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AIDSTAR-One Outreach to Most-at-Risk Populations through SIDC in Lebanon


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Successful outreach to most-at-risk populations (MARPs) recognizes the sociocultural context and particularly the gendered norms in which MARPs live. This case study (one of nine in a series) documents how outreach workers in Lebanon raise awareness about how gender norms can increase HIV risk; deliver basic information on HIV, hepatitis, and other STIs; offer counseling to support positive behavior change, and distribute free condoms, syringes, and lubricants.

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AIDSTAR-One Outreach to Most-at-Risk Populations through SIDC in Lebanon

  1. 1. AIDSTAR-One | CASE STUDY SERIES August 2011More Than Just HIV PreventionOutreach to Most-at-Risk Populations Through SIDC inLebanon T he inside of the van is hot. It is summer, and the battery- powered fan is doing its best to move the humid air around, but Kareem1 continues to sweat. The tall, heavyset Beirut resident scratches at the tattoo on his calf, then fidgets with his clothing. Kareem is trying to focus on what the counselor is saying Photo by Maha Aon about HIV and hepatitis, but he drifts away every few minutes. He pulls out a string of blue prayer beads from his pocket and begins shuffling them, but the heroin he injected half an hour ago makes it difficult for him to concentrate.A voluntary counseling and testingvan parked on the Beirut cornicheoffers HIV and hepatitis testing and Kareem has come to the Soins Infirmiers et Développementinformation. Communautaire (SIDC) van to get an HIV test and some unused syringes. The van is parked under a bridge in the Burj Hamoud district, an impromptu parking lot in the crowded city. Kareem had been clean for about 18 months after a nine-month stay at a nongovernmental organization (NGO) treatment center, but started reusing six months ago. He heard about the mobile center and its services from an outreach worker. At 28 years old, Kareem has veered far off the path of Lebanese social norms, which dictate that a man his age should be the head of a family, earning his own living. He stretches out his arm to show the counselor the round bulbs of clotted blood. He needs larger syringes, “I’m sorry that you are seeing me this way,” he says to the counselor. Forty minutes later, Kareem steps out of the van with a smile on his face. He has tested as HIV-negative. In Lebanon, NGOs such as SIDC are now working with the governmentBy Maha Aon to reach stigmatized and hidden populations whose very existence—as drug users, sex workers, or men who have sex with men (MSM)—is Names have been changed for anonymity. 1AIDSTAR-OneJohn Snow, Inc.1616 North Ft. Myer Drive, 11th Floor This publication was produced by the AIDS Support and Technical Assistance ResourcesArlington, VA 22209 USA (AIDSTAR-One) Project, Sector 1, Task Order 1.Tel.: +1 703-528-7474 USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Agency for International Development or the United States Government.
  2. 2. AIDSTAR-One | CASE STUDY SERIESillegal. These groups suffer the biggest brunt of the treatment, and care to these populations (Joint U.N.HIV epidemic in many parts of the world, yet they Programme on HIV/AIDS [UNAIDS] 2009a, 2009b;represent only a fraction of those accessing public World Health Organization 2005).services. The outreach conducted by these NGOshighlights the intrinsic link between HIV and numerous Successful outreach to most-at-risk populationshealth problems, including sexually transmitted (MARPs) recognizes the sociocultural context andinfections (STIs) and hepatitis C. It also shows particularly the gendered norms in which MARPshow work on HIV can inspire social movements live. It aims to strengthen access to basic serviceschallenging such issues as gender norms and human through a human rights-based approach, empowersrights violations. The story of SIDC and its partners clients to improve their socio-economic status,presents a living example of the daily successes and reduces violence, and educates service providersfailures associated with an outreach program, the hard on intersections of gender and HIV risk as well aswork involved in gaining the trust of target populations, strategies to reduce stigma and discrimination. Toand the challenges of scaling up to ensure sustainable achieve this, outreach workers raise awareness ofnational coverage. how gender norms can increase HIV risk; deliver basic information on HIV, hepatitis, and other STIs; offer counseling to support positive behavior change,Prevention for Most-at-Risk such as correct and consistent use of condoms and sterile injecting equipment; and distribute freePopulations condoms, syringes, and lubricants. Outreach workers also support clients’ efforts to take charge of theirPeople who inject drugs (PWID), sex workers, lives by improving their condom negotiation skills,and MSM are identified by the U.S. President’s referring them to vocational training as appropriate,Emergency Plan for AIDS Relief as populations most and discussing actions to take in cases of risk of HIV infection. Global guidance stresses the They also provide referrals to such key services asimportance of tailoring gender-sensitive prevention, HIV testing or treatment. Outreach is most successful when conducted by peers or individuals who have access to and are trusted by the MARP communities. International experience shows that programs must also address structural issues that reinforce practices that directly or indirectly promote stigma, discrimination, and violence towards MARPs. Longer- term programming aimed at addressing these legal and social constraints related to social and gender norms should complement outreach to MARPs. Photo by Maha Aon The Lebanese Context With a population of over 4 million, Lebanon has an estimated 3,000 persons living with HIV. ReportedPackages distributed by outreach workers include malecondoms, lubricant packs, material on HIV/STIs/hepatitis, HIV cases indicate a 4:1 male-to-female ratio, withand injecting equipment. sexual transmission as the main mode of infection2 AIDSTAR-One | August 2011
  3. 3. AIDSTAR-One | CASE STUDY SERIES(87 percent; National AIDS Control Programme, study only 15 percent of female sex workers saidMinistry of Public Health 2010). National adult they would stop a sexual relationship when facedprevalence is approximately 0.1 percent. However, with violence, mainly because of their need for thewhat appears to be a low level of HIV is not income or their sense of disempowerment (Nationalnecessarily the whole picture of HIV in Lebanon. As AIDS Control Programme, Ministry of Public Healthglobal experience shows, such national-level data 2008).may mask the potential for smaller but more intenseepidemics within certain communities or regions of The national HIV strategy has designated MARPs—the country. specifically MSM, PWID, and sex workers—a priority for Lebanon’s HIV programming efforts, andAs in many parts of the world, those most vulnerable there is a national push to include MARPs in suchto HIV in Lebanon are likely to experience key processes as national strategic planning. Themarginalization and stigma because of their national HIV strategy highlights MARPs in three of itssexuality, gender identity, or illegal behavior, such four priority areas: human rights, advocacy (to reviewas drug use and sex work. Although there is no law policies and legislation related to MARPs), preventionagainst homosexuality, an article in the national (to promote voluntary counseling and testing [VCT],penal code outlaws “sexual intercourse contrary and to work on the prevention of HIV and STIsto nature,” which many consider to be a reference among the three MARPs), and surveillance (toto homosexual intercourse. These populations develop second-generation surveillance strategiesalso face serious stigma within their communities targeting MARPs).because they are seen to deviate from acceptedgender, sexuality, and social norms.National government and nongovernmental SIDC: Outreach to Thosepartners in Lebanon recognize this situation and Most at Riskthe consequent increased HIV infection risk amongmarginalized populations. Indeed, research indicates The SIDC outreach program began in 2001 as ahigh risk rates: 43 percent of female sex workers do collaboration with the National AIDS Program (NAP).not use condoms with irregular clients (clients who A decade earlier, SIDC volunteers began noticingmay only visit the sex worker once or infrequently), drug use issues in their districts and contacted the43 percent of PWID did not use a condom during NAP, which trains youth on HIV and drug use. Thattheir last sexual intercourse with a partner (non- same year, SIDC also established a hotline that latersex worker), and 62 percent of MSM report having expanded into a counseling center. In 1996, SIDCsex only with sex workers, which indicates how collaborated with the U.N. Office on Drugs andpervasive male sex work is among MSM (National Crime to conduct Lebanon’s first street-based studyAIDS Control Programme, Ministry of Public Health with drug users. In 1999, at UNAIDS’s request, SIDC2008). This additionally demonstrates the overlap in began conducting outreach to PWID, sex workers,risk among different MARP groups. The distinction and MSM.between the groups may be blurred on manyoccasions. SIDC’s goal is to better understand these hidden communities, improve their access to services, andSocial and economic pressures also increase the address social norms that render them vulnerable.vulnerabilities of MARPs. For example, in one An advisory committee that includes the Ministry More Than Just HIV Prevention: Outreach to Most-at-Risk Populations Through SIDC in Lebanon 3
  4. 4. AIDSTAR-One | CASE STUDY SERIES of Interior, Interior Forces, and U.N. agencies supports SIDC outreach PEPFAR GENDER activities. A network of field workers affiliated with four main partner STRATEGIES NGOs conduct the outreach (see Figure 1). Funding comes from ADDRESSED BY THE different sources, starting with the United Nations in 2001; currently, SIDC OUTREACH the Drosos Foundation and the International HIV/AIDS Alliance provide PROGRAM funding. Some of the donors have funded the entire program, while others support only certain program elements or only activities related to • Increasing gender equity in HIV one of the MARPs. programs and services • Addressing harmful gender The key principles that govern program implementation include norms and behaviors inclusiveness and partnership with the target population, peer education, • Increasing legal protection harm reduction, flexibility and continuity of activities, capacity building, experience sharing, partnership development, and confidentiality. • Increasing access to income and productive resources. Most outreach workers are themselves either MSM, former sex workers, or PWID. Among the factors considered in their selection are communication, networking, and listening skills; their passion for and personal belief in the mission and principles of the program; their level of education; and their reliability. The outreach workers receive standardized training from SIDC. Gender norms are an important feature of the training under the topics of vulnerability to HIV infection, sexuality definitions and nuances, stigma Figure 1. NGO Implementers of the MARPs Outreach Program Helem Est. 2001 Advocacy and services for LGBTQI individuals** (Outreach focus: MSM) Oui pour la Vie SIDC Dar al Amal Est. 2008 Est. 1987 Est. 1969 Humanitarian and HIV-related advocacy Services to sex workers social services to local and services (Outreach focus: communties (Outreach focus: MSM, sex workers) (Outreach focus: MSM,* PWID,* sex workers) PWID, sex workers) NGO Forum Saida Est. 1993 Humanitarian and social services to local communties (Outreach focus: MSM, PWID, sex workers) * indicates focus on this particular population. * indicates focus on this particular population. ** LGBTQI: lesbian, gay, bisexual, transvestite, queer, and intersex. ** LGBTQI: lesbian, gay, bisexual, transvestite, queer, and intersex.4 AIDSTAR-One | August 2011
  5. 5. AIDSTAR-One | CASE STUDY SERIESas it relates to gender and sexuality, and gender- by a VCT counselor. The outreach workers workbased violence (detection, counseling, and referral). with the counselors to coordinate a schedule of siteThe outreach workers also conduct exercises on locations and timing that suits their target population.condom negotiating skills and on how to empowertheir clients and build confidence. Outreach workers also discuss violence with their clients: how to avoid it and how to address it. InAll outreach workers, regardless of the group some cases, an NGO may intervene to assist athey target or their NGO affiliation, use a unified client with violence-related issues. In some cases,monitoring system. Outreach workers complete a Dar al Amal, the NGO dealing mainly with femalereporting form after each outreach session, entering sex workers, provides shelter for sex workers facingstandard data on their target group, discussions, and physical violence from their pimps. The NGO hasservices given. The NGO coordinator transfers the mediated disputes between sex workers and theirforms to SIDC. SIDC analyzes the data, produces pimps and, when needed, brings in the police toa unified report, and shares it with a wide range of protect the sex and NAP. All data are disaggregated by sexand gender, including male, female, and transgender; If appropriate or the client asks for it, the outreachas well as by target population, including sex worker, worker also offers information and advice aboutPWID, and MSM. The goal is to help SIDC staff vocational training and skill-building opportunities tounderstand the gender dimensions of the target enhance their income earnings, and may refer thegroups, such as whether certain locations are better client to one of the NGOs offering such training.suited to reach female clientele, or if male clients aremore likely than female clients to ask for condoms. The outreach program is linked to a well-developed referral system, including a telephone hotline. A totalOutreach workers establish relationships with of 52 NGOs are members of this referral system,individuals in their target group and chat with them offering a range of medical, legal, psychological,about the services they offer. They find their clients and social services. These services include, butthrough social networks and by visiting locations are not limited to, raising awareness, testing,known to be frequented by their target populations.Selecting outreach workers who possess theappropriate skills, attitudes, and experience plays abig role in their ability and readiness to locate andgain the trust of individuals in the target group.The outreach workers tell their clients about HIV,other STIs, and hepatitis, and engage their clientsin discussions about safer-sex behavior, such asnegotiating condom use and dealing with peerpressure to share needles. The outreach workersdistribute male condoms, lubricants, and syringes, Photo by SIDCand inform their target group about where to accesskey health, legal, and social services, such as theSIDC mobile VCT van. The van is equipped withrapid HIV and hepatitis C testing kits and is staffed Outreach workers offer handouts and referrals. More Than Just HIV Prevention: Outreach to Most-at-Risk Populations Through SIDC in Lebanon 5
  6. 6. AIDSTAR-One | CASE STUDY SERIESdiagnosis, treatment of infections, drug addiction 8,946 individuals within MARPs. This includes 2,509and rehabilitation services, social and psychological MSM (including male sex workers), 3,550 female sexcounseling, legal assistance, and vocational training. workers, and 2,854 PWID.Referral NGOs all abide by a unified referral protocol.SIDC produced a user-friendly referral pack listingthe NGOs, the services they offer, working hours,and contact details. The outreach workers use What Worked Wellthe packs to refer their target population to theappropriate NGOs. Referral NGOs complete monthly Programming for multiple MARPs: Onereporting forms and submit them to SIDC for overall of the strengths of SIDC’s outreach program isprogram monitoring. that it covers three MARPs. This is an effective methodology because of the overlap betweenFinally, the outreach program is complemented by groups and the multiple risks that some of themother activities aimed at changing, in the longer- are exposed to, such as drug use by sex workers,term, the environment that contributes to making or sex work by MSM. This approach reducesMARPs vulnerable. SIDC and its partners are transaction costs so that, for example, outreachconducting a legal review of the laws governing workers can attend the same training sessions andsuch risk behaviors as sex work and homosexuality. use the same monitoring program and servicesContinuous advocacy is conducted with officials, the referral pack. However, one issue is the correctmedia, and the public on these issues to challenge selection of the NGOs and outreach workers whogender norms. In addition, some implementing will work with each group. A peer outreach workerNGOs document and research stigma associated with one group may hold stigmatizing views or notwith gender norms. Helem, for example, produced have an in-depth understanding of other groups.studies on stigma associated with sexual orientationin Lebanese universities and among health care A strong NGO partnership structure:providers, and it documents human rights violations Another unique strength of the program is theand general homophobia in the country. SIDC and two levels of partnership among the NGOs. TheDar al Amal participated in studies documenting the first level is depicted in Figure 1, where SIDCstatus of female sex workers in Lebanon, including coordinates the management, administration, andtheir experience with gender-based violence and logistics of the program (and implements partother violations of their rights. In partnership with of it), and the other four NGOs (including SIDC)government partners, they completed four studies implement the program. The second level is thedocumenting the situation of sex work in Lebanon, large referral network of 52 NGOs that ensuresincluding a legal review, a quantitative and qualitative members know about each others’ work andstudy of clients and pimps with a sample size of benefit from each others’ comparative advantage400 individuals, a situation analysis of female sex to improve effectiveness and efficiency. Bothworkers, and a mapping of available services for sex partnership levels are governed by formal contractsworkers in Lebanon. outlining each partner’s roles and responsibilities, including reporting. An annual stakeholder meetingAccording to program data, from 2003 to the end brings together all NGOs, the government, donors,of 2009, SIDC and its partners trained a total of 80 and international partners. The meeting is anpeer outreach workers and 70 social and health opportunity to provide updates on the programcare workers, and succeeded in reaching a total of status and agree on the way forward.6 AIDSTAR-One | August 2011
  7. 7. AIDSTAR-One | CASE STUDY SERIESChallenges populations who remain hidden, but there is little data to explain why. For example, the programLack of basic population data for MARPs: only managed to reach two females who injectCoverage is difficult to measure, because no MARP drugs in 2008 and 2009. Men who inject drugsnational size estimations exist. Thus it is impossible experience stigma and fear, but females who injectto determine the proportion of MARPs being reached drugs are further burdened with gender normsor whether SIDC’s monitoring system may be and expectations that make it even harder forcounting clients more than once. them to seek services. Females who inject drugs may face double stigma if they are involved inLimited geographical range: In principle, sex work, a practice that may occur to enable theoutreach is supposed to reach MARPs throughout purchase of drugs. There have been attempts tothe country; however, program implementation reach females who inject drugs, including activeoutside the capital has been poor for a variety of searches by outreach workers and the recruitmentreasons, including limited NGO and staff capacities of female outreach workers, but in vain. SIDC mayand/or interest, and funding constraints. With only be able to improve outreach efforts to these groupsone VCT van, traveling to all parts of Lebanon on through targeted research relating to the gendereda regular basis is a major logistical and financial challenges of accessing health services.challenge. Insufficient support from the government:The need for assessment data: While The national HIV strategy clearly outlinesprogram monitoring does provide a picture of programming with MARPs as a priority, and theimplementation status (number of persons reached, NAP manager salutes SIDC and its partners’condoms distributed, tests conducted, and so outreach program as “outstanding.” There is fullon), it is impossible to ascertain behavioral and coordination and ongoing communication betweenattitudinal changes in the absence of an impact or SIDC and NAP on the implementation and progressoutcome assessment. The outreach program has of the program, and monitoring forms are fullybeen working for almost a decade to reduce these aligned to national reporting, especially as it relatesrisks, yet no outcome/impact assessment has been to such medical issues as VCT. However, theconducted to date. SIDC is hoping to implement such Lebanese government’s attitude is more accuratelyan assessment in the near future to determine if its described as tolerant rather than supportive. Whileefforts have made a difference and to better adapt the Ministry of Interior is fully informed about thethe program to the needs of the target population. program, senior officials are publicly ambiguousMeanwhile, it relies on its programmatic data and about syringe distribution to PWID, althoughlimited studies conducted with the target groups. efforts are under way to change that policy and the government has recently signed a decreeThe need for more in-depth gender allowing opioid substitution therapy. In addition,analysis: While the SIDC outreach program while Helem is an NGO, it never received an officialis responsive to what is generally known about NGO registration number. Helem—which worksgendered behaviors and related risks for HIV primarily with sexual minorities—is legal by virtue oftransmission for MARPs, there is not a strong the Lebanese legal practice that if an organizationevidence base about how gender impacts health- does not receive a response from the Ministry ofseeking behaviors for all target groups. Monitoring Interior to its registration application within twodata reveals challenges in reaching specific target months, it automatically assumes legal existence. More Than Just HIV Prevention: Outreach to Most-at-Risk Populations Through SIDC in Lebanon 7
  8. 8. AIDSTAR-One | CASE STUDY SERIESHowever, the absence of a registration number A need for funding continuity andprevents Helem from opening a bank account and sustainability: From the onset of the programfunctioning normally as a legal entity. in 2001, SIDC has relied on donor support, which has been both limited and intermittent. Sometimes,Female condoms are not available: the program has to split work into numerousAlthough outreach workers are briefly informed categories to suit donor interest (e.g., only oneabout the female condom in their training, the population or only one element of the outreachdevice is not available for distribution through the program). This impacts both the quantity andgovernment health system and is very expensive quality of services provided. Instead of deliveringin the private market. Female condoms remain integrated services addressing multiple needsthe only female-initiated barrier method and are of individuals, programming at times has to behighly effective in preventing HIV, other STIs, and segmented according to what is considered mostunintended pregnancies. Some research in other relevant for a defined target group. In addition therecountries indicates that female condoms may be are often delays between funding cycles impedingpreferred by men for anal sex (Kelvin et al. 2009), fieldwork, particularly when outreach workers do nota significant mode of HIV transmission among receive transport compensation, which limits theirMSM. There is a need to examine the feasibility and movement and reduces or halts VCT van operations.cost-benefit of introducing female condoms to this Communication with the target population is alsoprogram. interrupted and, although it can be resumed once Figure 2. Total Number of MARPs Reached by Funding Cycles (SIDC 2010)* 1800 1600 1400 1200 1000 IDUs Reached 800 MSM Reached 600 FSWs Reached 400 200 0 2003-2005 2006 2007 2008 2009 Jan-Sept 2010 *SIDC signed a funding agreement with Drosos for a two-year period (2008 to 2009). The large jump in coverage in 2009 shows the potential a funding agreement with Drosos funding is ensured for justto 2009). The cycle. *SIDC signed for increased coverage when for a two-year period (2008 a two-year large jump in coverage in 2009 shows the potential for increased coverage when funding is ensured for just a two-year cycle.8 AIDSTAR-One | August 2011
  9. 9. AIDSTAR-One | CASE STUDY SERIESfunding restarts, data indicate that it may take time to and threatened by clients and pimps, and MSMre-establish relations (such as in 2007 and again in are confronted with physical abuse related to2010, as indicated in Figure 2). homophobia. Gender-based violence is therefore one of the key components of the program. Outreach workers are trained to detect it and offer counseling.Recommendations However, some cases may require follow-up and more support. One NGO cannot address all theCultivate longer-term social change: needs of all MARPs, so a strong partnership withDelivering information and services is essential to other NGOs is essential to the success of thean outreach program. However, at the root of the program. SIDC successfully brought together fivemarginalization and risk MARPs experience are NGOs to implement one common program in astructural and social factors that breed stigma, strong partnership that supports the capacity of allencroach on the rights of MARPs, and compromise involved. It created a second level of partnershiptheir access to services. SIDC’s outreach program among a wider group of 52 NGOs serving asaddresses structural factors in a number of ways, referral centers to the target population for a wideincluding the following: range of services. This strong partnership reduces redundancies and promotes horizontal learning• SIDC and partner NGOs are part of an initiative between the NGOs. Outreach workers can refer their to review and propose changes to laws related to clients to a number of NGOs offering services for homosexuality and sex work. victims of violence, among a variety of other services such as vocational training and legal assistance.• Advocacy and discussions with government, the media, and community members are normalizing Keep an eye on changing needs: One of the debate around such sensitive issues as the key elements of this program is that it maintains gender norms and sexuality. For example, when it a strong link with its target population, continually first opened, residents in the neighborhood of one updating its services based on needs. One way drop-in center complained it was bringing MSM to do that is to ensure constant collection of to their communities. After repeated discussions data. The outreach program established a basic with the outreach workers and witnessing how but comprehensive monitoring system where all the NGO functioned, the neighborhood residents collected data are disaggregated by gender and sex. reversed course and started referring MSM to the This enables planners to monitor program uptake center. by gender and sex and, for example, determine whether a certain service is being used more by• As an indirect effect of the outreach program, men or by women. SIDC’s outreach program has a group of outreach workers initiated a lesbian, evolved several times to respond to changing needs. gay, bisexual, transvestite, queer, and intersex It began in the late 1980s, when SIDC initiated a (LGBTQI) NGO, Helem, which advocates for drug use prevention program. This eventually led to equality in access and rights of persons with establishing an HIV hotline in 1991. The outreach alternative sexualities. program began qualitative research in 2001. Since then, it has gone through many changes beforeA strong NGO partnership helps address it arrived at its current form. Selection criteria forgender-based violence: Among the risks outreach workers changed, the content of theirfaced by all three MARPs is gender-based violence. training was enhanced, the services delivered wereFor example, sex workers may be beaten up upgraded (e.g., adding the mobile van), and the More Than Just HIV Prevention: Outreach to Most-at-Risk Populations Through SIDC in Lebanon 9
  10. 10. AIDSTAR-One | CASE STUDY SERIESreferral network was strengthened over the years. Females who inject drugs consequently face bothHowever, in order to enrich its monitoring, SIDC and compounded risk and compounded stigma. Thusits partners may look towards including program there is a need for more gender-responsive services.outcome and program impact indicators in their data These may include recruiting and training femalecollection in order to better understand program outreach workers (especially females who used toperformance. inject drugs), reviewing prevention and care materials to make them more gender-sensitive, working withDeliver tangible, gender-sensitive drug-dependence treatment and rehabilitationservices: Information is vital but not sufficient services to encourage the admission of femaleto guarantee behavior change. This program goes clients and the delivery of a gender-responsivebeyond sharing information to offer counseling and approach (e.g., taking into consideration issuestangible services to the target population. MARPs related to motherhood, children, and reproductivereceive free condoms and syringes, as well as health), and access to essential gender-sensitivefree HIV and hepatitis testing both on the spot and prevention commodities such as female condoms.through a referral network. Such tangible services Given the difficulty many programs face in reachingare more likely to influence behavior change and females who inject drugs, consultation with otherstrengthen the target populations’ trust in the NGOs that have managed to reach these women inprogram. It is important, however, to ensure that other countries may be particularly useful.these services are gender-sensitive. For example,only the male condom is currently distributed. Work toward long-term funding: One of theOutreach workers have little information about the key challenges of the Lebanon outreach programfemale condom, and it is not advocated for in the is intermittent, unpredictable, and limited fundinggeneral national context. Given the importance of that interrupts implementation. NGOs should takefemale condoms in empowering women to protect the initiative to forge a harmonized program withthemselves and the preference of female condoms funding cycles that are at least two years long.for anal sex, it is vital that they be made available Funding should last for no less than two years toand that staff are better informed about them. avoid gaps in program implementation; any less, and outreach workers and program staff contractsReach out to the most vulnerable: There become unstable and relationships within the fieldare MARP subgroups that are particularly vulnerable. are interrupted. NGOs and donors should also lookThis program is one of the first of its kind in the into the possibility of pooled funding to cut down onregion to tackle the issue of equal access to services transaction and administrative costs.for transgender individuals. Implementing NGOs,especially Helem, are searching for innovative waysto reach this hidden and highly stigmatized group. Future ProgrammingAnother important group that requires specialattention are females who inject drugs. Of the 2,854 SIDC is planning to expand its work with PWIDPWID reached through this program, only 2 were by opening Lebanon’s first drop-in center offeringfemale. Females who inject drugs are exposed to counseling, testing, and other key services, includingmultiple risks: women are more vulnerable to HIV opioid substitution therapy, which SIDC is workinginfection both biologically and socially (e.g., they with the government to introduce. SIDC is alsohave less negotiating power for safer sex), and they planning to conduct an external evaluation of theare more vulnerable to physical and sexual abuse. outreach program covering all implementing partners10 AIDSTAR-One | August 2011
  11. 11. AIDSTAR-One | CASE STUDY SERIESand MARPs to help the organization scientifically UNAIDS. 2009b. UNAIDS Action Framework: Universal Accessassess its work over the years. The evaluation for Men who have Sex with Men and Transgender People. Geneva, Switzerland: UNAIDS. Available at http://data.unaids.should facilitate resource mobilization to sustain the org/pub/report/2009/jc1720_action_framework_msm_en.pdfoutreach program and perhaps help it develop into (accessed July 2011)an ongoing national program, rather than a time-limited project working in only a few areas. Finally, World Health Organization. 2005. Policy and ProgrammingSIDC is collecting all its training material into one Guide for HIV/AIDS Prevention and Care Among Injectingtraining module on outreach to MARPs to support Drug Users. Geneva, Switzerland: World Health Organization. Available at (accessedthe work of partners in the region and beyond. n July 2011)REFERENCES ACKNOWLEDGMENTSKelvin, E. A., R. A. Smith, J. E. Mantell, and Z. A. Stein. 2009.Adding the Female Condom to the Public Health Agenda on Sincere gratitude goes to the entire staff of SIDC, most notablyPrevention of HIV and Other Sexually Transmitted Infections Ms. Nadia Badran, HIV/AIDS Program Coordinator, who spentAmong Men and Women During Anal Intercourse. American a lot of time providing information, responding to queries,Journal of Public Health 99 (6):985-987. Available at www.ncbi. and coordinating the field work conducted for this case (accessed July 2011) Thanks to Mr. Elie Aaraj, SIDC Director, for an honest and rich history of the program, and Dr. Mustafa El Nakib, NationalNational AIDS Control Programme, Ministry of Public Health. AIDS Control Program Manager, for his time and support.2008. An Integrated Bio-Behavioral Surveillance Study Among Outreach workers provide the backbone of the program, andMost at Risk Populations in Lebanon: Female Sex Workers, sincere acknowledgment is owed to them for their passion andInjecting Drug Users, Men who have Sex with Men, And hard work, and for taking the time to meet with the author andPrisoners. Beirut, Lebanon: Lebanese Republic Ministry of share their personal stories. A special thanks is owed to thePublic Health. anonymous people who inject drugs who invited the author to the confidential VCT van session, and to Mr. Charbel Zaccour,National AIDS Control Programme, Ministry of Public Health. the VCT counselor on duty, as well as to Mr. Elie Daou, Injecting2010. UNGASS Country Progress Report, Lebanon. Beirut, Drug User Outreach Coordinator, Mr. Dany Bilal, VCT vanLebanon: Lebanese Republic Ministry of Public Health. driver, and Mr. Talal, the MSM outreach worker who allowed theAvailable at author to accompany their field work. Gratitude is owed to alluntryprogress/2010progressreportssubmittedbycountries/ interviewees and every individual who donated time to providelebanon_2010_country_progress_report_en.pdf (accessed July information for this case study, most notably the staff of Dar al2011) Amal, Helem, NGO Forum Saida, Oui Pour La Vie, and SIDC. Thanks also to the PEPFAR Gender Technical Working GroupSIDC. 2010. Interview and correspondence with Ms. Nadia for their support and careful review of this case study.Badran, HIV/AIDS Program Coordinator, SIDC, and SIDC 2010PowerPoint Presentation, “Outreach & Community DevelopmentHIV/AIDS Prevention Targeting Vulnerable Groups.” RECOMMENDED CITATIONUNAIDS. 2009a. UNAIDS Guidance Note on HIV and Sex Aon, Maha. 2011. More Than Just HIV Prevention: OutreachWork. Geneva, Switzerland: UNAIDS. Available at http://data. to Most-at-Risk Populations through SIDC in Lebanon. Study Series. Arlington, VA: USAID’s AIDS Support andhiv_and_sexwork_en.pdf (accessed July 2011) Technical Assistance Resources, AIDSTAR-One, Task Order 1. More Than Just HIV Prevention: Outreach to Most-at-Risk Populations Through SIDC in Lebanon 11
  12. 12. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.