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Scientific Sessions 2015: Barriers to scaling up of services for msm 1

Dr Jayadarie Ranatunga, Consultant Venereologists, Teaching Hospital, Ragama

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Scientific Sessions 2015: Barriers to scaling up of services for msm 1

  1. 1. Dr Jayadarie Ranatunga Consultant venereologist North Colombo Teaching Hospital 1
  2. 2. Outline of the presentation Definition of key populations , country context and their importance The importance of MSM to the Sri Lanakan epidemic  Comprehensive care for MSM Access to STI services Commonly identified barriers Novel methods to overcome barriers Some key points in overcoming barriers Success story of the peer escort model Challenges in peer escort and out reach models 2
  3. 3. Definition of key populations with regard to HIV Epidemiologically, the group faces increased risk, vulnerability and/or burden with respect to HIV due to a combination of biological, socioeconomic and structural factors  Access to relevant services is significantly lower for the group than for the rest of the population 3
  4. 4. Key populations The group faces frequent human rights violations, social and economic marginalization and/or criminalization which increases vulnerability and risk with reduced access to essential services. 4
  5. 5. Who are key populations in the context of HIV ( At risk and vulnerable) Female sex workers (FSWs) Male sex workers (MSWs) Injecting drug users (IDUs) Men having sex with men (MSM) People infected with HIV People affected by HIV  HIV orphans, uninfected partners of sero- discordant couples. Beach boys Prisoners  Sexual minority groups  Socially marginalized (eg Lesbians, Transgender, )  5
  6. 6. Key populations are important In many low- and middle-income countries, key populations face HIV prevalence rates that are 15-25% higher than the surrounding general populations. The HIV prevalance among MSM in Sri Lanka is 0.88  UNAIDS (2012). Report on the global AIDS epidemic. Available:  IBBS -2014 6
  7. 7. General target • About 60%of MARPs need to adopt safer behaviours if HIV epidemics are to be reversed • To achieve that level of behaviour change, service coverage has to reach at least 80% (MDG 6) Report of the commission on AIDS in Asia 2008 7
  8. 8. MSM are an important key population in most of the countries 8
  9. 9. The importance of MSM to the Sri Lankan epidemic Sri Lanka is classified as a country with a low level epidemic of HIV with an estimated HIV prevalence of less than 0.1% among adults (15-49 years). In low level epidemics, the key strategy for scaling up HIV prevention, treatment and care is targeting key populations. The NSACP has identified this group in the national strategic plan. 9
  10. 10. What is included in comprehensive care for MSM Aims of providing comprehensive services for MSM Minimize the transmission of HIV Reduce HIV related 1.Mortality 2. Morbidity 3.Stigma and discrimination. Which contribute to the attainment of the three Zeros: Zero new HIV infections, Zero discrimination, and Zero AIDS-related deaths. 10
  11. 11. Human rights and inclusiveHuman rights and inclusive environmentsenvironments Good Practice Individual Sexual BehaviouralIndividual Sexual Behavioural Non-discrimination in health-Non-discrimination in health- care settingcare setting HIV Testing and CounsellingHIV Testing and Counselling Behavioural interventions and IECBehavioural interventions and IEC Substance use,Substance use, prevention of blood-borne infections,prevention of blood-borne infections, male circumcisionmale circumcision HIV care and treatmentHIV care and treatment Prevention and care of other STIsPrevention and care of other STIs Prevention HTC Care Provision of comprehensive care 8/17
  12. 12. The Comprehensive Package of MSM and TG Services 12 Strategic InformationStrategic Information AdvocacyAdvocacy Legal FrameworksLegal Frameworks PolicyPolicy Relationships with gatekeepersRelationships with gatekeepers Stigma and discrimination programmes Stigma and discrimination programmes Organizational developmentOrganizational development Capacity BuildingCapacity Building Community mobilizationCommunity mobilization Structural InterventionsStructural Interventions THE COMPREHENSIVE PACKAGE  HIV Prevention  Access to HIV treatment, care and support  An enabling environment for prevention and care services  Strategic Information 3/6
  13. 13. HIV diagnosis, Prevention, Teatment, Care and support Services should be offered on voluntary basis Linkage to care and treatment services should be provided for those infected with HIV and in need of care  Linkage and referral mechanisms to community support programmes should be established to ensure retention and follow up into care and treatment services. 13
  14. 14. Some identified barriers in treatment and care All MSM are started on treatment after diagnosis irrespective of the CD4 count so many of them are asymptomatic at the start of ART Most of them are unmarried and no person to support Reluctant to join HIV support groups Reluctant to divulge sero status due to their MSM behaviour The fear of identification as a Retroviral positive by the peers 14
  15. 15. Managing common infections, co-infections and co-morbidities Diagnosis and management of STIs. Syndromic/ Etiological Prevention and treatment of Hepatitis C and B Interventions for harmful alcohol and substance use 15
  16. 16. Social behavioural interventions for HIV prevention  Provide community-based outreach and peer education incorporated into service delivery to improve engagement and connectivity to health and other social services  Community empowerment interventions should be developed to empower on their rights and access to health  Messages promoting consistent and correct use of condoms for them and their sexual partners or clients are needed. 16
  17. 17. Providing services to MSM in Sri Lanka ( access to STI services) Voluntary Peer escort model ( under the global fund) Out reach by STD services Referrals 17
  18. 18. Common methods of reaching MSM through STI services 1. As STI patients at the clinic 2. Through contact tracing process 3. As clients for STI/HIV screening 4. Escorted persons from NGOs working in the field 5. Networking techniques/Snowballing 6. Through outreaching programmes 7. As a part of sentinel sero-surveillance 8. Participation of programmes organized by MARP groups/NGO 9. Partnership with MARP groups and NGOs working with them 10. In ad hoc surveys and research
  19. 19. Why should we analyze the barriers The targets by 2020 Ensure that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy 90% of all people receiving antiretroviral therapy will have viral suppression. 19
  20. 20. The commonly identified barriers to provide comprehensive care Legal barriers Stigma and Discrimination Self stigma Factors related to service provision Factors related to prioritizing activities Funding 20
  21. 21. The Enabling Environment 21  An enabling environment for prevention and care services Harmonize HIV policies with laws that impede HIV prevention and care including age of consent laws Reduce harassment, violence, stigma Ensure continuity and consistency of programmes and services Support MSM & transgender CBOs and NGOs Improve quality and flow of strategic information Remove structural barriers to the use of services 4/6
  22. 22. Laws and policies that impact on MSM and transgender people Sodomy and other sexual behaviour laws Differential age of consent laws Relationship recognition Adoption and family law Immigration Public decency and nuisance laws Pornography laws Drug laws Mental health law 22 3/8
  23. 23. Effects of stigma and discrimination Fear or actual experience with S&D 1. Avoid the practice of prevention (Continue risk behaviour) 2. Reduce access to HTC services (avoid testing) 3. Non-disclosure of HIV status to others 4. Reduce access for HIV treatment care and counselling services 5. Discourage people from using other social services 6. Suffering from Psychological distress As a result, that hamper prevention and care efforts and fuel the HIV/AIDS epidemic ©karawita
  24. 24. The situation of stigma in Sri Lanka The level of stigma and discrimination in Sri Lanka experienced by the MSM community is not similar to other SEA countries. Sri Lanka's education as a service has reached out for many for a considerable period of time The influence of Buddhism encourages people to respect diversity. The cultural factors have a significant negative impact on stigma 24
  25. 25. The barrier which is most difficult to overcome MSM population, especially the bisexual males remain largely hidden and mobilizing them to access testing requires a different approach. 25
  26. 26. Barriers …….  Majority of the MSMs who are educated and economically sound, access medical care and information as much as a non gay person would access without experiencing any difficulty. But the transgenders and socially and economically marginalized males resort to sex work and get away from services 26
  27. 27. Behavioural interventions and novel communication strategies/outreach Conditional recommendations • Implementing individual and community-level behavioural interventions • Targeted internet-based targeted information • Using social marketing strategies • Implementing sex venue- based outreach strategies 13/17
  28. 28. Overcoming barriers …….. To improve the health literacy among key populations More trainings on human rights and legal services Development of synergies such as linkages to employment, education, and social protection services. Investing more on service delivery. 28
  29. 29. Provision of targeted technical assistance to support the meaningful engagement of key populations as well as broader communities Planning of interventions which specifically addresses the communities, rights and gender issues 29
  30. 30. Evidence shows that community- and peer-led education and services can be more conducive for key populations. Scale-up of community oriented and peer-led service delivery is an essential component. Community systems strengthening is a major component in overcoming barriers 30
  31. 31. Community systems strengthening Key populations often depend more upon community systems than members of the general population. The development of social networks and organizations for support, advocacy, is crucial for key populations who often fear and mistrust government affiliated health systems, receive poor treatment within those systems, and fear disclosure. Strengthening these social networks and organizations can have a positive impact on the ability of key populations to engage in health care. 31
  32. 32. Community systems strengthening It is observed that there is a global increase in net works of key populations Further development of these networks can serve to build national and local level capacity to advocate for and provide services to key populations. 32
  33. 33. A success story of the peer escort model 33
  34. 34. The attendance of MSM to STD clinic/ NCTH 34
  35. 35. Diagnosis of STI/HIV among MSM in STD clinic/NCTH 35
  36. 36. Number of STI/HIV among MSM in STD clinic/ NCTH 36
  37. 37. Some challenges in peer escort model Low level of personal/institutional management No control/ influence over their peers The reach is only limited to some social strata As it is a funded project, the sustainability of the model is a question 37
  38. 38. Some challenges in the out reach model They are mostly a hidden population unlike the FSW and drug users They are a very diverse population in all aspects so different models should be used for different groups (eg- for MSM, TG, BISEXUAL) It is practically difficult to out reach without the support of community groups The working hours of government services and the lack of trained staff in out reaching is an obstacle to efficient out reach 38
  39. 39. Conclusions There are many barriers in providing comprehensive care to MSM The legal barriers and human rights should be discussed and relevant changes should be made The social net works of MSM should be analysed in detail for behaviour change through IEC The government services must strive more to provide services without stigma and discrimination Mass media support is necessary for educating society on the present status of the epidemic and the importance of early identification Country specific interventions should be identified 39
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