prevention: Technical Positive Health, Dignity 2009. Rights of People Living with HIV: and Reproductive Health and Human Advancing the Sexual A Guidance Package, Increasing Access to Contraception for Clients with HIV: A Toolkit, with HIV: for Clients Access to Contraception Increasing International, 2008. 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 så så så så så så så så så så så så så så så så så så så så 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 så så så så så Resources relatedtoHIV/SRHRintegrationforsex workers så så så så så så så så så så så så så så så så 2006. HIV andSTIPreventionamong SexWorkers inEastern EuropeandCentralAsia Sex Work, Violence andHIV Associacao BrasileiraInterdisciplinardeAIDS,2010. Sexuality and Development: Brazilian National Response to HIV/AIDS Amongst Sex Workers, with HIV: Advancing theSexualandReproductiveHealthHuman RightsofSexWorkers Living presentation), UNFPAAsiaPacificRegionalOffice,August 2011. Advancing SexualandReproductiveHealthRights forSexWorkers, Tools inFP/ART-Integrated forFacilitativeSupervision Services, Hormonal ImplantsandDualProtectionMessages inZimbabwe: Case Study:Zimbabwe,IntegrationofFamilyPlanningandHIVServices Progress andChallengesunderIMPACT 2010, Study,Caribbean: Country ofAchievements, Studies:AGlobalSummary AllianceCountry Gateways toIntegration:ACaseStudyfromHaiti, Gateways to Integration: A Case Study from Kenya AIDS Policies,Programs,andServices, Strategic ConsiderationsforStrengtheningtheLinkagesbetweenFamilyPlanningandHIV/ 2009. Gateways toIntegration:ACaseStudyfromSerbia Zambia: BriefingPaper Needs, ChallengesandOpportunities:AdolescentsYoung PeopleLivingwithHIVin Ukraine Study:InsightsfromSouthAfrica,TanzaniaHIV DiscordantCouples:AnExploratory andthe IPAS, September2010. Expanding ReproductiveRightsandKnowledgeAmongHIV-Positive Women andGirls Becoming PregnantWhenYou’re HIVPositive Healthy, HappyandHot the Ukraine, Study:InsightsfromSouthAfrica,TanzaniaHIV DiscordantCouples–AnExploratory and Evidence fromBangladesh,DominicanRepublicandEthiopia, Piecing ItTogether forWomen andGirls:TheGenderDimensionsofHIV-Related Stigma: Linking FamilyPlanningtoPMTCT: EmpoweringWomen LivingwithHIV, website ofGuttmacherInstitute),November2006. Meeting theSexualandReproductiveHealthNeedsofPeopleLivingwithHIV, š š š š š Supervisory StyleSelf-AssessmentChecklist. Services Checklist forAssessingPerformanceoftheOn-SiteSupervisor:FP-IntegratedART Services Checklist forAssessingPerformanceoftheOff-SiteSupervisor:FP-IntegratedART Supervision forFP-IntegratedAntiretroviralTherapyServices Essential ElementsofanFP-IntegratedAntiretroviralTreatment(ART)Program , GNP+,HSRCandUniversityoftheWitwatersr,June2009. Policy Briefing,GNP+andNSWP,May2010. GNP+,HRSCandUniversityofWitwatersr,2009. , InternationalHIV/AIDSAlliance,2011. , IPPF,2010. , InternationalHIV/AIDSAlliance, 2008. WHO,USAIDandFamilyHealthInternational,2009. , TheBody,2010. International HIV/AIDSAlliance. , PSIZimbabwe. WHO, UNFPA,UNAIDSandIPPF,2008. , WHO, UNFPA, UNAIDS and IPPF, 2008. , WHO,UNFPA,UNAIDSandIPPF, IPPF, 2011. EngenderHealth,2007: (powerpoint WHO. (Articleon , UNAIDS, ,

85 HIV/SRHR integration for key populations

Family , India HIV/AIDS , International HIV/ (powerpoint , International HIV/AIDS , Horizons, 2010. , Khmer HIV/AIDS NGO Family Health International. , Khmer HIV/AIDS NGO Alliance, July , Khmer HIV/AIDS , (powerpoint presentation), FHI 360 Asia Pacific , (powerpoint presentation), FHI 360 , Young Power in Social Action, 2008. GNP+ and MSMGF, May 2010. , UNIFEM 2009. , UNIFEM Michael L Rekart, the Lancet Volume 366, December 2005. the Lancet Volume 366, December Michael L Rekart, International HIV/AIDS Alliance. UNAIDS, 2006. , NAZ Foundation International. UNDP, ASEAN, WHO, UNESCO, UNAIDS, USAID, APCOM, 2009. Pacific, HIV and Men Who Have Sex With Best Practice Men in Asia and the Pacific: UNAIDS Collection, Families Standard Package of Activities: Men Who Have Sex With Men 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 Country Study: Morocco, Health Needs of Looking Back, Moving Forward: Understanding the HIV Risk and Sexual Men Who Have Sex With Men: Horizons Studies 2001 to 2008 Health, Welfare Developing Community-Based Organisations Addressing HIV/AIDS, Sexual and Human Rights Issues for Males-Who-Have-Sex-With-Males, Partners and Their Advocacy Brief: Integration of Sexual and Reproductive Health and HIV-Related Services and Reproductive Health and HIV-Related Advocacy Brief: Integration of Sexual People in India, (draft), 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 Men Alliance, August 2003. Region, August 2011. Summary and Programme Recommendations: From FHI MSM Report of Key Findings Indonesia and Nepal), Programme Evaluations (Bangladesh, Health and Human Rights of Men Who Have Sex Advancing the Sexual and Reproductive Policy Briefing, with Men Living with HIV: presentation), International HIV/AIDS Alliance. presentation), International HIV/AIDS in Asia and the Sexual and Reproductive Health Services for MSM and Transgenders Pacific: Challenges for Future Programming 2008. AIDS Prevention Projects: Case of Integrated Health Linking Reproductive Health to HIV & Centers (IHCs) in Chittagong, Bangladesh The Experience of SRH & HIV/AIDS NGOs and CBOS in Ecuador: Together Working Hourcade Bellocq, LAC Team, Frontiers Prevention Programme, Javier AIDS Alliance, May 2008. AIDS Alliance, May Community- the Results of Monitoring and Evaluating Learning from and Sex Work: Violence in India: Think Piece Female Sex Workers Responses among Led Violence Alliance. of Activities: Entertainment Workers Standard Package and Violence against Women against and Violence Counselling: A Meeting Report, and in HIV Testing Women against Addressing Violence WHO, 2006. Harm Reduction, Sex Work with Sex Workers A Guide for Programmes and HIV: Violence Sex Work, Development Connections: A Manual for Integrating the Programmes and Services the Programmes A Manual for Integrating Connections: Development of HIV så så så så så så så så så så Resources related to HIV/SRHR integration for men who have sex with men and Resources related to HIV/SRHR integration transgender people så så så så så så så så så 86 HIV/SRHR integration for key populations Good practicestandard11 Good practicestandard10 så så så så så så så så så så så Resources relatedtoHIV/SRHRintegrationpeoplewhousedrugs så så så så aidsalliance.org Hidden Women Guide, HIV andDrugUse:CommunityResponsestoInjectingUseHIV: GoodPractice South EastAsiaandOceaniaRegionIPPF,2011. Linking SRHandHIV: AdvocacyBriefonPeopleWhoUseDrugs,Indonesia, 2007. for HIV-Positive InjectingDrugUsers Module 11:PsychiatricIllness,PsychosocialCareandSexualHealthTreatment andCare OSI. Women, HarmReductionandHIV Drugs Linking SexualandReproductiveHealthHIV: AdvocacyBriefonPeopleWhoUse Living withHIV: PolicyBriefing, Advancing theSexualandReproductiveHealthHumanRightsofInjectingDrugUsers International HIV/AIDSAlliance,UNESCOandPurpleSkyNetwork,2007. with Men:AReferenceManualforPeerandOutreachWorkers, Peer OutreachandEducationforImprovingtheSexualHealthofMenWhoHaveSex Policy Initiative,2008. The Value ofInvestinginMSMProgramtheAsia–PacificRegion:PolicyBrief, Transgender People Menand UNAIDS ActionFramework:UniversalAccesstoMenWhoHaveSexWith WHO, 2008. menandTransgenderWho HaveSexWith Populations: ReportofaTechnical Consultation, Prevention andTreatment ofHIVandOtherSexuallyTransmitted InfectionsAmongMen Making HarmReductionWork forWomen: TheUkrainianExperience Standard PackageofActivities:DrugUsers Response Developing HIV/AIDSWork Assessment and withDrugUsers–AGuidetoParticipatory Report, Female DrugUsersandRegularSexPartnersofMaleinBangladesh:A , Indonesia,IPPFEastandSouthAsiaOceaniaregion,2011. InternationalHIV/AIDSAlliance,2010. UNAIDS,ICDDRB,UNODCandWHO,2010. , InternationalHIV/AIDSAlliance. ; accessed5.4.11) (webpageonwomenwhoinjectdrugsinMalaysia)(pageof , UNAIDS,2009. GNP+andINPUD,May2010. , InternationalHarmReductionDevelopmentProgramme, , FamilyHealthInterantional,USAID,ASEANandWHO, , KhmerHIV/AIDSNGOAlliance,July2008. USAID,FHI,PSIAsia, , OSI,2010. (draft)Eastand www. Health

87 HIV/SRHR integration for key populations Comprehensive information information Comprehensive and services to allow a healthy and satisfying sexual life. Choice about abortion safe contraception, and whether or not to have children. risk of HIV Ability to reduce transmission to children. 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. š š š š š š š What change is needed? Integration of HIV and Sexual and Reproductive Health and Sexual and Reproductive Health Integration of HIV and , International HIV/AIDS Alliance, 2010: , International HIV/AIDS Increased risk of STIs, cancers and Increased maternal mortality. 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. Stigma and discrimination can lead to 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 Lack of financial resources 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. 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. š š š š š š š š š š Key SRHR vulnerabilities Group People living with HIV Alliance Good Practice Guide Good Practice Alliance extract from The following is an Guide Rights: Good Practice Annex 2: Key SRHR vulnerabilities for key populations: populations: for key vulnerabilities 2: Key SRHR Annex 88 HIV/SRHR integration for key populations use drugs People who š š š š š Focus onpreventing HIVtransmission services. partners ofmenwhousedrugslack Women whousedrugsandfemale Multiple causesofstigma. children takenintocare. Childbearing isdisapproved ofand treatment inpregnancy andlabour. of pooraccesstoopiatesubstitution because offeararrest andbecause Babies maybeabandonedatbirth via injectingomitsSRHneeds. š š š š reduction services. integrated intoharm services alongsideor STI diagnosisandtreatment exclude activedrugusers. must ensure theydon’t and otherhealthservices reduction services.SRH drug users,linkedtoharm Friendly SRHservicesfor 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 than thepill. implants more acceptable contraceptives suchas may findlongeracting 89 HIV/SRHR integration for key populations creation 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. 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 š š š š š š invisible and difficult to reach. and judiciary, even where 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 rather than meet the SRH and HIV needs 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 physical and verbal 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 protect that laws discrimination of sex workers. or in moralistic Social attitudes result sex work to stop punitive approaches Sex workers experience stigma and Sex workers experience through discrimination demonstrated š š š š š š š š (In addition to the SRHR vulnerabilities of to the SRHR vulnerabilities (In addition all women) š workers Female sex Female sex 90 HIV/SRHR integration for key populations sex workers transgender Male and with men have sex Men who š š š š š š š š š š š Social attitudesresult inmoralisticor and HIVstatus. between men,sexwork,genderidentity Multiple layersofstigmarelated tosex 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 š š š š š š š š š š gonorrhoea, hepatitisand damage, oralandanal related toanusandrectum services; forexample, Specific informationand 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. 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 Small condoms for neopenises and urgent consultation if condoms slip or break. Lubrication for neo- vaginas. Information on possible interaction between ART and hormones 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. š š š š š š š š š 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. Multiple causes of stigma, discrimination of stigma, discrimination Multiple causes and criminalization. rape and murder. Violence, law and state. Persecution by the š š š š š š š š š š š female transgender and transsexual people Male to 92 HIV/SRHR integration for key populations 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 så så så så så så use andHIVweinclude: for men,butsomeareverydifferent.Whenwespeakaboutwomen’sneedsinrelationtodrug Women areaffectedbydruguseinmanyways.Someoftheseeffectssimilarorthesame Women Drug UseandHIV: GoodPracticeGuide, The followingtextisanextractfrom: Alliance GoodPracticeGuide Annex 3:GenderandSRHRissuesforpeoplewhousedrugs: så så så Gender isanimportantfactorinvulnerabilitytoHIV: Gender andvulnerability work effectivelywithwomenwhousedrugs. such asSRHservicesormicro-financingprogrammes,oftenlacktheskillsandexperienceto intimidate women,orsimplynotmeettheirneeds.Alongsidethis,servicestargeting children. Supportgroupsorpeereducationrunbymenwhousedrugscanexclude services, donotofferpregnancyormaternalhealthservicesprogrammesforwomenwith 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 HIV andDrugUse:CommunityResponsestoInjecting InternationalHIV/AIDSAlliance,2010. . 93 HIV/SRHR integration for key populations who inject drugs are often dependent 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 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 promote maternal health. Mothers who use drugs may fear losing custody 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. 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 assume that their drugs will be causing substantial harm to their unborn 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 more clients and use condoms less 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 place to stay or food. For example, women 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 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 så 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 and transitional countries is also reflected in social patterns that can affect injecting practices. that can affect injecting practices. is also reflected in social patterns and transitional countries For example, women: så så Studies in nine European countries show that the average HIV prevalence among 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 Women and injecting – risks and vulnerabilities injecting – risks Women and 94 HIV/SRHR integration for key populations sexually transmittedinfections. with anothercontraceptivemethod.Stresstheimportanceofpreventingbothpregnancyand male andfemaleclientstousecondomscorrectlyconsistently, 6. Fosterdualprotectionanddual-methoduse. records. and currentcontraceptiveuse.Screenclientsatregularintervalsupdateinformationintheir and allmenshouldbeaskedabouttheirsexualactivity,desireforpregnancyinthenearfuture, 5. Screenallclientsforanunmetneedcontraception. Internet, organizein-housestudygroups,andusepeer-to-peersupport. criteria forcontraceptiveusebypeoplelivingwithHIV.Accessfreetrainingmaterialsonthe cadres andcommunityhealthworkers.LearntheWorldHealthOrganization’smedicaleligibility 4. Trainproviders. network andwithinthefacility. contraceptives andHIVsupplies.Developaplanforreliablesupplysystemwithinthelocal 3. Ensurecommoditysecurity. and clientcosts. rearranging moveablefixtures.Determinehowservicescanbechangedtoreducewaitingtime available space;reducecostsbyofferingservicesindifferentrooms,modifyingwaitingareas,or 2. Organizeservices. groups totellothers. brochures, andleaflets.Encouragecommunityhealthworkers,volunteers,localsupport 1. Generatedemandforintegratedservices. and HIVserviceintegration(FamilyHealthInternational) Annex 4:Tenessentialstepstostrengthenfamilyplanning [Reference: Review thedataasateam and usethatinformationtoimprovetheservicesyouprovide. service dataduringanappropriate timeframe,usingstandardindicatorsandreporting systems. the HIVserviceisresponsibleforreportingdelivery ofintegratedservices.Collectrelevant 10. Monitorandevaluateperformance. promoting dualprotectionanddual-methoduse. of integratedservices.Makesurethesedocumentsaddress contraceptionandchallengesin monitoring forms,providerjobdescriptions,andchecklists—for consistencywiththeprovision 9. Strengthenskillsforsupportivesupervision. monthly follow-upsystemtotrackcompletedreferrals. organizations). Developacontactlistwithphonenumbers ande-mailaddresses.Institutea provided onsite(publicandprivatefacilitiesthoseoperatedbynongovernmental 8. Reinforcereferralsystems. healthy sexualrelationshipsandtobecomepregnantifdesired. are inappropriateforpeoplelivingwithHIV.SupporttherightofHIVtoenjoy neglect othercontraceptivemethods.Correctthefalsebeliefthatsomemethods 7. Challengeproviderbias. Ten Integration, EssentialSteps:HowtoStrengthenFamilyPlanningandHIVService Provide informationandtraininginbasiccounselingskillstolowerlevel Learn howyourclientsmovethroughthefacility.Drawadiagramof Address thetendencyofproviderstoemphasizecondomsand Map allavailablesourcesofcontraceptivemethodsnot Register yourfacilitywiththeappropriateauthoritiestoreceive Determine whetherthefamilyplanningserviceor Advertize toyourclientsusingposters, Update documents—supervisionprotocols, Develop counselingstrategiestoencourage FamilyHealthInternational] All womenofchild-bearingage

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