Alliance Country Studies: A global summary by International HIV/AIDS Alliance

Supporting community action on AIDS in developing countries

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

Contents Bangladesh. .......................................................................................3 Bolivia.................................................................................................5 Burkina Faso. .....................................................................................7 Cambodia. ..........................................................................................9 Caribbean........................................................................................ 11 China................................................................................................ 14 Colombia. ........................................................................................ 16 Côte d’Ivoire.................................................................................... 18 Ecuador. .......................................................................................... 20 El Salvador. ..................................................................................... 22 Haiti.................................................................................................. 23 India................................................................................................. 27 Indonesia......................................................................................... 30 Kenya............................................................................................... 32 Kyrgyzstan....................................................................................... 35 Madagascar. ................................................................................... 37 Mexico............................................................................................. 39 Mongolia.......................................................................................... 42 Morocco........................................................................................... 44 Mozambique.................................................................................... 46 Myanmar. ........................................................................................ 48 Nigeria............................................................................................. 51 Peru.................................................................................................. 54 Senegal............................................................................................ 57 Sudan. ............................................................................................. 60 Uganda. ........................................................................................... 62 Ukraine. ............................................................................................64 Zambia..............................................................................................67

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY COUNTRYSTUDY STUDIES 2

In late 2010 the Alliance secretariat completed a series of country syntheses to provide a qualitative document reflecting information against the first three strategic directions from the Alliance’s strategic framework for 2008-2010, IMPACT 2010. Over a period of three months more than 200 documents including restricted donor reports (e.g. Global Fund and USAID reports), evaluations and monitoring reports were reviewed in order to capture and summarise information on achievements, progress, challenges and lessons learned from 28 Alliance countries. The following is an illustration of our work with communities in 28 different countries across Africa, Asia, Eastern Europe and Latin America towards meeting our collective mission of reducing the spread of HIV and meeting the challenges of AIDS.

Strategic direction 1: Scaled up quality community programmes delivered and access to health and HIV services improved We captured examples of the Alliance’s significant contribution to scaling up highquality, targeted and context-specific HIV programming.

Strategic direction 2: Increase civil society capacity to implement effective community responses We documented examples of the Alliance’s commitment in practice to strengthening the leadership and capacity of civil society organisations to take action on HIV by providing them with technical resources, building their skills and supporting their organisational development.

Strategic direction 3: Strengthen communities influence in national programming and in national and international policy We focused on capturing the work of the Alliance in the area of policy and advocacy with regional, global and national institutions, and the use of community action to tackle major policy obstacles to universal access.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

BANGLADESH

Bangladesh has maintained a relatively low HIV prevalence, with an estimated 12,000 people living with HIV in 2008 out of a population of over 150 million. Rates of HIV infection are considerably high among injecting drug users (IDU), with prevalence rates of 7% among IDU in Dhaka, and 11% in one cohort in central Bangladesh. HIV/AIDS and Social Action Bangladesh (HASAB) is the leading NGO in the country working on HIV and sexually transmitted infections (STIs). HASAB was established by the Alliance in 1994, and became an independent Linking Organisation in 1998. It implements and funds a wide range of HIV prevention, care and support programmes, targeting a range of populations – IDU, sex workers, transgenders (hijiras), men who have sex with men (MSM), young people, people living with HIV (PLHIV) and internal migrants (e.g. rickshaw workers, dock labourers, factory workers). Many programmes have gender, human rights, sexual and reproductive health (SRH) and social development components. HASAB’s strategic focus has been broadened to wider health and development-related issues, without losing its HIV/AIDS core focus. Most of HASAB’s funding is from Global Fund Rounds 2 and 6, but it is also funded by a wide range of other donors.

SD 1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of people reached through HIV prevention activities

Data unavailable

178,991

Number of individuals reached through stigma and discrimination reduction initiatives

Data unavailable

8,736

In 2009, HASAB achieved 21% of the UNGASS national target for most-at-risk populations reached by prevention programmes – making an impact on the national epidemic in Bangladesh. One of HASAB’s key achievements is its presence across every region of Bangladesh. In 2009, HASAB was involved in 10 different projects. For example, it is a lead implementer of a prevention programme targeted at clients of sex workers, which operates in 10 districts through 13 drop-in centres (DICs) and 32 DIC outlets. This project, which was managed through UNICEF Bangladesh, entered a third phase in January 2008. Its main strategies included:

HIV prevention material for injecting drug users, Bangladesh © Liza Tong for the Alliance

(1) creation of a supportive environment (advocacy/ sensitisation meetings); (2) provision of a package of services with comprehensive reach (behaviour change sessions/STI clinical sessions/condom promotion); (3) establishing referral linkages; (4) community participation and utilisation of local resources. This phase ended in March 2009, and neither HASAB nor UNICEF are involved in the fourth phase. With funding from GTZ, HASAB has led a peereducation programme in universities entitled ‘Join-in Circuit’. This programme has been introduced in 21 universities and 13 colleges, and addresses a range of issues, including: HIV and AIDS, STI, gender and human rights. The first phase ran from September 2007 to December 2009. The programme has continued on a smaller scale with funding from HSBC bank. Through its ‘Promoting Rights of Extreme Socially Excluded People’ (PRESEP) programme, HASAB seeks to create an enabling environment for marginalised communities by reducing stigma and discriminatory attitudes and by increasing access to a range of services (legal, social, health etc). Working with 10 strategic partners in seven districts, PRESEP aims to realise the social and health rights of marginalised communities, particularly sex workers, transgenders, MSM and IDU.

SD2: Increase civil society capacity to implement effective community responses Over the past 16 years, HASAB has built the capacity of around 240 NGOs, community-based organisations (CBOs) and self-help groups in HIV programme planning and implementation, by providing them with both technical and financial

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 4

support. One of its programmes, ‘Strengthening the capacity of NGOs/ CBOs in HIV prevention, care and/or treatment for vulnerable and high-risk practice groups’ sought to train not only NGOs and CBOs, but government officials as well. It offered workshops on the following subjects: (1) Project development considering sexual health, care and support, and treatment needs; (2) Gender, sexual health, sexuality, human rights and HIV; (3) Peer education, advocacy and networking; (4) HIV counselling and testing; and (5) Programme, financial and human resource management, and monitoring and evaluation. This programme was rolled out across the country, and ran from 2007-2009. Recognising that the national response mainly focused on awareness-raising for prevention, HASAB initiated the ‘Continuum of Care and Support’ project to address the gap in this programmatic area. Through this project HASAB, in conjunction with other NGOs, build the capacity of organisations to work in this area. In 2006, HASAB established the Centre for Research, Education and Technical Excellence (CREATE). It aims to build the organisational capacity and technical excellence of people from both non-governmental and governmental sectors to implement HIV programmes through a process of continuous learning. One project funded by Oxfam Novib (2008-2011), entitled ‘Widening Responses to HIV/AIDS Mainstreaming’, works with senior management of partner NGOs to build their capacity on workplace policy, including HIV, gender and human rights. Strengthening the capacity of NGOs, CBOs and selfhelp groups to mobilise marginalised communities to advocate for their social, legal and health rights is one of the key objectives of the PRESEP programme. In instances where groups do not exist, HASAB provides technical support for their creation. For example, through PRESEP, HASAB has successfully worked with hijiras to help them advocate for equal land inheritance rights.

SD3: Strengthen communities influence in national programming and in national and international policy With funding from the Global Fund (2004-2012), HASAB delivers life skills education for young people through existing youth clubs/ organisations, and establishes youth-friendly services within primary health care facilities. HASAB has also played a central role in advocating for the expansion of youthfriendly health-services and life skills education for young people across Bangladesh. HASAB also places significant emphasis on research work in order to generate a strong evidence base for influencing national policy. This includes periodical surveys, operations research and policy level action research on HIV/AIDS and related issues. For example, HASAB undertook a project entitled ‘TB/ HIV Monitoring and Advocacy Initiative’, which was supported by the Open Society Institute (OSI). The project focused on participatory monitoring, research and process documentation to generate learning and an evidence base on TB/HIV in Bangladesh. HASAB organised stakeholder meetings with policy makers and other actors in order to share their research findings and raise awareness of the importance of TB/HIV as a policy priority and to obtain their views on ways forward. The European Commission is providing financial support for a three-year South Asia regional project on adolescent SRH policy and advocacy (20102013). The project is led by the Alliance Secretariat and Alliance India, and involves Indian Linking Organisations working in two states and HASAB working in four districts. The project focuses on enabling youth networks and groups to participate in policy and programme forums in relation to young people’s sexual and reproductive health. This is done through meaningful participation, knowledge sharing and dialogue with decision-makers, resulting in greater access to comprehensive SRH education and services, especially for youth from vulnerable and marginalised communities. The project aims to support up to 30 CSOs in each country, that will in turn support the formation and/ or strengthening of three youth groups per CSO (180 youth groups in total).

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Bolivia

Bolivia is one of the poorest countries in Latin America. Although its overall HIV prevalence is quite low, it is surrounded by countries with higher rates of HIV infection such as Brazil and Peru. There are an estimated 10,000 people living with HIV in Bolivia, with 19% of cases estimated to be in Cochabamba, Bolivia’s third largest city. Rates are highest among women and young people between 15 and 29 years of age. Most HIV infections are acquired through unprotected heterosexual sex, but a rising number are among men who have sex with men (MSM). Despite the efficient government response to HIV, Bolivia’s health system reaches only 70% of the population. The remainder live in rural and impoverished areas with little access to treatment facilities. The Alliance has worked with Linking Organisation Instituto de Desarrollo Humano (IDH) since 2005, supporting it to strengthen the capacity of Bolivian civil society to participate actively and efficiently in national responses to HIV. IDH works with young people and adults affected by HIV through prevention and care programmes, and is strongly engaged in advocacy. An ‘HIV/AIDS Advocacy with Key Populations’ project has supported community groups of sex workers, people living with HIV (PLHIV), transgender people and MSM to organise and undertake advocacy work at regional and national level.

SD 1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of people reached through HIV prevention activities

Data unavailable

7,688

25,452

Number of individuals reached through stigma and discrimination reduction initiatives

Data unavailable

8,830

IDH has been running a major prevention project over a period of 11 years in the cities of Cochabamba, La Paz and Santa Cruz, reaching the general population but including a specific focus on young people in schools and universities. The aim is to increase knowledge about HIV and reduce risky behaviour by spreading messages through special events and the media. In Cochabamba in 2009, a total of 23 events took place. For example, carnivals, theatre shows and radio programmes (in Spanish and Quechua) have helped people to learn about sexuality and how to prevent HIV infection. At the same time, stigma and discrimination is also tackled. IDH carries out surveys to monitor how people’s attitudes have changed – for example, comparing their opinions before and after watching a play dealing with issues around HIV. In addition, IDH succeeded in convincing the government to include sexuality and HIV in the school curriculum for pre-adolsecents as well as older students. It has trained and supported teachers to deliver lessons on these themes. Over a period of seven years, 99,704 students in most of the schools in the three cities have been reached in this way. Since 1998, IDH has organised an annual ‘Exposida’ to raise awareness of HIV and AIDS among Cochabamba’s general population. Every year since 2002, it has attracted an average of 20,000 visitors. As a lack of information from their parents means that adolescents have limited guidance on sexuality and HIV, the Expo in 2010 focused on the challenges of addressing this within families. It engaged visitors with art exhibitions, theatre, competitions, workshops, dance and poetry. The aim was to help break taboos that can prevent sexuality and HIV being discussed within families, and also tackle the issue of migration. Students took part in competitions to win cash prizes and sports equipment for their schools with their knowledge of sexuality and HIV. A project to empower women living with HIV in Bolivia was successful in increasing self-esteem and knowledge of treatment. The women improved their adherence to treatment, as well as their attendance at health centres. Several women designed their own diaries to keep track of their medication; they recorded the exact times they took their drugs and they lost their fear of antiretrovirals. The women’s uptake of health services increased and many went on to receive gynaecological treatment. Experiences of stigma and discrimination from healthcare professionals were overcome as the women began to understand their rights and insist that they be respected.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 6

SD2: Increase civil society capacity to implement effective community responses From 2007 to 2009, 120 members of key populations were trained in advocacy. The aim was to support activists from sexual diversity organisations, MSM and transgenders, sex workers and PLHIV to take action on issues related to HIV and AIDS. Participants received technical advice, administrative and organisational support and financial resources to implement advocacy actions, with an emphasis on leadership, planning and finance. For example, key population members felt discriminated against in hospitals, violating their right to healthcare and dignity. They gathered data through interviews, surveys and focus groups, involving key populations and institutions. This helped raise awareness and provide evidence for future advocacy work. By acquiring skills in advocacy, leadership, planning and implementing actions, activists from communities of sex workers, transgenders, PLHIV and MSM increased their visibility and positioning and strengthened their organisations. Communication and negotiation skills of key populations also increased in the context of cooperation with decisionmakers and public agencies. The role of the key populations themselves was essential in achieving their advocacy goals. As one commented, â&#x20AC;&#x2DC;Before, only those who were trained could speak for us and we could only listen. And itâ&#x20AC;&#x2122;s not the same if someone whose rights are infringed tells their experience to the decision-makers as someone else doing it, as they might not have such an impactâ&#x20AC;&#x2122;. Around 50 women from La Paz and Cochabamba participated in training workshops on participation, community engagement in antiretroviral treatment and advocacy, as well as meetings on the theme of gender and leadership. The aim was to empower them to participate in decision-making spaces and advocate for their sexual and reproductive health and rights. The women strengthened their leadership abilities and also their skills and knowledge as individuals and as a collective. There was an increase in the number of women leaders participating in and influencing local and national decision-making spaces. Awareness was raised among authorities and health service providers, and the women became involved in public policy.

SD3: Strengthen communities influence in national programming and in national and international policy Since 2005, IDH has been working to strengthen the participation of PLHIV, sex workers, MSM and transgender people in decision-making spaces and the national health system. As a result of this work, in 2008 a resolution was passed by the Ministry of Health and Sports incorporating amendments to the new Bolivian constitution (Resolution 668). This resolution made it mandatory for health programmes

and services to provide comprehensive healthcare and respect for the dignity and rights of key populations. Following on from this, and through collaboration with other stakeholders, penalization of discrimination on the grounds of sexual orientation or gender identity was included in the new constitution. Another achievement was the passing of other legal instruments such as Law 3729 for the Prevention of HIV/AIDS and the National Health Plan. A National Working Table (NWT) and 4 Regional Working Tables (RWT) have been set up in La Paz, Cochabamba, Santa Cruz and Tarija, each comprising members of the 4 key populations, to influence national debate. Since then, the tables have succeeded in positioning themselves as fundamental reference points in civil society in the formulation of policies and decisions to improve the response to HIV/AIDS in Bolivia. Ties have been established with officials in the Ministry of Health, the Ombudsman, the National AIDS Committee (CONASIDA) and the Country Coordinating Mechanism of the Global Fund, as well as with representatives of other civil society groups. The Working Tables lobby and advocate for quality, non-discriminatory care services from public health providers trained in human rights and care for PLHIV, sex workers and people of sexual diversities and gender. After Resolution 688 was successfully passed, the NWT began a process of monitoring progress and application of this law. In 2008, it set up a Citizen Observatory, a watchdog body designed to monitor government policy, ensure the observance of legislation, and report on the delivery of health services to key populations. It ensures that key populations have access to friendly, high quality and non-discriminatory services. It also lobbies for the dignity, privacy and confidentiality of all patients and acts as an intermediary in cases of discrimination or other complaints. Observatory activities are implemented by the RWT, and overseen by the NWT. The data gathered by the Observatory provides useful, reliable evidence which can be used as a tool for lobbying and advocacy. Using this data (on seroprevalence among MSM; research among the transgender population engaged in sex work; on access to health care for PLHIV; and research into knowledge, attitudes and practices among sex workers), it has been possible to put together a baseline document outlining the context for key populations in Bolivia. This information is useful to the NWT and RWT in their advocacy. It has been used in decision-making spaces like the Global Fund Country Coordinating Mechanisms (CCMs). One of the successes of this initiative is that the Coordinator of the Regional Working Table of La Paz is now a member of the CCM representing the transgender population and is able to demonstrate the need to work with key populations.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

BURKINA FASO

Burkina Faso is one of the world’s least developed countries, and has a generalised HIV epidemic, with a national adult prevalence rate estimated at 1.6% in 2007. Approximately 100,000 children have lost at least one parent due to AIDS. The national response is still limited as well as the civil society contribution. Initiative Privee et Communautaire de lutte Contre le VIH/SIDA au Burkina Faso (IPC) was established by the Alliance as a Country Office in 1994, and by 1998 it had evolved into a national NGO and a Linking Organisation of the Alliance. IPC aims to strengthen civil society in order to address the gaps in the national response, and has been a key player in the national HIV response over the last decade. Providing support to more than 500 community projects working on AIDS issues since 1995, it has received project funding from a range of donors. The Swedish International Development Cooperation Agency (SIDA) supported a project to expand integrated community responses to HIV in three provinces (2006-2008). Others include MAC AIDS, which funded a treatment adherence and care and support project for adults and children living with HIV (2007-2009), and AIDS FONDS, which supported ‘Project Orange’ (2002-2009). This latter project was led by Association African Solidarite (AAS) in partnership with IPC and the Alliance, with the objectives to increase access to treatment, improve treatment adherence, provide home-based care, implement prevention activities, and advocate for sustainable access to treatment. IPC also receives funding from the Alliance’s Africa Regional Programme (ARP) to support national advocacy for quality prevention interventions for sex workers and other key populations, and to strengthen the people living with HIV (PLHIV) network, Network for Greater Involvement of People Infected with HIV (REGIPIV).

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of orphans and/ or vulnerable children receiving care and support within the community

15,438

17,365

12,843

Number of people reached through HIV prevention activities

36,599

23,660

20,529

In Rambo village football games and other sports are organised to help the children to forget their worries © Gideon Mendel for the Alliance

In 2009, IPC achieved 19% of the UNGASS national target for orphans and vulnerable children (OVC) aged under 18 living in households who received a basic external support package – making an impact on the national epidemic in Burkina Faso. Two of the main objectives of the SIDA project aimed at increasing both the coverage and quality of prevention, care and support interventions in three provinces. A marked increase in the coverage of services was achieved by the project’s end in 2008, and the improved quality of services and interventions encouraged more people to access them. A notable example of this was the significant rise in the numbers of people seeking HIV testing through the project. A key achievement of the SIDA project was the dramatic reduction in stigmatisation of PLHIV and OVC, as well as the new found commitment of communities to OVC care and support. The socio-professional OVC integration programme aimed at out-of-school youth aged 14-17 was a unique aspect of the project’s OVC work, providing vocational training such as sewing, woodwork, metalwork and motorbike mechanics. Home-based care and psychosocial support was provided to PLHIV, in addition to nutritional support and revenue generating activities that took into account the intersection between poverty and health. Effective information, education and communication activities comprised the project’s prevention interventions, and in 2008 some partners introduced prevention of mother to child transmission (PMTCT) services.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 8

SD2: Increase civil society capacity to implement effective community responses

SD3: Strengthen communities influence in national programming and in national and international policy

IPC hosts the West and North Africa Technical Support Hub. By drawing on expertise across the Alliance, it provides evidence-based, context specific and timely technical support to Alliance Linking Organisations, non-governmental organisations, community-based organisations (CBOs), umbrella organisations, co-ordinating bodies, governmental organisations, Country Coordinating Mechanisms (CCMs), UN agencies and private sector organisations. The Hub provided 491 days of technical support across 9 countries between November 2008 and July 2010.

One of IPC’s key policy achievements relates to Project Orange. The pilot phase of the project had been successful in providing comprehensive care and support to PLHIV, including antiretroviral medication. However, when the pilot came to an end in 2006, AAS was faced with ensuring the sustainability and scale-up of the gains made. During 2007, AAS supported by IPC and the Alliance held several discussions with the government of Burkina Faso to advocate for people receiving treatment under AAS to be integrated into government programmes. This was approved by the National AIDS Council in early 2008. Therefore the government took responsibility for ART provision, while Project Orange continued to provide biological monitoring and psychosocial support to clients.

Since 1995, IPC has strengthened the capacity of over 200 CBOs across 25 provinces, through providing organisational development and technical HIV expertise. IPC provided financial support to 64 organisations working at community level in 2008 and 58 organisations in 2009. In 2009, IPC secured funding from the ARP to lead a capacity analysis of REGIPIV and to develop a threeyear capacity building plan. Implementation of this plan is now underway, and by 2012 the plan’s four goals should be achieved, those being to (1) make the network dynamic through its structures and members; (2) make the human and finance resource management more professional; (3) increase the network’s advocacy and resource mobilisation capacity; and (4) improve the communication system within the network. Following recommendations from the SIDA project’s mid-term evaluation, an ‘intermediary CBO’ approach was adopted to ensure that new and less experienced organisations could become implementing partners. The intermediary CBO approach provided grants to stronger CBOs, who in turn provided support and funding to weaker CBOs. The introduction of this model allowed strong CBOs to gain leadership and new skills, while allowing weaker organisations to be part of a successful project at provincial level.

Through Project Orange, AAS has built a reputation as an organisation at the front line of community care for PLHIV. Its expertise has been sought by national and regional stakeholders. The government officially recognised its Centre Oasis as a centre of best practice for HIV treatment, and expressed an interest in replicating it as a model in other sites. During 2009, an ARP grant funded IPC’s national advocacy activities promoting quality prevention activities for key populations in general, and sex workers in particular. IPC engaged with key actors at national level in order to raise the awareness of political leaders and decision-makers around the need for additional financial resources to be invested in interventions targeting key populations. Lastly, IPC has been heavily involved at the national level advocating for the integration of sexual and reproductive health and HIV programming. Highlighting gender issues has been an important part of this work. IPC has not only drawn attention to the importance of working with women as a target group, but it has also advocated the value of male participation in PMTCT programmes.

The capacity of IPC has continued to grow over the years, and IPC was chosen to be Co-Principal Recipient in a recent proposal for Global Fund Round 10, which shows that IPC is increasingly recognised for its leadership in the field of sexual and reproductive health rights/HIV integration in Burkina Faso.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

CAMBODIA

Cambodia is one of the few countries to achieve the Millennium Development Goal of halting and reversing the spread of HIV, with prevalence falling from 3% in 1997 to 0.8% in 2007. This decline in prevalence was due to a rapid and coordinated response by the government in collaboration with non-governmental organisations and civil society. Infections among sex workers fell after the promotion of 100% condom use. However, poverty, gender inequality and changes in sexual behaviour continue to drive the epidemic. There is a need for more prevention services for couples and key populations including young people, men who have sex with men (MSM), injecting drug users (IDU), amphetamine-type substance users, parkbased sex workers and truck drivers. The Alliance has worked in Cambodia since 1997, and its Linking Organisation Khmer HIV/AIDS NGO Alliance (KHANA) became registered in 2000. KHANA is now the largest local NGO implementing HIV/AIDS programmes in Cambodia, and is one of the most credible and respected NGOs working in the health sector. It supports 66 partners to implement prevention, treatment, care and support programmes in 17 of the country’s 24 provinces and municipalities, which are those most affected by HIV. KHANA’s excellent relationship with the government and public sector supports the successful delivery of its services. Through technical support visits, training, workshops and exchange visits, KHANA builds the capacity of its partners to implement programmes, carry out evaluations and manage resources. KHANA is a Sub-Recipient of the Global Fund.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of orphans and/ or vulnerable children receiving care and support within the community

18,095

21,670

22,370

Number of people reached through HIV prevention activities

283,835

334,619

236,089

In 2009, KHANA achieved 55% of the UNGASS national target for OVC aged under 18 living in households who received a basic external support package – making an impact on the national epidemic in Cambodia. Since 2005, KHANA has provided material, nutritional, educational and psychosocial support to over 52,000 OVC.

Children playing outside, Cambodia © Michael Nott/KHANA

KHANA supports 51% of all home-based care services in Cambodia. The Integrated Care and Prevention Programme (ICP) is its largest. It focuses on the provision of home-based care services by trained teams to people living with HIV, OVC and their families. Services include referrals to health care, positive prevention information, access to income generating activities, nutritional assistance, support for antiretroviral treatment adherence, self help groups and support for school attendance. Through the ICP, KHANA is making a significant contribution to achieving universal access to HIVrelated services, supporting 47,743 adults as well as 22,370 children in 2009. The ICP is implemented in collaboration with the government and is considered a flagship programme, influencing the development and implementation of the government’s continuum of care model. In October 2009 KHANA launched a $13.4 million programme, SAHACOM (Sustainable Action against HIV and AIDS in Communities). SAHACOM is working closely with 26 local non-government and community-based organisations to make vital, high quality care and support services available to over 19,000 PLHIV, including OVC. It will provide prevention information and services to at least 8,000 most at risk people (sex workers, MSM and IDU) in eight priority provinces and the municipality of Phnom Penh. KHANA’s Focused Prevention Programme prioritises the needs of those most at risk of infection. Most of the 14,000 people reached are sex workers, IDU or MSM. Other beneficiaries include youth, mobile populations, married couples, PLHIV, and OVC. The programme provides outreach and peer education, and challenges community norms and stigma. Specific tools and training materials have

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 10

been developed by KHANA in collaboration with its community partners and members of the key populations. KHANA successfully complements its HIV prevention and home and community-based care services with effective links and active referrals between HIV and AIDS and other health services, such as SRH and TB. Referrals are also made to non health-support services that provide nutrition, social support and income generation activities. In an effort to augment declining incomes and improve livelihoods, KHANA has embarked on a microfinance project aimed at improving the livelihoods of PLHIV in partnership with VisionFund Cambodia. The project aims to increase the economic activity, entrepreneurship and skills at community level through providing micro credit. An evaluation of the pilot phase has recommended that KHANA pilot expand the microfinance project in more sites. The evaluation also provided evidence of increased income and savings among respondents accessing KHANA/VisionFund Cambodia loans. Improvements in household welfare such as food security and housing conditions were also reported.

SD2: Increase civil society capacity to implement effective community responses KHANA hosts the East and South East Asia Technical Support Hub. By drawing on expertise across the Alliance, it provides evidence-based, context specific and timely technical support to Linking Organisations, non-governmental organisations, community-based organisations, umbrella organisations, coordinating bodies, governmental organisations, CCMs, UN agencies and private sector organisations. For example, UNFPA commissioned a mapping assignment from the Hub to provide an overview of youth sexual and reproductive health networking throughout the Asia region, and to identify potential areas for capacity building. Originally designed to inform the UNFPA regional strategy, the Hub’s report was considered so comprehensive that UNFPA disseminated it to a far broader audience and is using the work as a springboard for further regional and national cooperation between the Alliance and UNFPA.

improving its programme and financial management and planning, monitoring and reporting. This led to Korsang improving its skills as an organisation, and understanding more about good practice and good governance. Korsang has gone on to make real achievements in reaching large numbers of people and changing attitudes among IDU, through its model of using former IDU as peer educators or peer facilitators. KHANA has supported the establishment of national networks of people living with HIV and men who have sex with men.

SD3: Strengthen communities influence in national programming and in national and international policy KHANA works in close cooperation with the government’s national AIDS programme. It has staff on seven government HIV/AIDS technical working groups and two regional committees. Through these bodies, KHANA advocates for improved policies and influences the development and implementation of Cambodia’s National Strategic Plans. For World AIDS Day on 1 December 2008, KHANA worked with UNAIDS to organise the World AIDS Campaign to increase awareness and fight against prejudice. It succeeded in involving thousands of people from government and implementing agencies, supporters and beneficiaries. The slogan ‘Stop AIDS: Keep the Promise’ encouraged governments, policy makers and regional health authorities to maintain their response in the fight against HIV and AIDS, especially the promise of Universal Access to HIV treatment, care and support, and prevention services by 2010. In September 2008, KHANA and other government, national and international agencies implementing HIV/AIDS programmes co-organised the Third National AIDS conference, which was attended by around 900 policy-makers, activists, PLHIV, sex workers and MSM. Throughout the conference, KHANA advocated strongly to government partners the importance of sustaining focused prevention efforts. Despite the decline in HIV prevalence, experts warned that unless prevention is treated as a priority issue, Cambodia could see a second wave of infection.

At the community level, KHANA supports local organisations to deliver HIV prevention, treatment and care services. It conducts needs assessments to identify the needs of its partners, and draws up a plan accordingly for providing appropriate technical assistance. For example, Korsang is a Cambodian organisation set up in 2004 to work with injecting drug users and provide harm reduction services. KHANA worked with Korsang to make it even more effective through building its technical capacity and understanding of theories, as well as

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

CARIBBEAN

The Caribbean has the second highest rate of HIV infection in the world after ub-Saharan Africa. Overall adult HIV prevalence in the region is estimated at 1.1%, but national infection rates vary from 0.1% in Cuba to 3% in the Bahamas. In 2008, there were an estimated 240,000 people living with HIV. There has already been a transition from a low prevalence to a generalised epidemic in many countries. Heterosexual intercourse is the main primary mode of transmission. There is a higher rate of infection among men; however, the proportion of women infected is increasing, especially among the young. Prevalence rates in young people aged 15-24 years range up to 3.2%. Despite some progress made, estimates indicate that the HIV epidemic will continue to grow in the Caribbean over the next five years. As the number of people living with HIV (PLHIV) increases, Caribbean countries will face a serious challenge in providing adequate care, treatment and support. The Alliance has worked in the Caribbean since 2003, initially through a Country Office which became an independent Linking Organisation – Caribbean HIV & AIDS Alliance (CHAA) – in 2008. It runs programmes in Antigua and Barbuda, Barbados, Jamaica, St Kitts and Nevis, and St Vincent and the Grenadines, and also distributes condoms in five other Eastern Caribbean countries. It builds the capacity of community based organisations and reaches out to most-at-risk or key populations (sex workers, men who have sex with men (MSM) and PLHIV). Two major programmes include one which increased the involvement of the hotel and tourism sector in Jamaica and Barbados in the HIV and AIDS response, and one which is increasing access to HIV services in Antigua and Barbuda, Barbados, St Kitts and Nevis and St Vincent and the Grenadines.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

9,290

4,060

13,752

Number of individuals reached through stigma and discrimination reduction initiatives

Data unavailable

1,210

At the 2008 Antigua carnival, CHAA reached more than one fifth of the island’s population with its Think Safe, Act Smart! campaign © Alliance

In 2009, CHAA achieved 42% of the UNGASS national target for most at risk populations reached by prevention programmes – making an impact on the national epidemic in the Caribbean. CHAA’s prevention strategy is based on the peer outreach model: using peer educators drawn from most-at-risk populations (MARPs). Peer educators facilitate access to MARPs and provide MARPfriendly support and services. Because they are part of these communities, they are familiar with subcultures within marginalised groups and are effective at initiating behaviour change. For example, they have reported a reduction in the number of sexual partners among their clients. Representatives from National AIDS Programmes in Antigua and Barbuda, Barbados, St Kitts and Nevis and St Vincent and the Grenadines have said that the peer educators are the leading, and in some cases only, means of reaching MARPs with HIV prevention interventions. The use of good quality voluntary counselling and testing is also an essential component of a prevention strategy. In the Caribbean, HIV prevalence is as high as 27% among female sex workers and 32% among MSM. Marginalised populations are deterred from accessing HIV testing services due to fear that their sexual practices or HIV status will lead to discrimination, violence, rejection or loss of income. CHAA is therefore supporting the introduction of HIV rapid testing, whilst building capacity in the community to develop a decentralised model of community-based counselling and rapid testing. Best practice shows that decentralised, HIV community-based counselling and testing increases the numbers of people getting tested. When clientcentred, sensitive HIV rapid testing is available, MARPs access it more readily. Rapid testing is

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 12

attractive because it provides same-day results, instead of the delay which follows laboratory-based testing by providing same-day results. Also, mobile testing reduces the stigma associated with the testing process. The project working with the tourism sector has contributed to reducing stigma and discrimination. For example, a poster targeting youth with antistigma messages was designed and tested by youth, and used in the formal and informal tourism sector. Requests have been made by other agencies to distribute the posters in related outlets (schools, tertiary education institutions, doctors’ offices etc). The project also developed a groundbreaking antistigma video: ‘Stigma begins and ends with you’ and carried out workplace and street-based edudramas. The video produced was extremely well received by a wide array of stakeholders. Requests for copies have been made from the Caribbean Broadcasting Media Partnership, Barbados National HIV and AIDS Commission, Ministry of Tourism and Ministry of Labour. As a result of the project, decreased discrimination, increased trust between managers and employees and a less stigmatizing workplace environment have been reported. Also, links have been established between hotels and health services, leading to increased access (for both HIV positive and negative employees) to voluntary counselling and testing and treatment, care and support services. To ensure that its interventions with MARPs are informed by evidence of need, programmatic possibilities and impact, CHAA has conducted studies in Eastern Caribbean countries in collaboration with the University of California San Francisco. These have examined, for example, the capacity and willingness of faith-based organisations to engage in HIV programming; the barriers and facilitators to implementing community-based rapid counselling and testing in Antigua and Barbuda; and the feasibility of prevention approaches which have proven effective in the USA.

SD2: Increase civil society capacity to implement effective community responses CHAA hosts the Caribbean Technical Support Hub, newly established in May 2010 to increase the sustainability and effectiveness of the AIDS response in the region, mobilising a broad range of non-governmental and community groups. Drawing on expertise across the Alliance and CHAA’s programme strengths, the Hub provides evidencebased, context specific and timely technical support. It aims to increase capacity in relation to prevention, care and support, human rights and civil society engagement, and to empower vulnerable and marginalised communities. The Hub’s assignments have included: developing and conducting a training programme on HIV and AIDS case management

for HIV project implementing partners and national entities in Antigua; health systems strengthening in the HIV and AIDS response, targeting MARPs in concentrated epidemic settings; and HIV and AIDS training workshops for faith-based organisations in St. Kitts. In Jamaica and Barbados, all sub-grantees participating in the tourism project benefited from capacity building activities. In Jamaica, this included basic knowledge and skills about HIV and HIV prevention, as only half of the sub-grantee agencies had some prior experience. The training they received produced a cadre of sexual health and HIV peer educators, peer counsellors and sub-project managers who were better able to represent their agencies; conduct community outreach; influence peers to access voluntary counselling and testing services; develop information, education and communication material; and support edu-drama presentations. All sub-grantees participated in a regional capacity building workshop in October 2008. It aimed to improve programme planning, management and implementation of sub-projects, and also provided an opportunity for sub-grantees to hone their presentation and public speaking skills and to practise fielding questions about their projects. In addition to strengthening the capacity of subgrantees, the tourism project also built the capacity of implementation partners and other stakeholders. Hotel workers and community NGOs have been enabled to disseminate policies, and counsel and support tourism workers and those affected or at risk of HIV in the community. Their leadership and public speaking skills were developed to promote participation in HIV communication programmes and to better articulate health needs and rights. Recognising the important role that faith-based organisations can play in the response to HIV and AIDS in the region, two workshops on HIV and AIDS sensitisation and stigma and discrimination were held for the leadership of the General Board of Global Ministries. Over 125 church leaders from throughout the wider Caribbean region participated in the Barbados workshop and 30 in the St. Kitts workshop. As part of the workshops, the Alliance facilitated and moderated sessions to develop action frameworks for faith-based responses to HIV and AIDS in the Caribbean region. A peer educators’ workshop in September 2009 helped to build their understanding of wider sexual and reproductive health issues. Sexual and reproductive health has been included within their resource pack and in a life-skills cartoon book for sex workers, MSM and PLHIV.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 13

SD3: Strengthen communities influence in national programming and in national and international policy A key deliverable of the tourism project was the development of an HIV/AIDS Responsible Tourism (RT) Model. This is important advocacy intervention provides guidance to leaders, policy makers and the tourism sector on developing and implementing responsible tourism interventions which encompass HIV and AIDS. Responsible tourism ensures that the benefits of tourism planning, policy, and development are optimally distributed among those populations, governments, tourists and investors affected by tourism. The RT Model contains tools and strategies for promoting buy-in for responsible tourism in relation to HIV and AIDS; the development of workplace policies; promoting uptake of services; building capacity in civil society and the private sector; building effective multi-sectoral partnerships; and advocacy against stigma and discrimination. One important tool is an advocacy DVD focusing on business peers and industry leaders Two peer educators participated in a workshop of the United Nations Development Programme Bureau for Development Policy on universal access for MSM and transgender people. This increased their knowledge on themes related to human rights

based approaches, gender mainstreaming and sexual diversity approaches to HIV responses and programmes. It provided important insight into actions currently untaken regarding universal access, as well as challenges and successes in human rights related issues throughout the region. This has been shared with other peer educators. The follow up to this workshop will focus on development of tools and advocacy initiatives to strengthen national AIDS responses, and better integrate human rights and strategies to address the needs of MSM and transgenders. Following a meeting with the Assistant Commissioner of Police in Antigua, at which the Alliance advocated for protection of sex workers from gender-based violence and support for migrant sex workers who are survivors of rape, a Spanish speaking police officer has been transferred to the Rape Unit at a newly laid out station which has more welcoming access than other stations on the island. This is critical to ensuring that Spanish speakers can access the services provided by the Rape Unit, and not be constrained by a language barrier or a lack of sensitivity to cultural issues. It is hoped that it will increase reporting among migrant Spanish speaking sex workers of any violations.

Carnival revellers in Trinidad ÂŠ Alliance

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

CHINA

China has a low adult prevalence (0.1%) but a large number of people are living with HIV (around 700,000). The epidemic disproportionately affects injecting drug users (IDU), sex workers and men who have sex with men (MSM). Rapidly growing infection rates among sex workers indicate a burgeoning sexually transmitted epidemic. Although HIV has been detected in all 22 provinces and municipalities of China, three quarters of people living with HIV (PLHIV) are in 5 provinces, and 90% of infections among IDU are in 7 provinces. There is a general consensus that the national response to HIV has improved dramatically since 2003. The government has increased funding for the response and committed to providing free treatment, care and prevention services. It is expanding its work with IDU, and has taken steps to protect the rights of PLHIV. The Alliance set up a Country Office in China (Alliance China) in Kunming in 2003. Alliance China works with 45 partner organisations in 10 cities across three provinces: Yunnan, Sichuan and Guangxi. Alliance China is one of several international NGOs (Coordinating Agencies) implementing the USAID programme in China. The Alliance’s contribution to this programme is through supporting community involvement and mobilisation. Alliance China’s support since 2008 includes: two managed community teams (a MSM group and a group of HIV positive methadone recipients) and their respective management partners; two provincial-level MSM networks; one provincial-level PLHIV network; and one autonomous PLHIV community-based organisation (CBO).

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

5,964

7,232

8,220

Number of individuals reached with care and support

2,394

Data unavailable

4,180

In the Chinese context, there are considerable challenges in supporting most-at-risk population (MARP) community involvement in HIV and AIDS programmes to be both meaningful and effective. China’s main form of community involvement follows a ‘government-led community group’ model. MARP groups are not able to register as independent notfor-profit organisations. In addition, IDU and sex

A transgender person, carrying a VCT service promotion card does outreach work for Chengdu Gay Community Care, Chengdu, Sichuan. Alliance supports the organisation with institutional capacity building and outreach service development © 2008 Kevin Sare for the Alliance

workers are criminalised populations, which make their involvement in the HIV and AIDS response even more challenging, in particular due to stigma, discrimination and the fear of being arrested. One of the exceptions, however, is the PLHIV CBO AIDS Care China, which gained its autonomy through its commercial registration. AIDS Care China has developed a distinctive service delivery model that integrates peer-led support services into the government’s clinic and hospital system. It has been successful in demonstrating the potential for PLHIV involvement in care and treatment support programming at scale. With a head office in Nanning and sub-branches across four provinces, it is an excellent example of scaling up. Some of its activities include peer-led adherence support, positive prevention activities, providing treatment literacy messages, and sending PLHIV regular adherence updates by SMS. Alliance China works with the Sichuan Association for STI/HIV Control and Prevention to provide organisational and programmatic support to an IDU group (Emei Five Hearts Service Centre), an MSM group (Chengdu Tongle Health Consultation Service Centre), and a female sex worker group (Mianyang Ziyun Group). The Association helped develop a number of interventions: a comprehensive IDU intervention platform operating through the Emei service centre, needle exchange outreach and methadone maintenance therapy (MMT) clinics; female condom promotion through building the capacity of sex worker community groups; and outreach activities and voluntary counselling and testing referrals provided in entertainment establishments in Chengdu MSM communities.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 15

The 2009 project reached 900 IDU, 3,000 MSM, and 800 sex workers. Alliance China set up a branch office in Nanning in late 2009, which partners with four MMT clinics in order to operate a peer-led MMT adherence support programme. Their peer-led MMT adherence support programme will be scaled up this year to include six more clinics. Alliance China’s portfolio has included livelihoods work. Between 2005 and 2009, the Alliance received three consecutive grants from Johnson & Johnson for a programme aimed at strengthening community support for women living with HIV in Yunnan through a pig farming livelihoods project.

SD2: Increase civil society capacity to implement effective community responses While there continue to be significant challenges around how to effectively involve communities in the HIV and AIDS response in China, a 2009 report to USAID stated that the China programme has built up a core of local technical expertise around how to support the involvement of MARP groups. One of Alliance China’s main contributions to the USAID programme is their work building the organisational and networking capacity of Managed Community Teams and their partners, and MARP Community Networks. Types of support include conducting network and group capacity analyses, financial and programme management support, and organisational development support. For example, the main technical support that Alliance China has provided to the PLHIV and MSM networks is developing the skills of the network coordinators, and supporting the members to take a greater role in managing the network. The groups now make their own decisions about new members and organise their own discussions and meetings. A higher level of ownership of the work has consequently developed, giving rise to a greater sense that this is a community-led process rather than an Allianceled process. Most recently Alliance China Office supported a group of MSM living with HIV to conduct a Participatory Community Assessment of the care and support needs of positive MSM. Key components of the Sichuan Association’s 2010 programme with IDU, MSM and sex worker groups focused on providing organisational development, project management training workshops, and support and guidance relating to civil registration.

SD3: Strengthen communities influence in national programming and in national and international policy Within China’s political context, Alliance China is limited in its ability to support community level engagement in national level political processes.

However, it does endeavour to influence the implementation and interpretation of policy within Yunnan, Sichuan and Guangxi provinces by establishing models of practice that create a significant and meaningful role for community in HIV/ AIDS programming. The Alliance Strategy in China (2008-2010) therefore adapted SD3 to: ‘Develop models of community involvement that can be used to influence effective policy implementation’. The three main intervention models showcased in the work of Alliance China are: the peer treatment adherence support model; MSM prevention model; and MMT adherence support model. Achievements through these models can be used to make the case for further reform. In addition, MARP community networks have participated in some advocacy activities. For example, the Yunnan PLHIV Network is developing an advocacy campaign to promote treatment access in Honghe prefecture, and the MSM networks are now engaged in a Voluntary Counselling and Testing/ STI promotion campaign led by Family Health International and supported by the Alliance. Since 2008, the Levi-Strauss Foundation has funded a successful programme aimed at building a supportive legal, policy and social environment for harm reduction programming in Emei City, Sichuan. The Levi-Strauss Foundation agreed to fund a second year of the programme in the existing site and to assess a second site (Funshun) in which to seed the model. The programme has made some progress in establishing an enabling environment for HIV prevention programmes for drug users. As part of this programme, a ‘Stakeholder Exchange Platform’ was established in 2008 with the aim of tackling policy issues that impinge upon the success of prevention programming for IDU. The platform involved participation from the Public Health Bureau, the Public Security Bureau (PSB), the Emei CDC, the Detoxification Centre, the Drug Control Bureau, the Neighbourhood Committee, the Methadone Clinic and the management of the Five Hearts IDU Drop-In Centre. While the PSB originally refused the participation of IDU from the Five Hearts Group in the platform meetings, 2-3 IDU do now attend these meetings and the attitude of the PSB toward IDU has significantly changed for the better. There is still a way to go, however, before the participation of IDU is fully accepted and valued on the platform. While Alliance China has not been able to stop the PSB from conducting drug user ‘cleanup’ campaigns, they have helped to ensure that such campaigns do not adversely affect harm reduction and HIV prevention programmes for IDU. Such incremental achievements represent a significant step towards creating a supportive environment for IDU programming in China.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY

COLOMBIA

Summary of country programme

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

The HIV epidemic in Colombia is concentrated among most-at-risk populations, mostly sex workers, men who have sex with men (MSM) and transgender people. Despite the high 2007 2008 2009 prevalence rate among these groups, they have Number of individuals Not Alliance Data 2,845 very limited access to reached through stigma member unavailable HIV prevention, treatment and discrimination reduction initiatives and care interventions due to structural and Number of individuals Not Alliance 130 0 cultural barriers such as reached with care and member support stigma and discrimination. Colombia is plagued with internal armed conflict and violence, resulting in pervasive human LigaSida works to identify the barriers to universal rights violations and breaches of international access to HIV prevention, treatment and care humanitarian law. State-endorsed or condoned services in Colombia, in particular for most at risk violence against most-at-risk populations populations such as PLHIV, transgender people, seriously undermines the national HIV response. MSM and sex workers. It also works to understand In her 2006 Annual Report on Colombia, the High Commissioner described ‘numerous and frequent violations of the rights to life and personal integrity, freedom and security, and the right to due process and judicial guarantees’.* This has been exacerbated by the internal armed conflict over the last 40 years, which has left substantial gaps in the provision of health care and other basic services in certain parts of the country. Colombia has the second largest internal displaced population in the world, and was a grant recipient of the first Global Fund programme focused on displaced populations affected by HIV and AIDS. The Alliance began working in Colombia at the end of 2008 through Liga Colombiana de Lucha Contra el Sida (LigaSida). LigaSida has 20 years’ experience working in the HIV and AIDS response. It is a member of the Latin America and the Caribbean Council of AIDS Service Organisations (LACCASO), which aims to achieve an effective community and multi-sectoral response to the epidemic while promoting and defending human rights. LigaSida’s work has been acknowledged by stakeholders at all levels, from Colombian civil society and regional networks to international agencies such as UNAIDS. Also, LigaSida currently sits on the Global Fund’s Country Coordination Mechanism (CCM). Its activities and interventions include HIV research; awareness-raising; national level advocacy work through direct support to transgender organisations; legal support to people living with HIV (PLHIV); and sexual and reproductive health and rights.

the socio-cultural drivers of the HIV epidemic and how they affect these populations. Liga Sida is part of a United Nations-led national research initiative on sero-prevalence among MSM and sex workers. With most of its activities being around policy, advocacy and campaigning (SD3), LigaSida is dedicated to fighting against stigma and discrimination, which is one of the biggest barriers to accessing health and HIV services for transgender people. It supports a number of community-based organisations (CBOs) to promote human rights, to raise awareness of human rights violations, and to fight stigma and discrimination: Colombia Diversa, a national Lesbian, Gay, Bisexual and Transgender (LGBT) human rights organisation; Fundación Santamaria in Cali, one of the most prominent transgender human rights organisation in Colombia; and Fundación Procrear in Bogota.

SD2: Increase civil society capacity to implement effective community responses LigaSida organised a workshop on the implementation of the Code of Good Practice for NGOs Responding to HIV/AIDS, in which Colombian HIV organisations received expert guidance. The Code draws on many years of experience to establish principles of good practice to ensure the ongoing effectiveness of HIV responses, and to encourage closer collaboration and dialogue between the government and civil society organisations.

* Office of the High Commissioner for Human Rights (OCHCHR) report introduction Human Rights in Colombia 2008-2009

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 17

The event was supported by the Alliance and the Colombian Red Cross, and sponsored by the International Federation of the Red Cross. The workshop supported organisations to improve the quality and consistency of their work, as well as their accountability to partners and the communities they serve. Among the many Bogota-based organisations participating in the workshop were Fundación Hope Worldwide, Fundación Tejedores de Vida, Fundación Henry Ardila, Fundación Huellas de Arte, Fundación Procrear, Fundación Milagros, Fundación Asivida and Corporación Vivir. Groups from other cities were also invited, including Fundarvi from Barranquilla, María Fortaleza from Pasto, Fundación Santamaría LGBT from Cali and the Santander branch of LigaSida itself. Fundación Santamaría received funding from USAID to produce a Self-Protection Manual that was developed with the meaningful participation of transgender women. This manual is the first of its kind to focus on protection and self-protection for transgender women. It is very much seen across the region as a powerful tool and an example to follow on issues such transphobia and other hate crime that violate transgender people’s rights. The learning process was shared with LigaSida, Colombia Diversa and Fundación Procrear, and the manual was adapted to the specific circumstances of transgender women in Bogota. The manual was also shared with the Latin America Regional Network, the Latin American and Caribbean Network of Transgender People (RedLacTrans) and other stakeholders in the region.

SD3: Strengthen communities influence in national programming and in national and international policy LigaSida implements advocacy and human rights activities with transgender populations, in partnership with Fundación Santamaria in Cali and Fundación Procrear in Bogota. This aims to raise awareness of stigma and discrimination against transgender people, with the active participation of transgender leaders and organisations.

adopted the same concept by painting a fuchsia star on the road, at the site of each violent death of a transgender woman in Cali. As a result, both organisations in Cali and Bogota were invited to be part of the advisory body working to revise the local Gender and Diversity policy, which touches upon subjects such as Human Rights and Legal Protections. They are also part of the Health Working Groups in both cities. Sadly, the need for increased self-protection among transgender women was reemphasised on 29 October 2009, when Fundación Procrear’s transgender group coordinator and human rights transgender activist Wanda Fox was killed in an act of transphobia. Fundación Procrear, one of LigaSida’s implementing partners, works in the highest risks areas in Bogota. It has a lot of experience in working with marginalised groups in very violent and stigmatising environments, and working on issues around human rights and legal protection as well as campaigning activities to promote transgender rights. It has monthly activities to commemorate transgender activists like Wanda Fox who have been killed. LigaSida has worked with Colombia Diversa, Fundación Santamaría and Fundación Procrear to increase the visibility of HIV and human rights on the national agenda. Colombia Diversa is now working on a second national report on violations against LGBT groups, which will be widely disseminated nationally as well as used as a tool by LGBT groups for campaigning and advocacy work at international level. LigaSida, together with the three organisations, has begun to establish a ‘community observatory’ for transgender populations. This body will monitor government policy, ensure the observance of existing legislation, and report on the delivery of health services to transgender people in Bogota and Cali.

Fundación Santamaría and Observatorio Ciudadano Trans implemented a new strategy to raise awareness of and condemn the continuing occurrence of murders of transgender women in Cali. Aimed at increasing the visibility of these extreme human rights abuses, the Fuchsia Stars campaign raised awareness, not just of the injustices committed, but also the lack of commitment from the authorities to follow-up these cases. The idea behind Fuchsia Stars was borrowed from a campaign to raise awareness of pedestrian deaths in Bogota, which painted black stars on the street at the exact locations where deaths occurred. On the basis of that campaign’s success, Santamaría Fundación

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

CÔte d’Ivoire

Côte d’Ivoire has the highest HIV prevalence rate in West Africa, with an estimated 3.9% of adults living with HIV in 2008. Approximately 420,000 of the nation’s children are orphans due to AIDS. The government is committed to its 2006-2010 National Strategic Plan, which aims to reduce HIV prevalence from 4.7% to 3.5%. However, a 2009 UNAIDS evaluation noted that large gaps remain in the response to the epidemic, especially in relation to care and support for people living with HIV (PLHIV) and orphans and vulnerable children (OVC), as well as prevention of mother to child transmission (PMTCT). Due to political and military conflict, access to health services is limited in conflict zones. The Alliance started working in Côte d’Ivoire through a Country Office established in 2005 with funding from USAID/PEPFAR. The Country Office transitioned rapidly to become a Linking Organisation, Alliance Nationale contre le SIDA en Côte d’Ivoire (ANS-CI), by the end of 2006. As a national umbrella NGO, ANS-CI manages sub-grants and provides financial and technical assistance to community-based and civil society organisations. ANS-CI was a Global Fund Sub-Recipient for Round 2 Phase 2 from 2007-2009, and is now a Principal Recipient for the Global Fund Round 9 programme for five years beginning in 2010. Programmatic areas of ANS-CI include: TB/HIV integration; voluntary counselling and testing (VCT); care and support for PLHIV and OVC; prevention interventions based on abstinence and being faithful; and focused prevention work with most-at-risk populations (sex workers, men who have sex with men, prisoners, truck drivers etc).

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

42,927

74,259

5,886

Number of individuals tested for HIV at VCT centres supported by the organisation

29,268

66,828

63,894

In 2009, ANS-CI achieved 23% of the UNGASS national target for most at risk populations reached by prevention programmes – making an impact on the national epidemic in Côte d’Ivoire. Since its establishment, ANS-CI has succeeded in expanding HIV/AIDS service coverage in 17 of

the 19 regions. Between 2005 and June 2010, ANS-CI and its implementing partners were able to reach: 200,837 people through abstinence and/ or being faithful focused activities; 136,367 most-at-risk populations through other prevention activities; 187,120 people through counselling and testing; 157,078 women aged 15-49 through PMTCT services; 32,237 PLHIV and 33,588 OVC through care and support. ANS-CI and its implementing partners have carried out largescale awareness-raising sessions on HIV/AIDS/ STI, VCT and condoms. ANS-CI’s OVC care and support programme includes OVC support groups, counselling for children and adolescents living with HIV, referrals to health services and other support services (e.g. payment of medical costs, assistance with school fees, food packages, and vocational training). From 2005 to 2009, ANS-CI worked in partnership with the Ministry of Health, local councils and NGOs to refurbish 24 HIV VCT centres and trained their technical and counselling staff. The engagement and optimising of the VCT centres was instrumental to ANS-CI’s Participatory Community Initiative, an approach which continued to be employed by ANS-CI. Under this approach, VCT centres acts as an entry point and link to OVC care and support activities, community mobilization activities for PMTCT and care and support activities for PLHIV. This approach has proven highly effective in encouraging people to get tested for HIV, facilitating access to comprehensive services and improving the overall quality of services for PLHIV and their families. Sex workers are a specific at-risk population within Côte d’Ivoire, and numbers of sex workers have increased as a result of the socio-political crisis since 2002. For populations displaced or otherwise

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 19

affected by the conflict, sex work has become a means for many women to provide for their families. ANS-CI piloted a sex worker outreach programme in 2007 and 2008, which operated in 2 regions where ANS-CI supports 2 implementing partners. Its sex worker mobile clinics initiative was the first of its size to be implemented in Côte d’Ivoire, and successfully achieved its objective to improve the access of sex workers to HIV/STI services. Through engaging sex workers during the implementation of the pilot, the initiative was able to identify a total of 68 sites where the mobile clinics are able to find and reach more than 5,500 female sex workers with HIV prevention, care and support services. Based on gaps identified in a programmatic case study, the proposed capacity building plan for 2010 to 2015 identifies the need to strengthen the programme’s capacity to provide contraceptives and treatment for opportunistic infections in addition to providing HIV/STI care.

SD2: Increase civil society capacity to implement effective community responses Since its establishment, ANS-CI has provided technical assistance and sub-grants to more than 80 CBOs. The implementing partners involved in the sex worker mobile clinic project emphasised that the monitoring and evaluation capacity building they received from ANS-CI was essential in achieving the project’s objectives. In addition, between 2005 and 2008, ANS-CI provided support to 8 organisations in 11 regions to provide care for people co-infected with TB/HIV. As a result, around 2,490 TB patients were tested for HIV, 16 community caregivers were trained and 3,211 people co-infected with TB/HIV were able to receive a support service. ANS-CI is planning to transfer its competency by identifying and training ‘intermediary organisations’ which would further provide technical capacity to their peers. ANS-CI has also provided ongoing financial and organisational support to 6 networks involved in the HIV response, including the West African Network of PLHIV (RAP+) and the Ivorian Network of PLHIV (RIP+), in order to scale up their community outreach and reduce stigma and discrimination. ANS-CI’s own capacity has grown over the years, as evidenced by its evolution from a Global Fund Sub-Recipient to Principal Recipient and its accreditation in 2009. Since its inception in 2005, ANS-CI has being receiving technical assistance from the Alliance Secretariat and through the Regional TS-Hubs. With pivotal start-up support from the Alliance Secretariat in 2005, ANS-CI is among the organisationss which strongly contribute to the achievements of the PEPFAR indicators. Technical assistance to ANS-CI has been in the areas of strategy development, partnership building, resource mobilisation, organisational and programme

development and management, as well as financial management and onwards granting systems.

SD3: Strengthen communities influence in national programming and in national and international policy ANS-CI seeks to influence national programming through its participation in national HIV/AIDS coordination meetings and in various national working groups, such as the technical VCT working group, OVC working group and mostrisk populations working group. It has developed partnerships with the country’s national TB control programme to facilitate the integration of CBOs in anti-TB centres in order to ensure a good continuum of care. Also, since February 2005, ANS-CI has been supporting the Ministry for the Fight against AIDS in Côte d’Ivoire to implement a system for monitoring community level activities on HIV/AIDS. In addition to conducting a national monitoring and evaluation (M&E) workshop with Ministry staff and NGOs, and working closely with the Ministry to understand their information needs and capacities, ANS-CI has adapted a database to capture national level monitoring and reporting for all HIV/AIDS community level interventions. The M&E framework is now officially adopted at national level and ANS-CI is currently assisting the Ministry to establish Regional Monitoring and Evaluation Units in four districts. During 2009, a study was carried out with truck drivers. The aim of this study was to provide actors and partners involved in the national AIDS response with reliable data in order to develop and implement prevention strategies along the transport corridor and at check points. In collaboration with the Ministry of AIDS and UNAIDS, ANS-CI organised a training in May 2010 for NGOs and other key actors. Participants were given training on the practical guidelines for increasing prevention efforts, as contained in the UNAIDS ‘Knowing your Epidemic’ document. This enabled participants to have a better understanding of the profile of the epidemic in Côte d’Ivoire and improve their HIV interventions. ANS-CI has engaged in advocacy activities aimed at the government to include part of the cost of VCT centres in the budgets of local authorities. The Alliance is supporting ANS-CI to develop a sustainable VCT strategy, which will integrate these into district health services. The emphasis will be on developing partnerships with key government ministries and organisations with the capacity to support smaller CBOs in their regions. In 2009, ANS-CI also facilitated the creation of a civil-society platform for HIV/AIDS to influence national policies for PLHIV. Recently the Ministry for the Fight against AIDS institutionalised a National Prevention Day following successful advocacy efforts by ANS-CI and the civil-society platform.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

ECUADOR

Ecuador has a concentrated HIV epidemic, with approximately 0.3% of adults infected (around 26,000 people live with HIV). Men who have sex with men (MSM) are the most affected, with an estimated prevalence of 19.3% in the capital city. Prevalence is also high among transgender people and sex workers, and the rate of new infections is steadily increasing. Despite some advances in recent years, access to high quality health care, for example HIV testing and counselling, is still inadequate and there are particular gaps in services targeted at vulnerable populations. Corporación Kimirina, a Linking Organisation since 2000, provides technical support to community organisations and helps mobilise key populations (sex workers, people living with HIV, transgender people and MSM) in the response to HIV. Kimirina also works to prevent sexually transmitted infections and improve voluntary counselling and testing services for key populations. It has successfully advocated for new national policies on HIV and helped to establish the Global Fund programme in Ecuador. In 2009, Kimirina began an advocacy and observatory project to support transgender people. Since the end of 2009, it has acted as Global Fund Principal Recipient (PR) for Malaria Round 8 and is about to start as PR for HIV Round 9. Kimirina is also implementing a three-year USAID-funded project on sex trafficking.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

12,808

226

Number of individuals reached through stigma and discrimination reduction initiatives

50,976

Data unavailable

2,028

The Frontiers Prevention Programme (FPP), an innovative $25 million six-year programme supported by the Bill & Melinda Gates Foundation in five low prevalence countries, came to an end in September 2007. In Ecuador, it worked with 40 different community-based organisations and NGO partners and helped to mobilise significant new groups of MSM, sex workers, transgender people and people living with HIV (PLHIV) in six cities. Kimirina has supported many projects involving communities in HIV prevention. In collaboration with

A peer outreach worker advises about HIV and safer sex in the Penthouse nightclub, Guayaquil, Ecuador © Gideon Mendel for the Alliance

local and regional governments, it has supported training activities for municipal employees and utilised innovative theatre and artistic techniques with youth in schools. To help engage the private sector in the HIV response, Kimirina has developed partnerships. In 2007, 2008 and 2009, it gained some funding from sports companies and an international children’s clothing company to support its work with children living with HIV. Kimirina works with partners Futpen and Alfil, both lesbian, gay, bisexual and transgender (LGBT) organisations, to improve access to health services for transgenders and combat stigma and discrimination. Activities carried out include outreach work with the local community; building awareness; education and information; legal support; access to microfinance; counselling; and sexual health care. With USAID funding, Kimirina is carrying out a pilot programme ‘Strengthening the reintegration of female victims of mistreatment into the workforce’ with the intention of ensuring that the women’s human rights are respected and that they are able to exercise them.

SD2: Increase civil society capacity to implement effective community responses Kimirina’s technical assistance for its partner organisations includes, for example, methodologies for peer training; building networks; planning; monitoring and evaluation; and advocacy. As well as developing training modules and delivering training, Kimirina has also produced publications and audio visual materials to improve knowledge about issues relating to HIV such as use and negotiation of condoms; rights, gender and sexual orientation; and nutrition.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 21

As part of FPP, Kimirina provided organisational and programmatic technical support to increase counselling and HIV testing services. In addition, it trained partner organisations to advocate with local and national decision-makers for expanded rights and access to services. With partner FUTPEN (Fundación Transgénero de la Península), local transgender leaders have been trained to represent the trans community and raise awareness of transphobia.

SD3: Strengthen communities influence in national programming and in national and international policy Within FPP, successful advocacy work achieved positive changes from municipalities, the health ministry and other institutions – for example, the inclusion of sex workers in a national programme providing free HIV and STI testing services. Most importantly in Ecuador, the project showed that key populations are integral to the HIV response and cannot be left out or ignored. RedTraSex, the Latin American and Caribbean Sex Workers Network, was set up to strengthen the rights of sex workers and is a partner of Kimirina. Its efforts have engendered greater acceptance and receptiveness toward sex workers, and brought about changes in social policies. For example, in association with the Ministry of Health and the national AIDS programme, it advocated for the enactment of the ‘National Guide on Laws and Procedures for Integrated Care for Sex Workers’. This new legislation represents a landmark in relations between sex worker organisations and the State. Now, a stigmatising ‘Sex Workers Health Card’ that recorded personal details with a photo and record of past infectious diseases has been replaced with a ‘Comprehensive Healthcare Card’, which cannot be retained by the police, health inspectors or pimps. This has increased access to healthcare for sex workers and decreased extortion and police persecution. In order to achieve this, the sex workers of Ecuador spent four years approaching decisionmakers, health care workers, authorities and partner organisations in order to raise awareness of the problems relating to the original identity cards and to convince them of the need to bring about change.

Silueta X is a key partner in advocacy work with transgender people in Ecuador. The group led a campaign to enable transgender men and women to legally change their name. Citing the antidiscrimination passages enshrined in Article 2 of Ecuador’s new constitution, they took the case to the Office of the Ombudsman which, in turn, took it up with the Director of the national Registry Office. This resulted in five group members receiving new identity cards within a week. It is expected that this legal precedent will result in the normalisation of the name-changing process. A ‘People Living with HIV Stigma Index’, designed to increase understanding of how HIV related stigma and discrimination is experienced, is part of a global initiative driven by the International Planned Parenthood Federation, Global Network of People living with HIV/AIDS, the International Community of Women with HIV/AIDS and UNAIDS. Voluntary and confidential questionnaires have been carried out to explore areas relating to the social environment, family, work, access to health services, knowledge of rights, HIV testing and treatment of HIV, having children and internal stigma. The technical advisory committee set up to oversee implementation of the Index is led by the Ecuadorian Coalition of PLHIV (a partner of Kimirina) and it includes Kimirina representatives, among others. The committee will ensure results of the study are suitable to be used at local, national and international level and influence public polices and interventions to tackle stigma and discrimination. It is also expected that the study will contribute to reducing the gap in availability of adequate, timely, accurate information on HIV in Ecuador. Following the success of similar projects in Bolivia and Peru, in 2009 the Alliance began an advocacy and observatory project to help transgender people in Ecuador. It is run by three organisations: Kimirina, FUTPEN and Alfil LGBT organisations. The project raises awareness of transsexual and transgender populations to enhance respect for their human rights and improve their access to health services. It follows up on cases of discrimination, mistreatment or abuse.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

El Salvador

COUNTRY STUDY Summary of country programme Around 0.8% of adults in El Salvador are living with HIV. The number of infected people has risen by around 10% each year since 2004, and the ratio of women to men has increased. Nevertheless El Salvador’s HIV epidemic remains concentrated. Prevalence is 25% among men who have sex with men (MSM), 23.7% among transgender people and 3.6% among sex workers, compared to 0.9% in the general population. HIV testing is not widely available in El Salvador, and at least 70% of infections remain undiagnosed until they begin to cause symptoms, by which time treatment may be less effective. Only half of people in need of antiretroviral therapy have access – due to lack of diagnosis, distance from health facilities or fear of discrimination. The Alliance began working with Asociacion Atlacatl Vivo Positivo (Atlacatl) in late 2008. Atlacatl was established in 1998 by a group of HIV positive activists, who took the Salvadoran government to the Inter-American Court of Human Rights to claim the right to free medication. As a result of their landmark victory, the government provides all people living with HIV (PLHIV) with free medication. Atlacatl is a significant regional player, leading the Salvadoran chapter of the Central American Human Rights Network on HIV/AIDS, and is active in the Central American Network of People Living with HIV/ AIDS (RedCa+). Working with the Alliance, Atlacatl focuses on building the capacity of organisations formed by and working with four key populations: MSM, transgender people, sex workers and PLHIV. This project has been sponsored by ViiV Healthcare’s Positive Action programme since 2010.

Number of individuals reached through stigma and discrimination reduction initiatives

2007

2008

2009

Not Alliance member

Data unavailable

11,488

campaign to raise awareness and fight discrimination against PLHIV. The campaign has received support from many high profile people, including the Vice President. In 2009, Atlacatl launched an anti-stigma project modelled on the successful Vida Digna initiative developed in Mexico by Alliance Linking Organisation Colectivo Sol. The model has been adapted to El Salvador, and will increase access to health care for key populations and improve comprehensive HIV services that are free from stigma and discrimination. Participatory Community Assessments (PCAs) have been completed by five local implementing partners in San Salvador – Fraternidad Gay Sin Fronteras (gay men), Orquideas del Mar (sex workers), ICW (women living with HIV), Aspidh Arcoiris and Movimiento por la Diversidad Sexual (transgender people). All of the partners include the active participation of key populations in their work, and most are led by and made up of key population leaders. They have proceeded to design anti-stigma projects based on the analysis of stigma and discrimination in their PCAs, received their initial grants and started implementing activities – for example, building links with decision makers and running awareness campaigns in hospitals and health centres.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

SD2: Increase civil society capacity to implement effective community responses

Atlacatl’s major projects include funding from a programme called Fomilenio, which is constructing a highway across the north of the country. Atlacatl’s role is HIV prevention and awareness with the construction workers and with the communities along the highway. In addition, Atlacatl works with the media to reach large numbers of people. It runs a weekly hour-long radio programme with national coverage to provide information and provoke debate about HIV and AIDS, and is also leading a media

At the start of the transfer of Vida Digna, Colectivo Sol provided technical assistance to the five implementing partners and Atlacatl. A workshop trained them on the use of PCA tools to understand the sources of stigma and discrimination, and its effects on the health and access to services of PLHIV, sex workers and transgenders. Participants also learned the process of data collection. The workshop was valuable for those who attended, and left them who eager to begin their PCAs in

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY San Salvador. Colectivo Sol continued to provide technical assistance from a distance, via email and telephone, to follow progress with the PCAs. A subsequent workshop by Colectivo Sol focused on analysis of the PCA results and the project design. The aim was to increase the knowledge and skills of the implementing partners to design projects that contribute to reduction of the stigma and discrimination faced by their target populations. The Alliance’s ‘Health Journey’ tool, where a person maps his or her experience in accessing health services, was used to help define a strategy for influencing health service providers. Part of the workshop was also spent training the partners on financial management of grants. As part of the technical assistance visits and workshops, Atlacatl were given forms, guidelines, support materials, background papers and additional materials to facilitate the coordination of the project. Atlacatl in turn adapted these and used them to work with their partners. As part of the USAID-funded AIDSTAR-Two programme, Atlacatl was also involved in mapping and did assessments in Nicaragua, Guatemala, Costa Rica, Honduras and El Salvador to identify the capacity building needs of the Central American Human Rights Network on HIV/AIDS. Atlacatl tested

the Alliance’s ‘Network Capacity Assessment Tool’ in El Salvador, made a few adaptations and then applied it in the other countries. The participatory assessments have provided the Network with very relevant recommendation on how to improve their performance and networking activities.

SD3: Strengthen communities influence in national programming and in national and international policy Atlacatl is influential in shaping HIV-related policy and is represented on key decision making forums such as the Central American Human Rights Network and the National Commission to reform the HIV law. Following a petition presented by Atlacatl with widespread support, a National Day of Solidarity with People Living with HIV will be recognised in El Salvador on 12th May each year. The date was chosen because Atlacatl was founded on 12th May 1998, and celebrated its 12th anniversary in 2010. Atlacatl’s success with the petition is the result of hard work and commitment from people who have taken on the struggle to enable PLHIV in El Salvador and the Central American region to enjoy their rights. Atlacatl has also been instrumental in changing Salvadoran labour laws, so they do not discriminate against PLHIV and employers cannot require a compulsory HIV test.

A workshop with representatives from eight organisations that work with key populations, El Salvador. Supported by Alliance partner, Asociacion Atlacatl Vivo Positivo © Atlacatl/Alliance

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY

HAITI

Summary of country programme Haiti has one of the highest rates of HIV infection outside Africa. The epidemic is worsened by extreme poverty, low levels of education, poor quality and availability of health and social services, and chronic political instability. However, prior to the earthquake of January 2010, prevalence rates in the major cities had fallen, and the country had set an example in the provision of anti-retroviral therapy (ART) in resource-poor settings. The earthquake left hundreds of thousands of people struggling to access shelter, water and food. At the same time, the vulnerability of people living with HIV (PLHIV) increased due to the breakdown of support systems and difficulties accessing the ART essential for their survival. 57% of PLHIV in the country and the majority of centres providing medication were based in the cities of Port au Prince, Petit Goave and Jacmel, which were seriously affected. In the humanitarian crisis, it is feared that HIV is no longer a priority on the agenda. The Alliance started working in Haiti in 2005, in Outreach worker for Promoteurs Objectif Zerosida (POZ) © POZ partnership with Promoteurs Objectif Zerosida (POZ), a national NGO which provides guidance, counselling and support to over 2,000 people SD1: Scaled up quality community programmes living with and affected by HIV. From 2005-2008, delivered and access to health and HIV services POZ worked to strengthen and raise the profile of improved the newly formed network of Haitian people living with HIV (PHAP). With the Alliance, it has also adapted 2007 2008 2009 resources for community service providers to help Number of individuals Data Data 6,454 orphans and vulnerable reached with care and unavailable unavailable children in Haiti. In June support 2008, POZ began a project Number of individuals Data Data 20,561 funded by the UK’s Big reached through stigma unavailable unavailable Lottery Fund to increase and discrimination uptake of HIV prevention, reduction initiatives care and treatment services by working with The Big Lottery-funded project made great local leaders, health providers and members of progress within its first year to address stigma and communities to address HIV-related stigma and discrimination, and increase uptake of prevention, discrimination. POZ is also a Sub-Recipient of the treatment and support services in Cap Haitien, Global Fund. Although the Global Fund grant to Haiti Jacmel and Port-au-Prince. PLHIV outreach workers was frozen, with activities suspended, it is due to and community leaders from diverse social sectors – restart. including the church and local authorities – reached over 13,000 people with anti-stigma messages. Following the earthquake, POZ’s 3 project offices were rendered unusable, but since February they have continued to work under an Emergency Response Programme. This has included offering clinical care, counselling and psychosocial support. POZ is also running activities in the temporary camps to tackle stigma and discrimination.

The project has 50 active PLHIV outreach workers. They raise awareness by discussing the consequences of stigma and explaining basic information on HIV and AIDS, through individual and small group sessions at markets, in hospitals, in their neighbourhoods and local churches. They also refer people to testing centres and for treatment support as needed, and give psychosocial support to PLHIV. Referrals by the outreach workers have

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 25

led to increased uptake of prevention, treatment and support services in the project sites, with more than 3,000 people being referred. Also, local groups of ‘anti-discrimination champion leaders’ have been created, who develop strategies to resolve reported cases of stigma and discrimination. By reaching out through ‘champion leaders’ who are members of the church and the wider community, the project aims to change attitudes in the long term and therefore ensure sustainability. The project has used a range of mass scale communications and media activities to broadcast positive images of people living with HIV and to speak about HIV as widely and openly as possible. Activities include radio shows, which have reached around 40,000 people, informing listeners about HIV and AIDS and encouraging them to change their attitudes towards PLHIV. Listeners have the opportunity to call in to ask questions about serodiscordant couples, prevention, confidentiality in hospitals and the kind of support required by someone living with HIV. Two peer outreach workers have given radio interviews about the difficulties they have experienced through stigma, and a report on the project was even broadcast on national television. Also public theatre and dance events led by PLHIV mobilise support from the public, and have been attended by over 6,000 people. A telephone service, Telephone Bleu, provides a means to report cases of stigma and discrimination and offers confidential advice on issues relating to HIV and AIDS, as well as referrals to health and psychosocial support services. It is promoted at the mass outreach events. Following the earthquake, POZ has been in the process of locating all of the 2,000 PLHIV and other vulnerable groups who had been accessing POZ services, working with outreach workers, community leaders and health service providers in Cap Haitien, Jacmel and Port-au-Prince. A communications campaign is using ‘Truck Sound’ – messages delivered from a truck – to reach people in the shelters and camps, and face-to-face visits from outreach workers going from tent to tent.

financial management, planning, monitoring and evaluation and reporting, as well as workshops on strategic planning, advocacy, resource mobilisation, project management and good governance. The project evaluation in 2008 concluded that PHAP was much better structured organisationally, having developed both a strategic plan and an action plan, and had consequently improved its capacity to mobilise funds as well as its capacity to mobilise the PLHIV community. When the project started, PHAP was funded only by the Alliance, but by March 2008 it had five more donors. Also, the number of member associations more than doubled from six at the beginning of the project to 13 in March 2008, which shows that the network had developed more credibility among PLHIV. The PLHIV member associations also improved their organisational, resource mobilisation and community mobilisation capacities as a result of the project. As part of the Big Lottery-funded project, 50 peer outreach workers living with HIV and 98 community leaders have been equipped with the information and skills to undertake outreach work, and give psychosocial support to PLHIV through counselling and referrals. Interested PLHIV attended peer training on stigma and prevention, and around half of those trained were selected to become peer outreach workers. They were then given further training on self-esteem, gender and communication. 152 health care providers have attended anti-stigma trainings which examined definitions and causes of stigma, how stigma is manifested in healthcare settings and the negative consequences stigma can have on health outcomes for PLHIV. Staff reflected on how stigmatising behaviour from staff can affect the people being treated and even lead to them abandoning treatment. The trainers developed action plans with staff, to improve the friendliness of HIV and health services in three project sites. This work in sensitising healthcare providers will ensure that stigma is reduced in the long term.

SD3: Strengthen communities influence in national programming and in national and international policy

SD2: Increase civil society capacity to implement effective community responses

Within the Haitian context, opportunities for civil society to achieve impact through advocacy and policy work for PLHIV are quite limited, and generally little work is being carried out in this area.

In 2005, the Alliance started work to strengthen and raise the profile of the newly formed Haitian PLHIV network Plateforme Haïtienne des Associations de Personnes Vivant Avec le VIH (PHAP), so that it could better represent its constituents while encouraging them to actively participate in HIV programme planning, decision making and advocacy. Technical support included one-to-one technical support visits by POZ staff to the six member associations of PHAP on issues such as project management,

POZ’s partner PHAP developed a form for documenting PLHIV rights violations in the country, with the aim of increasing visibility of the problem, and using the data collected for advocacy and fundraising. The form was disseminated among the PLHIV associations. Every time a PLHIV reported that their rights had been violated, the associations filled in the form and sent it to PHAP. PHAP then investigated. Where there was enough evidence

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 26

of a rights violation, the case was published in a national newspaper, Le Nouvelliste. Following on the publication and depending on the reactions to the case published, PHAP sometimes held press conferences. The project ended in 2008, but by increasing the visibility of the problem, awareness of HIV-related stigma has increased and there is more funding for HIV and AIDS initiatives. Decision-makers and PLHIV themselves have become more aware of the rights PLHIV are entitled to.

The work with PHAP also enabled the emergence of new HIV positive leaders. When the project started, only two people were able to attend meetings and events and speak on behalf of PLHIV. By the end, 15 people had enough credibility and legitimacy to represent PLHIV in the country. At the community level, through the Big Lotteryfunded project, work with health care providers and community leaders is helping them to understand why they should not stigmatise or discriminate against PLHIV. This is having a positive impact on the quality of the lives of PLHIV.

Images made by participants for a 2004 exhibition in Haiti on HIV-related stigma and discrimination ÂŠ Ken Morrison/HCP/Alliance

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY

INDIA

Summary of country programme An estimated 2.4 million people live with HIV in India. Nationally 0.29% of adults are infected, although two thirds of infections are reported in six of the country’s 29 states (Andhra Pradesh, Tamil Nadu, Maharashtra, Manipur, Nagaland and Karnataka) where the HIV prevalence is 4-5 times higher. Infection rates among sex workers remain high, and HIV remains uncontrolled among men who have sex with men (MSM), with infection rates of 7.4%. In the north eastern states, injecting drug use remains the primary risk factor for infection. UNICEF estimates that there are more than 25 million AIDS orphans in the country. The Alliance has worked in India since 1999. Supported by a national secretariat (the India HIV/ AIDS Alliance, or Alliance India) in Delhi and Linking Organisation Alliance for AIDS Action (AAA) in Volunteer from Arulagam Hospice with a first aid box arrives at her community, Andhra Pradesh, the Alliance’s presence in India Tamil Nadu, India © Gideon Mendel for the Alliance comprises five additional Linking Organisations in Andhra Pradesh, Tamil Nadu, Maharashtra and Delhi states and one state partner in Manipur, together This project, Pehchan, aims to strengthen 90 with their networks of over 100 community-based existing CBOs and establish 110 new ones for MSM, organisations. The Linking Organisations are Vasavya transgenders and hijra over five years in 17 Indian Mahila Mandali (VMM), Mamta Health Institute for states. It is the largest ever Global Fund grant for HIV Mother and Child (MAMTA), Palmyrah Workers prevention with these communities. Development Society (PWDS), LEPRA Society and the Humsafar Trust (HST); and the state partner is SD1: Scaled up quality community programmes Social Awareness Service Organisation (SASO). delivered and access to health and HIV services Alliance India facilitates inter-country learning and improved knowledge management through services including its online resource centre, SETU. 2007 2008 2009 Operations research and Number of people reached 38,463 80,311 114,235 best practice documentation through HIV prevention activities feed into its programmes and support its policy and Number of individuals diagnosed Data 51,710 61,586 and/or treated at supported STI unavailable advocacy initiatives. clinics

Activities cover prevention, Number of orphans and/ or 5,805 14,491 21,524 care, treatment and support, vulnerable children receiving care and support within the and building the capacity community of implementing NGOs and CBOs to deliver effective services. Programmes include In 2009, Alliance India achieved 36% of the UNGASS a child centered community-based care and support national target for most at risk populations reached project (CHAHA), for which Alliance India is funded by prevention programmes in Andhra Pradesh – by the Global Fund as Principal Recipient (PR). A making an impact on the epidemic in this state. focused prevention initiative funded by the Bill & Melinda Gates Foundation reaches sex workers, AAA has been implementing a focused prevention MSM and transgenders. In Manipur, a project with initiative (known as Avahan) as since 2004 in 14 injecting drug users (IDU) aims to reduce their districts across the Rayalseema and Telangana vulnerability by providing services and support, regions of Andhra Pradesh, working with 36 and is meeting the specific needs of female IDU. In implementing NGOs. A main objective of the 2010, Alliance India started an EC-funded project programme is to reduce STI prevalence among to improve the sexual and reproductive health and key populations such as sex workers and MSM. rights of young people in India and Bangladesh, Activities include reaching out to communities, focusing on marginalised youth. It has also been identifying the key populations, spreading awareness awarded a new Round 9 Global Fund grant as PR. on safer practices and linking them with the clinics Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 28

for healthcare facilities. Condom promotion, as part of the outreach strategy, includes undertaking condom demonstration, distribution and social marketing. Key population-friendly clinical services are provided through ‘Mythri’ clinics (meaning ‘friendship’ in Telugu). Attached to some of the clinics are drop-in centres for relaxation, recreation, sharing problems with peers and staff and group meetings. This has created an enabling environment for key populations to practice safe sex and adopt health seeking behaviour. Currently the project is being transitioned to the government’s State AIDS Control Societies (SACS) over five years, ensuring its sustainability. In 2000, the Alliance was the first organisation in India to pioneer and initiate an HIV home and community-based care and support programme to meet the needs of PLHIV and their families in Tamil Nadu, Andhra Pradesh and Delhi states. It scaled up to address the needs of children affected by HIV in 2001. With funding from Global Fund Round 6, an expanded child-centred project (CHAHA, meaning ‘a wish’ in Hindi) started in 2007 with Alliance India as PR together with 9 Sub-Recipients and 54 Sub-Sub-Recipients. Covering 40 districts in four states (Andhra Pradesh, Tamil Nadu, Manipur and Maharashtra), it reaches out to families and children affected by HIV, including children living with HIV and orphans and vulnerable children. Children benefit from a spectrum of services that supplement nutritional intake, help them get back to school and alleviate urgent shelter and medical needs. But CHAHA also responds to the needs of children in an integrated manner. For example, carers receive referral for treatment and adherence support, as well as support for income generation such as a small loan to start a business. If they are sick or otherwise unable to work, they benefit from emergency support. With a goal to provide a package of care and support services to 64,000 children by 2011, CHAHA is the only comprehensive care and support programme for children affected by HIV in India of this scale. It has consistently achieved the Global Fund’s A-grade rating and is in line with the strategic priorities of the National AIDS Control Programme III.

management; harm reduction; HIV prevention (especially with key populations); treatment and care; orphans and vulnerable children; HIV and sexual and reproductive health and rights. It has developed a niche in providing technical support on Global Fund mechanisms and processes. Several successful assignments have been undertaken with UN agencies including WHO, UNDP, UNICEF and the World Bank. One of the most significant, in terms of scale and scope for impact on civil society responses, was a 60-day research exercise commissioned by the WHO South East Asia Regional Office in 2009. It brought together published and unpublished observations, research and programme data on MSM and transgender populations in the region, and made specific recommendations to improve services. The Hub was selected for this work due to its links to the relevant communities, enabling it to source representative and comprehensive data, and to facilitate a community review process on the findings before the report was finalised. As part of CHAHA, various training programmes have been held for the staff of Sub-Recipients and SubSub-Recipients. These include state level training in community preparedness for antiretroviral therapy and life skills education. Outreach workers have been trained in the basics of HIV and AIDS, gender and HIV, opportunistic infection among children, treatment, addressing stigma and discrimination, home-based care, and the national framework on children and AIDS policy. Sub-Recipients and Sub-Sub-Recipients identified a particular need for advocacy training, and in response Alliance India designed a participatory three-day programme covering the concept of advocacy; the need for and benefits of advocacy; common methods; developing priorities, objectives and an action plan; use of evidence; practical advocacy skills; and working with media. Almost all participants felt that the training had been very useful, and that they had gained confidence in implementing advocacy activities and working with the government system.

SD2: Increase civil society capacity to implement effective community responses

SD3: Strengthen communities influence in national programming and in national and international policy

Alliance India hosts the South Asia Technical Support Hub. By drawing on expertise across the Alliance, it provides evidence-based, context specific and timely technical support to Alliance Linking Organisations, non-governmental organisations, communitybased organisations, umbrella organisations, co-ordinating bodies, governmental organisations, Country Coordinating Mechanisms (CCMs), UN agencies and private sector organisations. Its range of specialist areas include knowledge management and research; monitoring and evaluation; financial

CHAHA is actively involved in advocacy and policy formulation to mitigate the adverse impacts of HIV and AIDS on children. In June 2008, it held a national consultation meeting with stakeholders to disseminate the Children and AIDS Policy Framework (developed by the National AIDS Control Organisation (NACO) and the Ministry of Women and Child Development) and operational guidelines on protection, care and support. Following the national consultation, four state level consultations took place which were useful in sensitising policy

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

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makers on the need for a coordinated response, counselling for children and their caregivers, nutrition and educational support for children and reduction of stigma and discrimination.

organisations. They aim to achieve genuine dialogue and collaboration between civil society stakeholders and improved accountability and ownership of national HIV, SRH and TB policies and programmes.

Since then, Alliance India has been an active member of the National Task Force for Children Affected by AIDS (CABA) working on implementation of the Children and AIDS Policy in India. Alliance India supported NACO to conceptualise and design the CABA scheme, which is a pilot being implemented since May 2010 in 10 high prevalence districts in Andhra Pradesh, Tamilnadu, Maharashtra, Manipur, Karnataka and Delhi. Alliance India also developed an advocacy strategy to improve implementation of the Policy Framework, so that children living with and affected by HIV receive comprehensive care and support services. The Indian government has recognized the importance of CHAHA’s advocacy for children, and has partnered with the Alliance to roll out the Early Infant Diagnosis (EID) scheme.

In Manipur, ethnic conflict has exacerbated harassment and increased the barriers to health services for marginalized groups such as IDU, sex workers, MSM and PLHIV. After successful implementation of Core Advocacy Groups (CAGs) in Andhra Pradesh, Alliance India has replicated the approach in Manipur. CAGs consist primarily of community members and are supported by CBO staff and a lawyer. They aim to resolve community issues through Crisis Response Teams (CRTs), which engage in collective advocacy at community level to address violence and harassment. CRTs also challenge perceptions of marginalised communities as ‘immoral’, which often leads to human rights violations. Through the NPP, training programmes on legal literacy and on documentation skills have been conducted with communities and CRT staff. As a result, CRTs have been able to respond effectively to several cases of harassment and violence and have contributed to increased access to services.

Alliance India hosts a National Partnership Platform (NPP) which includes a broad variety of partner

Outreach workers and staff after a group meeting of the Avahan project and Alliance for AIDS Action, Towlichoki in Hyderabad, Andhra Pradesh © Satya Prabhu/Alliance India

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

INDONESIA

Indonesia has multiple regional epidemics of HIV, reflecting the country’s diverse archipelago of 17,000 islands. An epidemic among injecting drug users (IDU) overlaps with an epidemic among prisoners who use contaminated injecting equipment. According to the Integrated BioBehavioral Surveillance on HIV carried out in 2007 among most at risk populations, HIV prevalence is 10.4% among direct sex workers; 4.6% among indirect sex workers; and 24.4 % among waria (transgender). According to the UNAIDS Country Progress Report 2010, prevalence is 5.2% among men who have sex with men (MSM) and 52.4% among IDU. In the two eastern provinces of Papua and West Papua, there is a generalised HIV epidemic driven by unprotected commercial sex and concurrent sexual partnerships. Reaching affected populations can be difficult given Indonesia’s conservative social and religious environment. In 2007, national HIV prevention programmes reached around 40% of the most vulnerable groups. Alliance Linking Organisation Rumah Cemara was set up in 2003 by 5 former drug users, and joined the Alliance in 2009. It operates in West Java Province, which has one the highest levels of injecting drug use in Indonesia. It provides a range of HIV services through its three main programmes: promotion of harm reduction for IDU (in three cities), a rehabilitation centre, and peer support groups of people living with HIV (PLHIV) who have a history of drug use. Rumah Cemara’s harm reduction programme includes working with IDU in prison – offering referrals and giving information and psychosocial support. As well as directly providing services, Rumah Cemara supports more than 40 other community based organisations working with HIV positive IDU, changing and challenging the views of health service providers, law enforcement agencies and the local community.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of individuals reached through stigma and discrimination reduction initiatives

Not Alliance member

2,090

Number of individuals reached with care and support

Not Alliance member

1,537

Through football, Rumah Cemara has been winning tournaments and breaking down HIV-related stigma © Rumah Cemara

A Harm Reduction team reaches out to PLHIV to help prevent transmission of the virus, and to people who have not yet contracted HIV but who are at high risk of infection. Primarily this includes communities of IDU and sex workers, who benefit from a clean needle exchange programme and free condom distribution. In 2009 over 7,000 needles and 2,730 condoms were distributed, reaching roughly 600 IDU. Although clean needles can be obtained from clinics, users are reluctant to go there as they are hassled and intimidated. Rumah Cemara’s support groups provide care and support to PLHIV, and meet on a regular basis. One group based at Banceuy Prison is very important for its 22 members, being a place where they are free to share their problems and experiences without judgment. Belonging to the group has helped them to become more confident. They do peer outreach across the prison, encouraging inmates to take an HIV test and join the group for support. As information has spread, people understand more and the group has gained respect. It even developed a theatre show about stigma and discrimination, based on the personal experiences and discussions of the group, which was performed for people outside the prison as well. The show was successful in reducing stigma and discrimination. Rumah Cemara’s Treatment Centre, with capacity for around 25-30 people at any one time, combines the Theraputic Community and Twelve Steps models with both a peer and professional approach. The Treatment Centre works closely with doctors, psychologists and psychiatrists. Residents undergo 6 months of treatment, including both in-patient and aftercare periods. The programme follows up people’s detox with support to work and live at

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the centre and provision of psychosocial support. Between 2003 and end of 2009, 200 residents graduated successfully from the programme. A mobile health clinic in 2009 provided basic healthcare services to 4,300 people living in rural areas who otherwise have no access to health centres. In order to reach the general public, Rumah Cemara delivers HIV interventions through mainstream media such as concerts, football matches, art exhibitions and testimonials to educate the public about drug addiction and HIV. Rumah Cemara is also a national organiser of the Homeless World Cup. Rumah Cemara, which has won the National Cup of National Narcotics Board Football Tournament in the last two consecutive years (2009 and 2010), is now preparing to form the first PLHIV football team to participate in Homeless World Cup 2011 in Paris. Recently, Rumah Cemara launched a community fundraising campaign called ‘For Life’ in order to increase support from university students, the artist community and companies. ‘For Life’ has already been launched successfully amongst university students in Bandung who are expected to develop their own campus-based fundraising and informational programmes responding to the HIV in Indonesia. Similar relationships with business leaders are planned.

SD2: Increase civil society capacity to implement effective community responses Rumah Cemara provides organisational and programmatic technical support to build its partners’ capacity. For example, through training around organisational management, Garut Family Care was able to develop a logical strategic planning model and a well functioning structure. Rumah Cemara also helped it to define clear roles for staff and volunteers, to avoid miscommunication and misunderstanding. A newly formed peer support group, Cianjur Plus Support, was helped to develop a vision and mission, and establish an appropriate organisational structure. Additionally in 2008, Rumah Cemara initiated the West Java Umbrella Group (later renamed as West Java Initiator Group) with support from Spiritia Foundation. The Initiator Group encourages PLHIV to form a peer support group in their areas, and provides technical support for the groups to develop. This was due to the increasing numbers of PLHIV in West Java and increasing need for care and support.

for Indonesia (HCPI), developed the skills of 20 representatives of peer support groups in communications. The participants learned how to develop relations with the media, and following the training were given the task of organising radio talk shows in their city. A proposal writing training, again involving 20 participants, addressed the high level of dependency of the groups on Rumah Cemara as a funding source. The training involved speakers from donor organisations such as Spiritia Foundation, HCPI and the Media Officer of West Java Aids Commission. At the end of the training, all the participants felt that they had a good understanding and ability to prepare proposals. They produced proposal drafts ready to be submitted to potential funding sources. Due to differences in availability of services within West Java, there is a need for the voice of people living with HIV to be heard by local stakeholders and institutions responsible for HIV interventions. However, a lack of information about the roles and functions of stakeholders often led to groups focusing on the wrong targets. A three-day advocacy training was provided for representatives of 17 peer support groups, involving speakers and facilitators from Rumah Cemara and Spiritia Foundation. The aim was to enable peer support groups to advocate effectively for changes in local HIV interventions, and be able to work well with local stakeholders.

SD3: Strengthen communities influence in national programming and in national and international policy Rumah Cemara maintains good relationships with local government authorities and prison agencies in order to ensure that the perspectives of civil society and marginalised populations are reflected in local and provincial policy discussions. By passing on issues identified by its constituent PLHIV community based organistions to the National Network of PLHIV Support Groups, Rumah Cemara feeds into national policy discussions taking place on technical working groups and with the Ministry of Health. To ensure that the voices of PLHIV influence the design and implementation of HIV/AIDS interventions, Rumah Cemara emphasises the meaningful involvement of people living with HIV and AIDS (MIPA) at every level of their work, particularly in PLHIV involvement as staff, peer educators and other service providers. In this way, it is able to strengthen the role of PLHIV in the HIV response so that they are more visible, able to speak out about their experiences, and well positioned to feed into policy discussions.

A number of other trainings have successfully increased partners’ skills in a range of areas. One training, delivered with the West Java Aids Commission and the HIV Cooperation Program

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

KENYA

Kenya has a mixed HIV epidemic, affecting both most-at-risk populations (MARPs) and the general population. An estimated 1.3 to 1.6 million people are living with HIV. HIV prevalence has been declining over the past two decades, with the adult prevalence rate going from 10% in 1997 to 6.3% in 2009. Recent surveys show that the prevalence rate has now stabilised. MARPs in Kenya include female sex workers and their clients, men who have sex with men (MSM) and injecting drug users. Most new infections (44%) occur among men and women in a union or regular partnerships; MSM and prisoners account for about 15% of new infections and injecting drug use accounts for 3.8%. Around 2.4 million Kenyan children have lost a parent to AIDS. Although HIV testing has more than doubled in recent years, 80% of infected Kenyan adults do not know their status. Antiretroviral therapy is provided free in Kenya but supplementary expenses such as nutrition laboratory user fees and transport are a barrier to treatment and adherence. Kenya AIDS NGOs Consortium (KANCO) became an Alliance Linking Organisation in March 2009 and has quickly become an influential member of the Alliance family, providing guidance in policy and advocacy and development of technical support systems. It builds the capacity of civil society organisations (CSOs) to strengthen their organisational systems and technical expertise on HIV prevention, care and support, TB and reproductive health. Key areas include anti-stigma activities, advocating and engaging in policy discussions around gender and human rights issues and ensuring that people living with HIV (PLHIV) are fully engaged in the HIV response. It sits on national policy and coordination bodies working with policy makers and ministries to increase access to HIV and AIDS services. KANCO is a Sub-Recipient for Global Fund HIV Round 7 and TB Round 9.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

Not Alliance member

417,408

Number of individuals reached through stigma and discrimination reduction initiatives

Not Alliance member

105,520

A member of GALCK, an association of men who have sex with men in Kenya, poses behind words he wants to declare. For safety reasons he wanted to conceal his identity. Supported by Alliance Linking Organisation, KANCO. ÂŠ Nell Freeman for the Alliance

In 2009, KANCO achieved 35% of the UNGASS national target for most at risk populations reached by prevention programmes â&#x20AC;&#x201C; making an impact on the national epidemic in Kenya. KANCO has funded 61 organisations to implement programmes on HIV prevention, care and support, resulting in increased programming focused on MARPs. In 2009, KANCO reached 172,890 people with HIV prevention messages, 171,067 through treatment support and it counselled and tested 36,727 people for HIV. Its work with MARPs includes supporting MSM groups such as Ishtar. Ishtar is a health and social wellbeing organisation for MSM offering voluntary counselling and testing services; open forums and peer education; condoms and lube, together with safer sex information; and post test clubs. These are the only specific MSM health services in Nairobi. In Mombasa, KANCO coordinates the community component of a joint project with the Kenya Medical Research Institute (KEMRI) and the University of Washington. The community component of the project focuses on education and advocacy among MSM. The centre there provides outreach in night clubs, distributes condoms and water-based lubricant and also provides networking opportunities for groups working with MSM in the region. With funding from PEPFAR, KANCO coordinates a Drop-in Centre (DIC) for commercial sex workers (many of whom are young women). The DIC offers a forum for the sex workers to meet, share their experiences, offer support to one another and access resources, such as information education and communication (IEC) materials, trainings and

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small grants. Furthermore, DIC clients are able to access a free clinic for treatment and prevention of STIs, including HIV. The DIC, located in Ongata Rongai, now serves over 1,500 sex workers. To realise the goal of universal access to prevention, treatment, care and support as stipulated in the national strategic plan (KNASP III), KANCO has continuously expanded efforts to work not only with civil society organisations and the government, but also the private sector. The most successful partnership has been with Vestergaad Frandsen, the manufacturers of the ‘care pack’ package. An example is the integrated public health campaign launched in Lurambi District in 2008. As an incentive for their participation in a voluntary HIV counselling and testing programme, local residents were offered a CarePack® of preventive interventions (including a water filter, anti-malaria bed net, condoms and educational material). The aim was to tackle both the low testing rate and social stigma attached to testing and HIV positive people in an innovative way. By providing the tools to prevent diarrheal disease, HIV infection, STIs and malaria, this project received an overwhelmingly positive response from the community. More than 80% of the target population was counselled and tested for HIV over seven days, and more than 47,000 CarePacks® were distributed. KANCO ensured that people who tested HIV positive were referred for care and treatment. Due to the success of this partnership, the government of Kenya is planning to replicate the model across the entire western province as a demonstration and finally roll out the campaign in the entire country.

SD2: Increase civil society capacity to implement effective community responses Building on the historical successes of increased engagement of PLHIV, KANCO has mentored TB patients to become advocates through training and linking them into existing technical support and mechanisms such as defaulter tracing, community outreach and treatment support and referrals. One of the positive impacts of TB patient advocates has been in the area of multi-drug resistant (MDR) TB treatment. TB patient advocates are able to intervene early with newly diagnosed patients, and support them so that the necessity for MDR treatment, which is very challenging, is minimised. To date, KANCO have trained 260 former and current TB patients to be advocates. The National Network of PLHIV in Kenya (NEPHAK) encountered challenges which seriously affected its ability to function effectively during 2007-2009. Following an institutional capacity assessment, KANCO undertook activities towards the institutional strengthening of NEPHAK based on the recommendations of the assessment. This included review and development of a new constitution and of

new finance and human resources manuals; regional forums for the NEPHAK membership to nominate delegates to the National Delegates Conference (NDC); Board members induction and training; and development of strategic plan for NEPHAK. KANCO successfully facilitated the 3rd NDC in November 2009, which brought together key policy makers and over 150 PLHIV. The conference saw NEPHAK spring back to claim its space in national HIV policy issues and a new Board was elected during the conference to steer the network towards its mandate. To enable the in-coming Board start strongly, a four-day training was held with the support of KANCO and the Alliance in December 2009. The objectives were to orient the Board on current programmes, organisational strengths, successes and challenges, Board roles, responsibilities and operations, including meetings and resolutions; financial management, policies and procedures; and monitoring Board performance. KANCO has run training sessions for CSOs on budgeting and effective participation in national level open budget fora. As a result, more CSOs participate in the national budget tracking initiative which has led to allocation of resources for procurement of antiretroviral drugs by the government.

SD3: Strengthen communities influence in national programming and in national and international policy KANCO focuses its advocacy efforts at the national level, leveraging the grassroots experience of its members. In recent years, it has focused on promoting the voice of vulnerable and marginalised communities in the national policy formulation process and strategic planning. For example, the National AIDS Control Council’s (NACC) previous strategic plan (KNASP II) had little mention of MARPs. Through its wide network of CSOs, KANCO advocated for the formation of a technical working group and a taskforce on vulnerable groups within the NACC. This led to the meaningful inclusion of these groups in the KNASP III (2009-2013), with annual targets set to monitor progress. Supported by ICASO (International Council of AIDS Service Organizations) through AfriCASO (African Council of AIDS Service Organizations), KANCO’s advocacy on prevention has contributed to raising its profile and rethinking prevention in the wake of rising HIV incidences. Outcomes include the institutionalisation of an HIV prevention summit, the formation of a high level prevention task force hosted under NACC and a national programme for MARPs which is led by the National AIDS/STD Control Programme (NASCOP). In Kenya, there is often a lack of media interest, facts and correct information about TB/HIV. KANCO has been addressing this by supporting its members to

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COUNTRY STUDY 34

train journalists at grassroots level. As a result, TB coverage increased nationally, as well as the use of media to advocate for TB and HIV. KANCO has also mobilised people to demonstrate on TB/HIV issues. For example, at the 2009 Malaria Conference in Nairobi, a demonstration was held to protest against the reduction in funds available to Africa due to the global economic downturn. PLHIV marched through the city centre to remind donors of their commitments. The march was covered by CNN live and featured in the Wall Street Journal. KANCO also helped to facilitate a postcard campaign for Kenyans to write to President Obama about HIV, TB and malaria, as a reminder of his obligations. KANCO works to create links with government bodies involved in budgeting to try to influence increased funds for TB and for integrated TB/ HIV activities. At first the Division of Leprosy, Tuberculosis and Lung Disease (DLTLD) was afraid that CSOs would use information and statistics to

work against them. However, CSOs now enjoy a close partnership with DLTLD. This has enabled them to access the vital information needed in order to effectively inform their advocacy efforts. Another benefit has been increased involvement of CSOs in national budgeting, as well as CSO understanding of the budgeting process and the mechanisms that exist for their involvement in it. A National Partnership Platform (NPP), a countrybased platform spearheading information exchange, dialogue and advocacy around HIV and TB, is in the process of being established. A country mapping assessment has been conducted and potential partners have been introduced to the NPP model and concept, leading to their participation in developing a vision for the NPP in Kenya. A partners meeting has successfully nominated the host organisations, the NPP chair and initiated the process of recruiting a NPP Coordinator.

Stephen and his wife Susan are members of a post-HIV test club at the Ray drop-in centre at Rongai, near Nairobi. The centre offers holistic care including testing for HIV, tuberculosis and pregnancy, other sexual and reproductive health services, and antiretroviral treatment supervision including prevention of mother-to-child HIV transmission ÂŠ Nell Freeman for the Alliance

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Kyrgyzstan

HIV arrived relatively recently in the Kyrgyz Republic – the first official diagnosis was made in 1997. Official data indicates that most people living with HIV are in Chui, Osh and Jalalabat provinces and Bishkek City. Poverty and unemployment – alongside high levels of injecting drug use – have been driving forces in the spread of HIV. Most people living with HIV (PLHIV) are injecting drug users, but recent data suggests that infections are increasing rapidly among sexual partners of drug users, and probably among men who have sex with men (MSM). The Alliance has worked with Anti-AIDS Association (AAA) since 2005 and it became an Alliance Linking Organisation at the start of 2009. Since 2007, it has been funded by the World Bank to implement the Central Asia AIDS Control Project (CAAP), to expand access to HIV prevention, care and support services in the four Central Asian countries of Kyrgyzstan, Kazakhstan, Uzbekistan and Tajikistan. The project also aims to strengthen the capacity of people living with and affected by HIV and AIDS and their involvement in programming and policy development. In addition, AAA is the lead SubRecipient of a Global Fund Round 7 grant, which is focused on scaling up the provision of prevention, treatment and care services to those in the poorest communities and those most vulnerable to HIV (MSM and sex workers).

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

Data unavailable

7,261

Number of people reached with VCT interventions

Data unavailable

2,280

Since 2003, AAA has been a national leader in HIV prevention among sex workers, and since 2008, in HIV prevention among among MSM. AAA’s Global Fund project focuses on sex workers, their clients, and MSM. It supports 11 sub-grantees, mostly community based organisations (CBOs), which provide a basic package of services to their communities – information, education, communication (IEC); condom promotion; access to STI diagnostics and treatment – as well as other key services such as HIV counselling, sexual and reproductive health counselling; primary medical care; legal and psychological support.

The project operates through peer outreach and the development of effective referral systems. Qualitative research was conducted in order to better understand the situation of sex workers and MSM. Thoughout the project, sex workers and MSM play a key participatory role in needs assessment, project design, implementation and evaluation. The CAAP project has increased access to HIV and AIDS prevention, care and support services for people living with and affected by HIV and AIDS. In 2007-2008 the Alliance was the prime recipient of CAAP Round 1, implemented through national partner organisations in Kazakhstan, Kyrgyzstan and Tajikistan, which aimed at developing PLHIV organisations and care and support services in the four countries. In 2009, in the third round of its subgranting programme, CAAP awarded AAA a $1.26 million grant to support continuation of the Round 1 activities. For voluntary testing and counselling (VCT), the so-called ‘3 steps model’ was developed and successfully implemented, in a country where access to counselling remains very limited. In Kyrgyzstan, NGOs can only provide pre-test counselling as part of government VCT programmes. These government programmes aim to provide post-test counselling themselves, and do not refer clients to NGOs for this. Therefore AAA aims to strengthen pre-test counselling provided by community groups and CBOs as much as possible, through peer counselling and by developing a robust system of referrals at that stage – initially to medical doctors or psychologists based in NGOs, who are then able to refer clients to a government-run VCT clinic as necessary. The ‘3 steps model’ includes: (1) counselling provided by trained peers and referral to a professional counsellor; (2) professional counselling and referral to clinics; (3) professional counselling provided in clinics by medical staff. Through this approach, more than 70% of sex workers have returned to clinics to be informed about their test results, which is a very high percentage for Kyrgyzstan.

SD2: Increase civil society capacity to implement effective community responses Since 2006, AAA has supported CBOs and PLHIV groups to provide services. It has produced information materials and guidelines, for example, Guidelines on HIV-related Stigma and Guidelines for trainers on Living with HIV, including a special section on HIV/TB. Guidelines on technical support have helped recipient organisations to clarify roles and responsibilities, ensuring that the support they receive is effective. In collaboration with the Kazakhstan Union of PLHIV (KU) and

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COUNTRY STUDY 36

colleagues from Uzbekistan, AAA developed two sets of programme standards (on palliative care and on self-support groups) on the basis of WHO recommendations. For Tais Plus (a sex worker organisation), Terra Sana (a PLHIV organisation) and Gender Vector (an organisation of gay people), AAA’s support enabled them to overcome some crucial barriers. For example, AAA helped them to establish financial management systems to comply with Kyrgyz law and donor requirements, and to improve the quality of their reporting and their monitoring and documentation systems. Administrative and field staff were selected carefully and trained properly. As a result, these organisations were better able to attract funds and have become more sustainable. Through the CAAP project, AAA and KU manage onward granting and technical support programmes for 26 PLHIV organisations and groups. AAA and KU support grant recipients in their assessment of PLHIV needs and the design as well as the implementation of their programmes. This mechanism of channelling support to community-based service providers has significantly increased the access of PLHIV to vital information and psychosocial support services. In several project sites, no care and support was previously available. For many beneficiaries, this is an entry point to life-saving antiretroviral treatment. In addition to existing organisations, through CAAP eight new groups of PLHIV were incorporated as legal Non-Governmental organisations (NGOs) and have become providers of community-based care and support services. Even in Uzbekistan, where the process of NGO official registration is not easy, AAA found a way to support local PLHIV groups which now work in good partnership with government facilities.

SD3: Strengthen communities influence in national programming and in national and international policy PLHIV representatives in three Central Asian countries are Global Fund Country Coordination Mechanism (CCM) members – Nurali Amanzholov from KU (Kazakhstan); Evgeniya Kalinichenko from Terra Sana (Kyrgyzstan); and Pulod Djamolov from SPIN Plus (Tajikistan). All these organisations are

AAA’s subgrantees. Also in Kyrgyzstan, Shakhnaz Islamova from Tais Plus was elected as an alternative member of the CCM as a sex worker representative. As the Deputy of the CCM Chair and with strong support from AAA, Evgeniya Kalinichenko developed Terms of Reference for PLHIV representation on the CCM, with a special section on accountability. This document was recommended as a template to all Central Asian CCM members. Currently Evgeniya, with AAA support, is part of the National Working Group on CCM reform in Kyrgyzstan and strongly promotes PLHIV and other vulnerable groups’ interests through this forum. For the first time in Kyrgyzstan, the country application to the Global Fund Round was based on wide and direct consultations with sex workers, MSM and PLHIV. In particular, PLHIV representatives promoted the inclusion of home-based palliative care, and sex workers promoted response to police pressure which decreases access to prevention programmes for sex workers. In 2010, there was also wide consultation with sex workers, MSM, injecting drug users, prisoners, and PLHIV on the impact of the International AIDS Conference in Vienna (AIDS 2010). Through 50 questionnaires and five focus groups, people expressed their opinions and their expectations for the next International AIDS Conference. The information collected was summarised in a report and submitted to the AIDS 2010 Secretariat for inclusion in the Evaluation Report. As lead Sub-Recipient of Global Fund Round 7, AAA has helped build capacity among civil society organisations to participate and meaningfully contribute to national decisions on policies affecting the human rights of most affected populations and their ability to access comprehensive health care services. It is developing and strengthening a network of leabian, gay, bisexual and transgender (LGBT) organisations in the region, through which to lobby government officials and policy makers. In 2009, AAA coordinated a national meeting of community-based LGBT organisations to discuss the outcomes of their capacity self-assessments and to discuss next steps towards establishment of the network.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Madagascar

Although HIV prevalence in Madagascar is quite low compared to other African countries (0.13%), there is evidence of much higher rates among vulnerable groups such as sex workers, men who have sex with men (MSM), youth and drug users. The Alliance established a Country Office, Alliance Madagascar, in 2003. As one of the first organisations to focus on prevention of HIV and sexually transmitted infections with high risk population groups, it successfully raised the profile of these vulnerable populations and put them at the heart of the country’s HIV response. It conducted a number of studies on vulnerable populations and sex work in Madagascar, and supported the development of the national five year action plan for vulnerable populations in collaboration with UNAIDS/ UNDP. The programme ended in October 2009 after eight successful years, passing on a well established and growing number of national networks working on HIV. The end of the programme does not mean the end of this work, as the thriving networks set up by the Alliance continue to take forward the community response to HIV, with many also continuing to receive support from other partners and donors.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved Alliance Madagascar’s partner FIMIZORE developed a new ‘red health card’ and trained sex workers on how to use it and the importance of regular health checks. This resulted in an increase in the number of sex workers voluntarily accessing health services. The language of universal human rights proved to be a useful approach in the prevention of STI and HIV infection, as sex workers are more willing to take care of their health when they are not forced to do so and when they understand the benefits to be gained.

2007

2008

2009

Number of people reached through HIV prevention activities

32,407

56,661

Programme ended October 2009

Number of individuals diagnosed and/or treated at supported STI clinics

Data unavailable

49,850

Programme ended October 2009

A member of the local sex workers cooperative MAMI in the centre of Diego, Madagascar. The Alliance facillitated the formation of sex workers cooperatives with aim of spreading HIV prevention messages and providing mutual social, professional and emotional support © Nell Freeman for the Alliance

As half of the population of Madagascar is young, the Alliance developed a programme focused on young people in the cities of Antsiranana, Nosy Be, Sainte Marie, Toamasina, Mahajanga, Antananarivo, Antsirabe, Fianarantsoa and Toliara Tolagnaro. It started in 2006 and continued for a period of three years. The main purpose was to contribute to achieving zero STI among youth in the project sites by promoting risk free behaviour, particularly the delay of sexual debut and the use of condoms during occasional sexual relations. As a result of the project, at least 70,000 young people aged 10 to 24 years directly benefited from education and skills building to ensure their sexual health. The project provided an original approach to the issues of sexual and reproductive health of young people, based on partnership with local institutions and national partners and stakeholders, and on a meaningful involvement of youth in problem analysis, project implementation and monitoring and evaluation.

SD2: Increase civil society capacity to implement effective community responses Alliance Madagascar was at the centre of the HIV response in the country, and facilitated the development of major networks of marginalised and vulnerable groups including people living with HIV (PLHIV), vulnerable youth, MSM, and sex workers. With the financial and programmatic support of the Alliance, these networks grew and strengthened over the years, and empowered their members to play an effective role in the national response. In 2008, over 80 organisations and networks were provided with organisational and programmatic support.

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COUNTRY STUDY 38

For example, the Alliance provided financial and organisational support to FIMIZORE, a network of sex workers organisations, since its creation in 2005. FIMIZORE works in 10 of Madagascar’s largest cities to prevent HIV and reduce the stigma and human rights abuses that many sex workers face. Personal and professional development workshops facilitated by the Alliance gave FIMIZORE members new skills including improved knowledge of STI and HIV prevention; decision-making, advocacy and leadership; financial management; and peer education. Members also received training in antistigma and discrimination. FIMIZORE gained the recognition and respect of stakeholders at national and international levels. Its representatives are now consistently invited to civil society meetings and have direct access to decision making bodies such as the National AIDS Council (CNLS). FIMIZORE also joined the national Information, Education and Communication (IEC) task force, which is responsible for approving all new IEC materials. In July 2008, FIMIZORE was awarded the prestigious UNAIDS Red Ribbon award in recognition of their outstanding community leadership and action on AIDS. Through the project to improve the sexual and reproductive health of young people, at least 65 NGOs and associations and 30 service providers developed greater ability to promote sexual and reproductive health and provide related services to youth, particularly to priority groups. Trainings were provided on education through media; project management; monitoring and evaluation; facilitation of participatory group discussions; and increasing knowledge of sexual and reproductive health. Also, the establishment of a Youth Platform to represent youth in the region of Vakinankaratra was made possible through technical and financial support from the Alliance.

SD3: Strengthen communities influence in national programming and in national and international policy Alliance Madagascar supported national networks of people living with HIV and sex workers to take action against stigma and discrimination. The networks compiled a record of cases of abuse and used this information to advocate for better access to health centres and employment opportunities. For example, research and documentation by a legal practitioner on the laws affecting sex work and HIV/ AIDS in Madagascar was used by the Alliance and FIMIZORE to inform sex workers of their rights. As a result, sex workers were more likely to report cases of abuse. The Alliance also documented evidence of abuse and violence towards sex workers and presented it to the relevant authorities in the law enforcement and medical sectors. With support from the Alliance, FIMIZORE and its member organisations lobbied decision-makers and local leaders, and negotiated with service providers for improved health services and a legal framework for sex workers. One important change was the abolition in Antananarivo (the capital) and Diégo-Suarez of the ‘white card’ for sex workers, which was previously used as an STI monitoring tool and was considered to be a system of external control rather than for health promotion.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY

mexico

Summary of country programme Mexico accounts for around 11% of those living with HIV in Latin America – an estimated 200,000 people. Although there are signs of increasing risk of HIV infection among women, men account for around 77% of cases. HIV prevalence among men who have sex with men (MSM) is estimated to be as high as 15.2%. HIV-related stigma and discrimination has a serious impact in Mexico. Sex workers suffer humiliation when seeking medical care; people living with HIV (PLHIV) are denied jobs; gay men are harassed by the police and transgender people are targets of violence. Such attitudes towards key population groups greatly hinder the national response to HIV. Founded in 1981, Linking Organisation Colectivo Sol has a long history of initiatives having social and political impact on efforts to combat AIDS and defend diversity in Mexico. Since 1998, the Alliance has worked with Colectivo Sol to reduce HIV-related stigma and discrimination in the central states of Mexico. These states have the weakest civil society response to HIV within a highly conservative social context, which limits access to HIV prevention and care. In 2005, Colectivo Sol began the Vida Digna (Life with Dignity) project, addressing HIV-related stigma and discrimination experienced by key populations in five cities in the four central states: Aguascalientes, Leon, Irapuato, Queretaro and San Luis Potosi. This project was sponsored by ViiV Healthcare’s Positive Action programme from 2005 to 2011. The Vida Digna strategy has also been implemented in El Salvador, and with further support from Positive Action, it is now expanding to five countries in Central America through the networks ReTraSex and RedLacTrans (2011–2013).

2007

2008

2009

Number of people reached through HIV prevention activities

1,849

698

4,094

Number of individuals reached through stigma and discrimination reduction initiatives

109

1,499

1,832

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved Colectivo Sol addressed the problem of lack of access to information and prevention services in remote communities through its Condomobile, an adapted flat bed truck that distributes information, as well as providing prevention services, condoms and educational workshops. The Condomobile

Jenny, a transgender leader and sex worker in San Luis Potosi, Mexico, visiting a bar where she distributes condoms, lubricants and prevention materials to her peers. FID, Jenny’s organisation, also lobbies to avoid discrimination and violence against transgender sex workers © Chris Martin for Colectivo Sol

has travelled 100,000 kilometres and has visited 25 states in Mexico and more than 40 towns since 1998. The project was designed as part of a prevention initiative to combat STI, HIV and unplanned pregnancies among young people and to encourage the acceptance and correct use of female and male condoms and water based lubricants. High levels of interaction with local communities were achieved by putting up an exhibition stand with a large inflatable condom next to it in each locality. These were accompanied by video debates, prevention posters, street theatre, educational games, short workshops on safer sex and individual counselling sessions. Around 1.2 million condoms have been distributed and more than 100,000 condoms were sold at low cost. The originality of the intervention allowed access to communities which had not previously been a priority for prevention and information work. The Mexican Health Department subsequently developed a similar project known as the Prevenmóviles, and the Condomobile team has provided training for the Prevenmóviles. The Vida Digna project, which ended in 2009, contributed to reducing HIV and AIDS-related stigma and discrimination experienced by key populations (sex workers, transgender people, MSM, injecting drug users and PLHIV). The project built the capacity of and granted funds to 13 communitybased and civil society partners to design and implement projects on information, education and communication with the media and the general population to reduce stigma and discrimination. Their activities included, for example: outreach to female and transgender sex workers to promote sexual health, human rights and prevention of HIV

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY and STI; harm reduction services for injecting drug users; provision of testing services, primary care and referral for HIV and STI; information, training and recreational and cultural activities at a community centre for lesbian, gay, bisexual and transgender (LGBT) populations in Aguascalientes; and production of a documentary video ‘Voices against discrimination’. Public events were also carried out, such as marches, information days and forums for debate against stigma and discrimination, with the public in general and with decision makers. The final two years of the project included additional work to raise awareness of stigma and discrimination among health service providers. This improved the quality of services such as early testing for STI and HIV, referral and care for STI and HIV, and access to antiretroviral treatment. It also increased demand for these services among key populations who were not previously accessing them. The Vida Digna project was presented at two national conferences on HIV and the International AIDS Conference in Mexico. An evaluation found that the implementing partners and health service providers highly valued its contribution to reducing stigma and discrimination. As the concept and model has been so successful in Mexico, it has been transferred to El Salvador and is now being implemented by Alliance partner organisation Atlacatl.

SD2: Increase civil society capacity to implement effective community responses The main purpose of the Vida Digna project was to strengthen civil society to respond to stigma and discrimination. As a result, it has helped key populations to build networks. It has strengthened the capacity of organisations to design and implement projects, as well as their organisational and administrative capacity and their grant management. This was achieved through periodical technical assistance visits to each partner organisation and capacity building workshops by Colectivo Sol. Workshop topics included participatory community assessment on stigma and discrimination; project design; case studies; participatory tools for health promotion; strategic planning; resource mobilisation and external relations; participatory methodologies; monitoring and evaluation; and administrative and financial management. Through the project, five new community based organisations were successfully created to represent transgenders, gay people and PLHIV, despite stigma against these populations. For example, partner Fortaleciendo la Diversidad (FID) was the first transgender organisation in the city of San Luis Potosi. FID’s innovative work was recognised when it won a UNAIDS Red Ribbon award at the 2008

International AIDS Conference. In 2010 another partner Ser Gay, which works to expose injustice and document human rights violations towards sexual minorities and marginalised groups in Aguascalientes, was also recognised with the Red Ribbon award for their work in human rights. An external evaluation found that Vida Digna had successfully contributed to improving the key skills needed by organisations to tackle stigma and discrimination, with particularly strong results in political advocacy – as can be seen in the organisations’ increased visibility and improved positioning in decision making areas. The organisations also became more established, developed a better ability to design and carry out stigma and discrimination reduction projects, and better infrastructure and internal processes. By securing official registration, they were able to access funding from the government, which had not been possible before. A USAID-funded project, which started in January 2010, aims to strengthen the programmatic, management and administrative capacities of organisations working on HIV prevention among MSM and transgenders, and to increase their resource mobilisation capacity. With additional funding from the national government’s AIDS programme, Colectivo Sol has been able to extend the project to organisations funded by the government. Through these sources, the project is reaching a total of 72 civil society organisations in 29 cities. They have benefited from horizontal exchange workshops on focused prevention strategies, and from organisational strengthening workshops covering organisational strategy, planning, sustainability and knowledge sharing. Technical assistance visits from Colectivo Sol to each partner have further helped to address needs, for example revising operational and strategic plans; developing monitoring and evaluation strategies; and developing resource mobilisation plans.

SD3: Strengthen communities influence in national programming and in national and international policy In Mexico’s regions, the State HIV and AIDS Committees (Consejo Estatal de VIH/SIDA, COESIDA) are key decision-making bodies where policy and programme priorities are defined. They are made up of representatives from the health, education and labour sectors, academia, the armed forces and civil society and should ensure the participation of at least one person living with HIV. When Vida Digna started, only one partner organisation was represented in these decisionmaking bodies. Due to the hard work, resilience and creativity of the project partners, the number participating in these important committees rose to 11. Also, in 2009, Jessica Bear from FID

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY and Julia Elizalde from Ser Gay, were selected as representatives of the transgender and gay populations respectively on the National Committee on Prevention and Control of HIV/AIDS. This has provided a valuable opportunity to position the key issues and improve the response to HIV-related stigma and discrimination. Recognising the role that journalists can play as agents of change in the fight against stigma and discrimination towards key populations, partner organisation Aquesex implemented a strategy to reduce the stigma and discrimination characterising media representation of issues relating to health, sexuality and HIV. This included training and raising awareness among media professionals; regular bulletins with objective and up-to-date information sent to contacts on an electronic network (known as Sexuanet); working together with other Vida Digna partners to monitor stigmatising or discriminatory articles in 16 newspapers; and writing letters to newspapers that publish information leading to negative perceptions or stigmatising or discriminatory attitudes. Aquesex’s work has resulted in regular exchanges with the media, which has allowed them to gain credibility, position themselves as a key reference and find allies. Colectivo Sol held workshops for health service providers, which concentrated on conceptual and practical issues relating to stigma and discrimination. The service providers were given the opportunity

to reflect on how their role can contribute to stigma and discrimination, and identify actions to avoid reproducing stigma in their work. A total of 605 health workers were reached and Colectivo Sol are currently about to sign contracts with the State Prevention Programmes in Queretaro and Puebla, to raise awareness among health service providers in those states. Workshops for the police successfully transformed attitudes. A member of FID commented, ‘As the workshop progressed, we were able to get them to understand that we are people. Then they asked for more workshops. We were so successful in making them aware of the issues that now we are not given such a hard time, far from it’. Since working with the police, the situation has improved considerably and there are fewer cases of physical aggression and harassment. In addition, project partners carried out a number of specific advocacy activities to improve the circumstances of key populations. For example, FID met with the Head of the State HIV programme to discuss the need of sex workers and transgender people to be able to access the Seguro Popular (social security). Fundacion Vihdha lobbied the Secretariat of Labour to employ PLHIV, which they subsequently did. They also worked to influence local business people to open up jobs for PLHIV.

PAGSIDA © Arturo Ramos Guerrero

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

mongolia

HIV prevalence in Mongolia is less than 0.1% but the number of new infections has risen significantly in recent years. The epidemic is mainly concentrated in two populations: female sex workers and men who have sex with men (MSM), who represent 11% and 65% of all cases respectively. Prevention efforts are hampered by criminalisation of sex work and discrimination against MSM. There is also an urgent need to address other sexual and reproductive health issues in Mongolia. The country has consistently high rates of sexually transmitted infections (STIs) among the general population, indicating patterns of sexual behaviour that could fuel the spread of HIV. In 2007, gonorrhea, syphilis and trichomoniasis together accounted for 30% of all communicable diseases. The National AIDS Foundation (NAF) joined the Alliance as a Linking Organisation in 2000, and has since provided support to more than 70 community based organisations. Currently, it supports activities in 10 out of 21 provinces in Mongolia considered to be most vulnerable to HIV, including Ulaanbaatar city and the border regions of Darkhan-Uul, Orkhon, Selenge, Dornogovi, Khovd and Dornod. Mongolia has a National Strategic Plan for 2010-2015 to fight HIV and STI, and NAF’s strategy is aligned with this. It seeks to generate interest and action on HIV within communities and to ensure that programmes are designed to meet their needs, focusing particularly on vulnerable and marginalised populations such as sex workers, MSM, injecting drug users, prisoners and cross-border traders. In Rounds 2, 5 and 7, NAF has been a lead Sub Recipient to the Global Fund. Funds from Round 7 have supported the scale up of universal access for vulnerable populations.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of people reached through HIV prevention activities

10,685

19,117

20,895

Number of individuals tested for HIV at VCT centres supported by the organisation

Data unavailable

539

NAF directly implements a number of projects, including running a mobile unit for voluntary counselling and HIV/STI testing (VCT). Being mobile, the service offers a flexible and accessible option for people who are hard to reach or cannot access existing services, including MSM, female sex

A mobile HIV support group © NAF

workers and artisanal miners. It has links to health clinics, so individuals are referred for treatment according to their needs. On one occasion, NAF provided VCT to passengers on a train while en route to a meeting in the south of the country, as an innovative way to reach its target population. Support groups for vulnerable populations educate and inform them about health and avoiding risky behaviour. In addition, NAF runs family support groups with family members of MSM and injecting drug users, encouraging them to create a supportive environment within the family. With NAF’s mentoring, financial management and technical support, many of these support groups have become independent NGOs implementing targeted prevention and support programmes within the community. Among these are two MSM and three sex worker organisations. A peer education programme targets MSM, sex workers, mobile populations and artisanal miners. It disseminates accurate information and delivers practical skills for preventing HIV and STI infection. More than 6,000 peer educators have been trained. In June 2010, three MSM partner organisations in Ulaanbaatar hosted a fashion show combined with a social fundraising event. The event also provided a relaxed and safe atmosphere where peer educators and outreach workers were able to reach members of the MSM community. NAF also supports income generation initiatives among community-based organisations (CBOs). In Ulaanbaatar, it has supported MSM groups by providing small grants to enable the start up of a small textile business, including necessary workshops and training in design and sewing, as well as overall management of the programme. It has

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 43

sponsored a similar income generation intiative with two sex worker organisations, Health and Support in Orkhon province and AIDS Free Future in Dornod. The women make and sell hand beaded accessories, and the programme is intended to supplement sex workers’ livelihoods and help cover their costs of health and national insurance in particular. A website, set up in collaboration with the UN Volunteers programme in Mongolia, provides online sexual health counselling targeted at youth in Mongolia. Visitors to the site can obtain information and professional medical advice on HIV and AIDS, STI and reproductive health. The site, www.dotno. mn, has been live since November 2004, and by the end of 2009 it had received nearly 50,000 visitors, including people outside Mongolia.

SD2: Increase civil society capacity to implement effective community responses NAF provides financial and technical support to CBOs working with most at risk populations, and builds their capacity to implement effective community based programmes through the development of training materials, coordination of workshops and exchanges of learning and experience. For example, in 2009 NAF ran 20 training sessions to build CBO capacity, involving 380 persons. Training topics covered thematic areas such as HIV and STI prevention, gender and sexual health, risky behaviour and alcohol addiction, and counselling skills. CBOs were also trained in organisational development areas such as administration and management, writing funding proposals, reporting systems and developing advocacy and IEC materials. Ongoing support is provided through follow up visits as well as remote support. A national forum for peer educators is held every year. The forum provides an opportunity for peer educators and outreach workers from civil society and CBO partners to share experiences and learn from one another. They also attend training sessions on fundraising activities, financial management, and more effective delivery of community based programmes to increased numbers of people. The last Peer Educator’s Forum, held in 2009, included an auction for the sale of handmade goods produced through income generating activities supported by NAF. To encourage mutual learning and cooperation, NAF organises regular experience exchanges between organisations implementing similar projects – for example, organisations working with mobile populations, organisations working with artisanal miners, organisations working with sex workers etc. In June 2010, NAF held its annual meeting for sex workers which was attended by participants from more than 30 organisations,

including a variety of stakeholders from civil society and CBOs, as well as those involved in programme management and delivery, government officials and UN representatives. The two day event included introductions to each of the programmes, followed by group work to discuss challenges and barriers to implementation and further strategies to address these; influencing policy and decision makers; and work towards creating a more enabling environment for such programmes.

SD3: Strengthen communities influence in national programming and in national and international policy While a member of Mongolia’s Country Coordinating Mechanism (CCM) for Global Fund Round 7, NAF played a key role in securing a new focus on integrating HIV and sexual and reproductive health (SRH) within the national response. Linking HIV-related services and SRH is key to achieving universal access to HIV prevention, treatment, care and support, as well as to reproductive health, because it increases the relevance, scale and costeffectiveness of community-based programmes and their impact on SRH and HIV outcomes. NAF cooperates with the Human Development, Reproductive Health and Rights NGO Network. The network includes 24 civil society organisation members and has been supported by UNFPA since its establishment in 2001. NAF has been selected as a working group member in developing policies on human rights and at-risk populations. It also contributes to capacity building of member organisations and organises joint advocacy activities with the Network. For example, NAF organises stakeholders meetings and as a result of the last meeting in January 2010, the Ministry of Health has started developing a strategy to work with civil society organisations. NAF is working towards coordinating efforts and reducing duplication of projects. It participated in a national consultative meeting on improvement of inter-sectoral coordination of HIV/AIDS and STI activities. Another meeting on strengthening partnership between public, private and civil society organisations was organised jointly with National Committee on AIDS. This has improved collaboration and a joint plan of action for future partnership has been developed. Public awareness raising activities led by NAF have included work with the media to promote correct representation of MSM; a campaign on World AIDS Day involving Ulaanbaatar’s Police Patrol Protection Unit, Road Traffic Police and State Special Defense Unit in pledging support for HIV prevention; and burning candles in respect for the memories of people who died of AIDS and to call for an end to discrimination against people living with HIV.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Morocco

An estimated 25,000 people were living with HIV in Morocco in 2009, or 0.1% of adults. While this indicates that Morocco is a low-prevalence country, among at-risk groups the prevalence rate is much higher. The prevalence rate among sex workers was 2.38% in 2009, and 4% among both men who have sex with men (MSM) and injecting drug users (IDU). The epidemic affects women disproportionately: in 2009 women represented 62% of infections in the 15-24 age group, and 55% among 25-34 year olds. Furthermore, seasonal workers and migrants from other African countries are sometimes vulnerable to HIV infection, many of whom live in unstable situations and lack knowledge of HIV transmission. Over the last few years, the national response to HIV has strengthened considerably. However, there remain significant barriers to people accessing services. The Alliance has worked with its Linking Organisation in Morocco, Association Marocaine de Solidarité et Développement (AMSED), since 1996. AMSED aims to develop a comprehensive package of services and make them more accessible for key populations, including MSM, sex workers, illiterate women, young people and STI service users. It trains and works with peer educators from key populations, developing focused information, education and communication materials. As part of the Alliance’s North Africa and Near East regional programme, AMSED works to prevent HIV among MSM. It also provides financial and technical support to community-based organisations (CBOs) to carry out HIV and STI prevention projects.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of people reached through HIV prevention activities

9,574

11,056

38,187

Number of people reached with VCT interventions

271

135

1,683

In 2007, AMSED put in place its scale-up strategy, which enabled the organisation to expand to new regions and provinces. AMSED currently works in 11 regions, nine of which are priority regions in the National Plan. Within these regions, the AMSED programme cover 28 towns through a network of 95 partner NGOs that implement HIV and AIDS projects. Overall, nearly 300 organisations have been mobilised by AMSED to integrate HIV prevention into their projects.

Rakia, a victim of physical and sexual violence, greets her case worker at Ennakhil, a Moroccan organisation dedicated to helping women and children © Nell Freeman for the Alliance

In 2004, the Alliance started a North Africa Regional Programme to reduce the spread of HIV among MSM in the sub-region. Since then, the project has supported 6 civil society implementing partners in Morocco, Algeria, Tunisia and Lebanon to lead focused prevention projects, contributing to the provision of services and support to MSM. MSM are trained as peer educators to do outreach work within the MSM community, helping them to access mobile or permanent VCT services. The mobile units have been successful in targeting hard to reach groups outside of the cities, including IDU and older men. Condoms and lubricant are also distributed. AMSED was a Sub-Recipient of Global Fund Round 6 (Phase 1: 2007-2009), led by the Ministry of Health, which aimed to integrate STI/HIV prevention into the National Literacy Curriculum and into community development projects. A total of 73 CBOs integrated HIV prevention into their activities in Phase 1 of the programme. AMSED is currently implementing Phase 2 (2010-2012), focusing on the integration of HIV/STI into development projects and capacity building for TB organisations. One of AMSED’s projects aimed to reduce the socio-economic impact of HIV in 7 urban areas in Morocco, with funding from l’Agence de Development Social and ALCS. The project’s income generating projects have resulted in a number of benefits for participants, such as improved selfesteem and confidence, better economic status, and decreased vulnerability. This project finished in 2009, but AMSED plans to be involved in a next phase.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY 45

SD2: Increase civil society capacity to implement effective community responses

SD3: Strengthen communities influence in national programming and in national and international policy

AMSED strengthens the capacity of CBOs though the provision of organisational and technical support. For AMSED’s income generation programme, its role is not only to coordinate and mobilise numerous implementing partners to deliver this programme, but to also undertake capacity analyses and help CBOs develop capacity building strategies.

AMSED is a member of the Round 6 Country Coordination Mechanism (CCM), representing the NGO sector. This highlights AMSED’s important role in putting forward a civil society perspective at the national level.

Another example of AMSED’s capacity building work includes an 18-month project funded by ALCS/ Sidaction and the Global Fund, which began in July 2009. This project aims to integrate human rights and community mobilisation into the focused prevention programmes of 6 CBOs working with over 600 sex workers. One of the key activities of this project is to build the CBOs’ capacity in addressing gender violence and stigma and discrimination in their programmes. AMSED has continuously mobilised organisations and trained them on the integration of HIV into their development projects. Over time, AMSED has gathered experience in its integration approach and has expanded its areas of work in line with priorities outlined in the National Plan to Combat AIDS. AMSED has a regional hub of seven organisations, known as Associations Focales Intermédiaires or AFIs (focal intermediary organisations). By providing these seven organisations with significant training and capacity building, AMSED has build a cadre of intermediary organisations capable of supporting AMSED in ensuring quality scale-up of its programme through mobilising and building the capacity of CBOs at local level.

Furthermore, AMSED is involved in Morocco’s national TB strategy (2006-2012). As part of this strategy, AMSED undertook a pilot project, in partnership with the Ministry of Health and with funding from the Global Fund, called ‘Mobilisation Sociale de Lutte Anti-Tuberculose’. This partnership enabled a multi-sectoral and community approach to addressing TB, particularly among vulnerable populations. From September 2010 to June 2012, AMSED will implement a similar project in the Casablanca region to reinforce and strengthen the capacities of eight local NGOs in TB work. Lastly, in association with the Ministry of Health, AMSED implemented Phase 2 (2007-2008) of a national programme to improve the quality and increase the coverage of STI/HIV prevention services in Morocco (funders included the Global Fund, the International HIV/AIDS Alliance, and Solidaridad Internationale et la Junta de Andalucia). The programme expanded services into a number of new regions, and one of the successes of this programme was to push the authorities and MoH officials to consider the Oriental Region as a priority zone.

AMSED also supports the institutional, organisational, and programmatic development of Morocco’s only PLHIV network, ‘l’Association le Jour’ to increase its involvement in the national HIV response. AMSED had planned to conduct a needs assessment of the network followed by a series of capacity building training on organisational and institutional development, but due to some problems within the network, the project is suspended until it is ready to benefit from the training.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Mozambique

Mozambique has the 7th highest prevalence rate of HIV in the world. Around 1.6 million Mozambicans are living with HIV and in those aged between 15-49 the prevalence is estimated at 16%. The current projections indicate that by 2010 the number of infected people will rise to 1.9 million. Mozambique is the only country in the Southern African region in which HIV incidence is increasing. Mozambique has developed its response considerably in the last 10 years in the fight against HIV, which threatens to weaken the economic achievements during this same period. Around 108,000 people living with HIV (PLHIV) received treatment by the end of 2008, but these numbers represent a small percentage of people eligible for treatment. The Alliance has been working in Mozambique since 2001 and established a Country Office in Beira in 2003, along with a representative office in Maputo. However, the Alliance is developing a new strategy for its work in Mozambique, which entailed the gradual close-out of the Country Office. The Alliance has embarked on a new partnership with MONASO (Mozambique National AIDS Service Organisation), an umbrella organisation for NGOs and communitybased organisations working on HIV and AIDS in the country. Although the Country Office is now closed, the Allianceâ&#x20AC;&#x2122;s new partnership reaffirms its commitment to the AIDS response in Mozambique. MONASO works to mobilise civil society organisations, as well as coordinate their activities in order to avoid duplication and ensure efficient use of resources. It also works to build the capacity of smaller organisations so they can develop and implement interventions at the community level.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of orphans and/ or vulnerable children receiving care and support within the community

3,546

17,970

19,069

Number of individuals reached with care and support

2,370

23,963

25,790

Condom distribution, Chimoio, Mozambique ÂŠ Gideon Mendel for the Alliance

The Alliance has being providing programmatic and organisational support to local organisations in the central provinces of Tete, Manica and Sofala, including faith-based organisations, CBOs, networks of PLHIV and governmental institutions to enable an effective response to HIV. These organisations have in turn directly supported approximately 27,000 orphans and vulnerable children (OVC), PLHIV and their families. As a result, these groups have been able to access more services including schools, health, and food, as well as live in a better environment with less fear of being stigmatised due to HIV and a greater ability to play a more productive role in society. From 2007-2009, Alliance Mozambique implemented a UNICEF programme to expand civil society responses to OVC and PLHIV in Manica and Sofala. The intervention also included a component to address stigma and discrimination. In 2008, Alliance Mozambique started a partnership with Health Communication Partnership (HCP) to encourage positive behaviour change and increase access to HIV services. This programme supported communities to identify and reduce barriers to behaviour change, working with local organisations and community leaders with an emphasis on gender and power relations. It aimed to reduce stigma as a barrier to people accessing HIV services, and fund activities to increased uptake. Furthermore, Alliance Mozambique started a programme in 2009 to support partners at national and sub-national level to implement comprehensive responses that include a continuum of care and support, with a particular emphasis on prevention for PLHIV and OVC.

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COUNTRY STUDY 47

In 2010, MONASO successfully secured $1.3M funding from the US government for the project ‘Community Partnership to fight HIV/AIDS’. The funding is from a newly created funding mechanism called the Rapid Results Fund. The 12-month project will focus on activities in 6 out of 11 provinces in Mozambique.

The Alliance’s reputation around building capacity of national organisations was key to MONASO’s successful application to the US government for the ‘Community Partnership to fight HIV/AIDS’ project. As part of the project, the Alliance will provide technical support to MONASO, from the Secretariat and the Hubs as appropriate.

SD2: Increase civil society capacity to implement effective community responses

SD3: Strengthen communities influence in national programming and in national and international policy

Alliance Mozambique has supported its partners to implement more comprehensive and integrated programmes to reach vulnerable and marginalised communities. In 2008, Alliance Mozambique provided 148 instances of technical assistance to 40 organisations.

Alliance Mozambique has supported local community organisations to have a greater involvement at the local and provincial level in the national AIDS response, and has supported civil society networks to advocate and influence national policy and strategies on PLHIV and OVC.

The Alliance’s capacity-building approach in Mozambique involved an intensive programme that focused on organisational development, formal training (in technical areas, finance and programme management), proposal writing, resource mobilisation, mentoring and follow-up support complemented by grants for project activities to each organisation. As a result, these newly emerging organisations were in a stronger position to identify issues and needs as well as to find local solutions for the causes and impacts of the epidemic.

As part of the Alliance’s Africa Regional Programme (ARP), in 2009 the Alliance began coordinating an advocacy programme between NAP and RENSIDA (the national network of PLHIV) for greater involvement of Mozambican PLHIV. Programme partners for the ARP’s prevention programme included RENSIDA, provincial networks and the provicial and district government HIV coordination bodies. An evaluation of the ARP is currently underway, which will identify the key successes and challenges of the ARP’s networks and prevention work in Mozambique.

Alliance Mozambique also implemented an Academy for Educational Development-funded programme to strengthen NGOs and networks to understand and challenge HIV-related stigma.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Myanmar

Myanmar is among the countries most affected by HIV in Asia, with the third largest epidemic in the region. The National AIDS Programme estimates that 230,000 adults and 60,000 children were living with HIV in 2007. This means that the prevalence rate among adults is around 0.7%. Prevalence is highest among specific key populations including injecting drug users, sex workers and men who have sex with men (MSM). However, Myanmar’s capacity to respond is among the region’s lowest. Its political situation still limits the operations of civil society and international non-governmental organisations as well as the availability of funding, which falls far short of what is needed. For example, fewer than 20% of the 76,000 people in need of antiretroviral treatment are receiving it. The Alliance opened an office in Myanmar in 2004, to build local capacity to organise and manage effective HIV prevention, care and support programmes. It has mobilised non-governmental organisations (NGOs) and community-based organisations (CBOs) to initiate HIV interventions and strengthened those already active in this area. Programmes target key populations affected by the disease, including people living with HIV (PLHIV), sex workers and MSM. Policy and advocacy work has promoted greater involvement of PLHIV through support to the establishment and ongoing work of the Myanmar Positive Group; participation in national Technical and Strategic Group on HIV/AIDS and Technical Working Groups; and civil society networking through the 3N (National Network of NGOs). Recently Alliance Myanmar was successful in Global Fund Round 9, becoming a Sub-Recipient in a project to expand community access to prevention, care and treatment.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

6,736

15,219

9,438

Number of individuals reached with care and support

3,591

2,858

9,998

Alliance Myanmar’s primary focus is to support new community-based efforts providing care and support to PLHIV and their families, and to support prevention efforts among MSM and female sex workers and their clients. Many partners incorporate both prevention and care and support into their work. Projects working on prevention activities are faced with the care and support needs of positive people encountered through the project as well. Similarly, projects focusing on care and support provide prevention education to reduce stigma and discrimination towards PLHIV. The range of prevention services for MSM and for sex workers (provided through drop-in centres or outreach) includes peer education; access to medical care, condoms and gel; psychosocial counselling; referrals for voluntary confidential counseling and testing (VCCT) and sexually transmitted infection (STI) diagnosis and treatment; and (for those who are HIV positive) nutritional support and vocational training support. MSM peer educators lead education sessions involving discussions and participatory activities to build solidarity, as well as to promote community norms supporting safer sex. Peer education and mobilisation approaches have been effective in addressing the stigma experienced by many MSM. For example, after one workshop 18 MSM were motivated to seek STI testing and treatment and six MSM accessed VCCT, having previously been inhibited from doing so. Sex workers also act as peer educators. They distribute condoms, provide information on how to reduce risk and make referrals to services for STI diagnosis, VCCT and medical care. Increasingly, they interact with pimps, clients and a range of actors who are linked indirectly with sex workers

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(e.g. trishaw and taxi drivers), some of whom attend education sessions and are thus exposed to prevention messages and techniques. Some sex workers have formed self help groups with riskmanagement and informal insurance mechanisms to cope with crisis situations, such as arbitrary arrest or sickness of their children, and establishing pooled funds to be used in such situations. Alliance Myanmar partners deliver a broad range of services to PLHIV and their families and caregivers. These include: routine visits and support for PLHIV in their homes and within community settings; bedside support for PLHIV during hospitalisation; medical care for opportunistic infections; discussion groups to learn about prevention including safer sex and prevention of mother to child transmission (PMTCT); condoms; nutritional support; vocational training and access to income generating activities; and psychosocial counseling for PLHIV. Partners refer people to local government clinics and hospitals, general practitioners and other NGOs for services that they do not provide themselves. Beneficiaries have confirmed that the package of care and support provided helps to reduce suffering and discrimination, and improves the quality of their lives and the lives their families and caregivers. Alliance Myanmar also works with 10 partners to improve access to quality community based services for orphans and vulnerable children. Services provided include educational support, medical care and health services, nutritional support as well as community awareness raising activities. In order to support the country to achieve universal access to care, support and treatment, Alliance Myanmar undertook an innovative pilot project known as ‘Private Partnership for Public Health’ in August 2008. It has been offering a continuum of care, including (from February 2009) antiretroviral therapy (ART) for PLHIV in Yangon. The partnership is a set of relationships between CBOs providing services for PLHIV and private sector general practitioner doctors practising in the community and providing ART. Laboratory services, TB care services, and public sector ART registration are included through referral by the private service providers. PLHIV receive a range of services from the CBOs, including selection for ART, referral to the private service provider of their choice, treatment education, home-based care, psychosocial support, inpatient support, and reproductive health counselling. 129 patients are currently taking treatment under this scheme, many of whom began when severely immunocompromised, and retention in the programme is high.

SD2: Increase civil society capacity to implement effective community responses Alliance Myanmar conducts an Organisational Capacity Assessment (OCA) when an organisation becomes a partner, and formal follow-up OCAs are conducted every 2-3 years. The capacity of many partners is growing rapidly, partly in response to the increasing demand for services and partly due to successful capacity building by the Alliance. Capacity building is provided through workshops, one-to-one technical support visits from Alliance staff and international consultants, and exchange visits among the partners. It covers areas such as counselling, safe sex skills and communication/ outreach, as well as organisational development skills such as project management, financial management, documentation and participatory monitoring and evaluation. Alliance Myanmar played a critical role in the evolution of Mahaythi Myitta Shin, an organisation working with sex workers. A case study of Mahaythi Myitta Shin noted that ‘prior to contact with the Alliance, the Mahaythi managers were somewhat conservative in their worldview and approach … it is highly unlikely that they would have considered the possibility of working with/ for sex workers if the Alliance had not provided the financial wherewithal, technical support, and most importantly moral support to do so’. For several partners, Alliance technical support was directly responsible for helping them to manage the transition from informal self-help groups into viable CBOs/Civil Society Organisations (CSOs). Recent workshops include training for both care and support partners and prevention partners in adherence support and home based care. This focused on understanding the basic concept of home based care and a standard package of activities; identifying physical and emotional needs of PLHIV; understanding medicines commonly used for PLHIV; and palliative care for the dying. Participants observed good practice in care and support through a field visit to an Alliance partner.

SD3: Strengthen communities influence in national programming and in national and international policy The Alliance programme has enabled communities and PLHIV to influence the response to the epidemic at national, regional and township levels. In particular the establishment and development of two national networks, now playing key roles in national networking, advocacy and expanding policy dialogue, represents a significant achievement. Alliance Myanmar fostered the development of a strong and viable national PLHIV network – the Myanmar Positive Group (MPG) – helping it evolve from an informal network of nine PLHIV groups into a

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strong national network organisation of 144 self help groups containing over 10,000 members. MPG is recognised as the national representive organisation for PLHIV. It is building key relationships between PLHIV and decision makers, and advocating for greater PLHIV representation on decision making bodies. Recently the Alliance has been successful in sourcing EC funding to expand the advocacy and capacity building activities of MPG and some of its PLHIV self help groups. In addition, Alliance Myanmar helped to establish and develop a national network of NGOs working in HIV and AIDS, known as the National NGO Network (3N), which has expanded to 120 member organisations. The establishment of these national networking organisations has been instrumental in securing civil society representation on the Country Coordination Mechanisms (CCM), the Technical and Strategic Group for HIV, the Care and Support Working Group and the Working Groups for the National Strategic Plan. This representation of civil societyâ&#x20AC;&#x2122;s voice on national fora has resulted in some recent advocacy achievements. The MPG representatives on the CCM were key in advocating for retaining the funding allocation for care and treatment in the recent Global Fund Round 9. Furthermore, representatives from 3N

helped convince the Global Fund that civil society has a viable voice in the national response, and highlighted the challenges involved in HIV and AIDS programming in Myanmar. The Alliance supported MPG to develop a position paper on access to treatment, addressed to all treatment service providers and donors. This was followed by a three-day advocacy workshop which trained 34 PLHIV to become advocates for access to treatment. It included an examination of advocacy strategies suitable to the Myanmar context. An outcome of the workshop was an advocacy plan, to be used in conjunction with the position paper. The plan identifies various government and NGO contacts to approach, and methods such as building relationships with key contacts and raising issues in appropriate fora. At township level, Alliance partners work to build good relationships with local authorities, so that they can continue programming despite not being able to register officially due to constraints on civil society. This type of local advocacy is essential for programming in Myanmar, to ensure the increased role of PLHIV and CBOs in the HIV response.

A health check up at the Myanmar Council of Churches (MCC) drop-in center ÂŠ MCC

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Nigeria

Nigeria has the world’s third largest number of people living with HIV (PLHIV) – an estimated 2.6 million (3.1% of adults). Around 1.2 million children have been orphaned by AIDS. Factors contributing to the spread of HIV in Nigeria include poverty, high population mobility, poor healthcare services, marriage practices such as polygamy, the trafficking of young girls, and lack of sexual health information and education. Many gaps and barriers remain in the provision of and access to HIV services. In 2007, only 26% of those in need of antiretroviral treatment were receiving it. The Alliance works through two Linking Organisations: Network on Ethics, Human Rights, Law, HIV/AIDS Prevention, Support and Care (NELA) and Civil Society for HIV/AIDS in Nigeria (CiSHAN). NELA has been a member of the Alliance since 2002. It provides care and support and prevention services for PLHIV, orphans and vulnerable children (OVC) and affected families. It also provides technical and financial support, training and mentoring for non-governmental organisations (NGOs) and faithbased organisations (FBOs), to help them develop and deliver quality HIV and AIDS services. CiSHAN joined the Alliance in 2008 and works through over 2,000 civil society and community-based organisations (CSOs and CBOs). It has a presence in all 36 states, as well as six zonal offices across Nigeria’s six geopolitical zones. CiSHAN facilitates and coordinates the response of civil society to HIV in Nigeria, and works in the following programmatic areas: prevention, care and support, treatment, advocacy, policy, gender, human rights and stigma reduction, institutional capacity strengthening, monitoring and evaluation, voluntary counselling and testing (VCT), poverty alleviation, gender and human rights and community mobilisation.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of people reached through HIV prevention activities

Data unavailable

33,009

Number of individuals reached with care and support

2,471

Data unavailable

44,163

A three-year USAID-funded project (October 2007 -October 2010) has been expanding community level prevention, care and support services to people infected and affected by HIV and AIDS (including OVC) and to reduce the rate of HIV transmission among youths, couples and the general population. NELA is the prime recipient in a consortium which includes CiSHAN, Federation of Muslim Women’s Associations in Nigeria and Society for Women and AIDS in Africa, Nigeria. The consortium is working through 24 local partners across the six geo-political zones of Nigeria. The prevention part of the project supports the National Prevention Plan and National Strategic Framework on HIV/AIDS. It has trained 762 peer educators to target couples and in-school and out-of-school youth, using a combination of HIV prevention strategies to promote behaviour change. The peer educators make referrals as appropriate to counselling and testing services. In addition, Anti-AIDS clubs have been established in the project schools to reinforce the peer educators’ messages, provide HIV information and education and carry out other activities aimed at risk reduction. NELA has particularly strong experience in home and community based care and support, which it uses as an entry point for a range of other support. High quality home-based care is provided to PLHIV and their families through trained community volunteers (including PLHIV themselves). Clients receive basic care kits to help them avert opportunistic infections, delay the progression of the disease and prevent transmission to others. They are referred to facilitybased health services, as well as to vocational and income generating skills training and micro-credit schemes for secure livelihoods, and are supported to adhere to their medication. The most vulnerable

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children are provided with holistic care and support through referrals (e.g. VCT), psychosocial support group activities for the older ones and Kids Clubs. In addition, childcare protection committees in the communities have been established to protect children from all forms of abuse, and children are trained to understand their right to be free of exploitation and neglect. A total of 3,169 children are supported through the project.

NELA has been strengthening the capacity of NGOs, CBOs and FBOs to implement prevention programmes for PLHIV, and to increase PLHIV access to comprehensive and sustainable positive prevention services. A national Training of Trainers workshop on Positive Health Dignity and Prevention was conducted in June 2010 for 19 out of 24 NGO, CBO and FBO partners from eight states. A similar training is planned for eight additional organisations.

NELA also runs a short-stay centre that provides basic primary health care services for PLHIV who cannot access hospital care due to stigma and discrimination. Services at the centre include nutritional support; PLHIV support group meetings; treatment of opportunistic infections; VCT; referrals for TB screening and DOTS (Directly Observed Treatment Short-Course) (including funding for transport); referrals of all positive pregnant women for prevention of mother to child transmission services (PMTCT); advice and support for breastfeeding mothers; immunisations and malaria testing. The centre also runs economic empowerment projects for PLHIV.

CiSHAN engaged in a project to strengthen civil society capacity through the development of a guide for HIV prevention interventions. It organised a series of meetings, leading to a comprehensive and robust draft Civil Society HIV/AIDS Prevention Plan written to meet the needs of civil society organisations and communities. Participants in the process were drawn from the private sector, religious groups, NGOs, PLHIV, sex workers, LGBT organisations, research, and human rights organisations.

A collaborative project between NELA and Damien Foundation, one of the leading TB advocates in Nigeria, has established a dual-referral system ensuring prompt case detection, diagnosis, treatment and support for PLHIV and people infected with TB. PLHIV seeking support from NELA’s short-stay care centre are referred to the Damien Foundation for TB screening, and TB patients are referred by the Damien Foundation to NELA’s shortstay care centre for HIV counselling and testing. The Oyo State TB control programme has also partnered with NELA for referral of TB patients and for support to the state TB DOTS programme.

SD2: Increase civil society capacity to implement effective community responses NELA provides technical and financial support to CBOs and FBOs and has successfully trained partners in participatory community assessment techniques, project design, finance and administration, and monitoring and evaluation, as well as in technical areas such as prevention, care and support, stigma and discrimination, working with OVC and psychosocial support. Evidence of successful capacity building can be seen in the involvement of Positive Life Association of Nigeria, a PLHIV support group, in the state and national level HIV response. NELA has also supported networks such as CiSHAN, the Federation of Muslim Women’s Associations in Nigeria and Society for Women and AIDS in Africa, Nigeria, to provide management, technical and financial support to their local chapters.

CiSHAN has also built the capacity of its member organisations and of the Nigerian Bar Association (NBA) on gender and human rights mainstreaming in HIV/AIDS. The aim was to help reduce incidences of gender and human rights abuses, and stigma and discrimination against PLHIV. CiSHAN conducted a participatory training needs assessment; developed a Gender and Human Rights Training Module and other information, education and communication materials on gender and human rights; and arranged a five-day training session. Engagement with the law continued with a three-day paralegal training, conducted by CiSHAN, to equip 31 CSO members with paralegal skills to provide legal advice to PLHIV and their families. CiSHAN is a Global Fund Round 8 Sub-Recipient in a 5-year project to support health systems overcome constraints in achieving improved outcomes for HIV/AIDS, tuberculosis and malaria (ATM) services. A key component of the project is Community Systems Strengthening, which aims to strengthen core processes of community-based networks and community level committees to ensure provision of an increased range and quality of services in scaled up ATM interventions.

SD3: Strengthen communities influence in national programming and in national and international policy The National Agency for the Control of AIDS (NACA) led key stakeholders to develop the National HIV/AIDS Srategic Framework 2010-2015 (NSF) which will guide the national response to HIV/AIDS during this period. NELA participated in the review of HIV/AIDS prevention policy documents during the development of the NSF in October 2009.

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NELA has advocated for syndromic STI management at the primary health care level, and worked in partnership with local government to ensure services are provided. It trained personnel and equipped laboratories at the primary health care level, while the government was responsible for the human resources, physical structure and commodities for the project. NELA is also currently working with State Ministries of Women’s Affairs in four states in Nigeria to advocate for the rights of OVC. Two of those states have passed a Child Rights Act, which encourages the promotion of children’s rights at different levels of programming and their participation in decisions affecting them. CiSHAN is doing important advocacy work around stigma and discrimination. Nigerians living with HIV have no law to protect them from losing their homes or jobs, or being mistreated by health workers, because of their status. In partnership with NACA, CiSHAN succeeded in putting a Stigma and Discrimination Bill before the National Assembly and is now waiting for it to be ratified. CiSHAN’s Human Rights specialist has also been leading an initiative to ensure that the general public are aware of their rights and of the efforts undertaken to enshrine these in national law. Stigma and discrimination awareness-raising workshops have been held in five states with a total of 110 lawyers attending. CISHAN has been involved in formulating a number of national documents such as the HIV/AIDS Emergency Action Plan (HEAP), the National HIV/AIDS Prevention Plan (2007-2009) and the Civil Society HIV/AIDS Prevention Plan. Also CiSHAN has contributed to the development of the National HIV/AIDS Behaviour Change Communication Strategy (2009-2014) and National Guidelines and Policy on OVC. It collaborates with the 37 State Action Committees on AIDS/ State AIDS Control Agencies (SACAs) and the NACA board where the highest policy issues on HIV/AIDS are determined.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

Peru

Peru’s HIV epidemic is concentrated in vulnerable populations such as sex workers, transgender people, gay men and other men who have sex with men (MSM). Peru has a history of political turmoil, which has weakened the social and health sectors. Most of the country’s population lives in extreme poverty and lacks access to health services. The Alliance began working with Linking Organisation Vía Libre in 2005. Through funding from the Global Fund as a Sub-Recipient, Via Libre is making extensive efforts to contribute to a multi-sectoral approach to HIV and AIDS. It provided technical assistance to the development of the country’s 2007-2011 Multi-sectoral Strategic Plan for the fight against HIV/AIDS, which aims to reduce the incidence of HIV and AIDS in vulnerable groups and prevent new cases among the general population. Vía Libre’s ‘HIV/AIDS Advocacy with Key Populations’ project trains and supports members of the populations most affected by HIV (with a particular focus on transgenders) to help improve regional and national responses to the epidemic. The project has also established an Observatory to safeguard health services for these populations.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of people reached through HIV prevention activities

Data unavailable

40,790

Number of people reached with VCT interventions

Data unavailable

31,098

31,484

In 2009, Via Libre achieved 72% of the UNGASS national target for most at risk populations reached by prevention programmes – making an impact on the national epidemic in Peru. It distributed 1.7 million condoms through a network of 200 outreach workers as part of its Global Fund programme. This programme covers 15 regions of Peru and focuses on HIV/STI transmission prevention among vulnerable MSM and sex worker communities. In addition to distributing condoms, the outreach workers are deployed throughout the regions to raise awareness of and promote safe sex. They are trained to be peer educators and to provide basic or first stage counselling and referral to appropriate services. They are also trained to provide information about patients’ rights and entitlements as a way to reduce stigma and discrimination. Via Libre is one of only two Linking Organisations

Diana Quispe Pari, secretary of the Lazos sin Fronteras working group on HIV advocacy with key populations in Arequipa, Peru © Alliance

providing treatment through Global Fund supported programmes. In Peru, around 14,000 people are currently on treatment. Via Libre provides treatment and care for 600 of these people through its on-site clinic, which specialises in HIV and HAART (highly active antiretroviral treatment) and is integrated within the public health system in Peru. The clinic provides services outside standard working hours and is open to people from any province fearing stigma and discrimination in their home community. Via Libre also offers psychosocial support to patients receiving treatment. The programme shows that the peer approach has a place within the public health system. Peer educators are empowered and well trained to provide peer counselling, and help to strengthen and improve the quality of services provided to people living with HIV (PLHIV). In 2010, Via Libre started hosting the Alliance’s first TB/HIV co-infection project in the Latin America region, to increase integration of the response. Supporting Callao’s Regional Strategy on TB and HIV, the project is increasing access to HIV testing for people affected by TB in Callao, raising awareness and encouraging them to take a test. HIV testing is offered at a mobile unit covering five districts in the most densely populated part of Peru. The mobile unit specifically targets areas which are difficult to access for people affected by TB.

SD2: Increase civil society capacity to implement effective community responses Via Libre hosts the Latin America Technical Support Hub. By drawing on expertise across the Alliance, it provides evidence-based, context specific and timely technical support to Alliance Linking Organisations, non-governmental organisations, community-based organisations, umbrella organisations, coordinating bodies, governmental organisations, Country

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Coordinating Mechanisms, UN agencies and private sector organisations. For example, when Kimirina, the Alliance’s Linking Organisation in Ecuador was selected as Principal Recipient for Global Fund Malaria Round 8 and HIV Round 9, it felt a need to strengthen its results-based management systems. The Hub helped Kimirina develop a manual for planning and monitoring and evaluation. A consultant was sourced from an experienced Global Fund PR in the region, establishing a relationship of cooperation between the two organisations. Also, the Hub organised a study visit to Via Libre for two Kimirina staff members, to learn from its experience of managing, monitoring and evaluating Global Fund projects. With funds from Global Fund Round 6, Via Libre strengthened the capacity of lesbian, gay, bisexual and transgender (LGBT) and sex worker communities. Two workshops were delivered to strengthen their skills, and they went on to develop Green Papers on ‘Prevention of discrimination against LGBT and sex workers and ways of penalising discrimination’ in the six regions of Arequipa, Ica, Ayacucho, Tacna, Moquegua and Callao. These Green Papers were aiming at setting a basis for the defence of LGBT human rights and were developed as advocacy tools for civil society. With support from Via Libre, UNAIDS and others, the Green Papers were presented to and were endorsed by local authorities in the Lima Provinces. The community groups in the other five regions are still working towards the same outcome. A strategic priority of the HIV/AIDS Advocacy with Key Populations project was to provide training and technical support to key populations, who responded in diverse ways. One of these was the creation of four Regional Advocacy Spaces (working tables comprising community-based organisations and individual representatives) in Arequipa, Ica, Loreto and Lambayeque. Skills and abilities useful for organisational management and operations were developed and consolidated, with 50 members of the four Regional Spaces receiving training. Previously, the situation had been very different as there were no strong HIV organisations in these regions. Now, the technical support provided by Vía Libre has enabled key population groups to position themselves to raise their issues relating to HIV with the government and civil society. Via Libre is promoting awareness about the importance of addressing HIV/TB co-infection among communities working in HIV and AIDS. It has supported community organisations – Association of People affected by TB in Callao, Despertar (Awakening) in Ica and Viviendo en Positivo (Living Positively) in Lambayeque – to include HIV/TB into the design and implementation of their projects. Training courses and discussion groups have helped

increase their awareness and have encouraged the inclusion of work on co-infection within their plans. A document has been adapted to the Peruvian context with recommendations for integration of TB/HIV work. A barrier preventing people affected by TB from accessing HIV testing is a lack of trained community leaders and health care providers. Training on TB/HIV co-infection, approved by experts in both HIV and TB, has therefore been provided to community leaders and health care workers in Callao. In addition, advocacy training has been provided to the health care workers, supporting efforts to get TB/HIV on technical and political agendas.

SD3: Strengthen communities influence in national programming and in national and international policy Another strategic priority of the HIV/AIDS Advocacy with Key Populations project was sustained participation by sex workers, PLHIV, transgenders and MSM in decision-making forums – leading to change in public policies to improve regional responses to HIV and AIDS. Community-based organisations Lazos sin Fronteras (Links without Frontiers) in Arequipa, Unidos por la Igualdad en la Región Loreto (United for Equality in the Loreto Region), Despertar in Ica and Viviendo en Positivo in Lambayeque have successfully positioned themselves as key points of reference on HIV/AIDS and anti-discrimination for national and regional bodies, with these themes being included in public policy agendas. They have established strategic alliances with civil society organisations at the regional and national levels. Through the Regional Advocacy Spaces, they have worked closely with the offices of the Human Rights Ombudsman to report and denounce rights violations. Representatives from the advocacy spaces joined and actively participated in the Regional Multi-sector Health Coordination Mechanism (COREMUSA), Health Forum, Regional AIDS Forum and in action platforms working with affected and vulnerable communities. For example, they participated in the process for the 2008 and 2009 participatory budget, both at local and regional level. They also engaged with mechanisms outside the health sector such as the Round Table against Poverty, the Round Table against Discrimination and regional and local participatory budgeting initiatives. This participation facilitated the establishment of a direct relationship between key populations and decision-makers in the four regions of the country. Currently there is a close relationship with the offices of the Human Rights Ombudsman, regional governments and the National Sanitary Strategy for the Prevention and Control of Sexually Transmitted Infections and HIV/AIDS – entities which form part of the Peruvian Health Ministry. Key population working groups coordinate and plan joint actions with other

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organisations related to HIV, sexual minorities and human rights, together with the Ombudsman and government ministries. Following successful advocacy, there was a need for key populations to play a more strategic role in influencing policy, actively participate in decisionmaking on issues affecting their lives (particularly in relation to stigma and discrimination) and claiming their rights. An Observatory (a community watchdog system) has been developed, so that key populations themselves can monitor implementation of public health policies by the government. This has enabled the identification of barriers to accessing health services (such as poverty and sexuality) and the gathering of evidence, so that alternative solutions can be proposed to the authorities. Via Libre is promoting strategies for integrating TB and HIV and building links with National and Regional Coordinators working in TB/HIV. One of its main activities is the development of a technical document making recommendations for the integration of policies on TB and HIV in Peru, within a framework of international policies on TB/HIV co-infection. An in-depth analysis was carried out on national public policies on TB and HIV, and efforts were made to involve key actors and decision makers at national level and to secure their approval of the technical document.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

senegal

Senegal has one of the lowest rates of HIV infection in sub-Saharan Africa, with an estimated 67,000 people living with HIV (1% of adults). It has been widely praised for preventing a more severe epidemic. This success is partly due to the prompt action of the government, but above all can be credited to the sustained efforts of numerous community-based organisations. However, while the epidemic appears stable in the general population, HIV has disproportionately affected the very poor, particularly those involved in sex work or migrant labour. There are also large regional disparities, with the Kolda and Ziguinchor regions in the south having the highest rates of HIV infection. Established in 1995 and an Alliance Linking Organisation from the same date, Alliance Nationale Contre le SIDA (ANCS) is one of the Alliance’s oldest and most successful Linking Organisations. It has become well known in Senegal for the scale and quality of its community level HIV work as well as its skills in organisational capacity building and developing and sharing tools. ANCS currently supports 340 NGOs and community-based organisations (CBOs) in all districts of the country to increase access to HIV services for vulnerable populations such as sex workers, injecting drug users (IDU), men who have sex with men (MSM), people living with HIV (PLHIV) and vulnerable children, and it has helped strengthen a national network of PLHIV. It has been Principal Recipient (PR) of Global Fund Rounds 1 and 6, and recently became PR of Round 9.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

22,630

55,670

118,853

Number of people reached with VCT interventions

2,525

1,932

13,621

In 2009, ANCS achieved 44% of the UNGASS national target for most at risk populations reached by prevention programmes – making an impact on the national epidemic in Senegal. In Senegal in 2005, problems of capacity and infrastructure constraints led the Global Fund to threaten the withdrawal of its grant. The Global Fund’s Country Coordinating Mechanism (CCM) for Senegal asked four international agencies for their

Flip chart from a social and discussion group for MSM raising concerns regarding exposure, Senegal © Nell Freeman for the Alliance

support, which included proposing a civil society PR. A committee of national and international organisations and networks went on to select ANCS, which became a grant recipient of the Global Fund for the first time. Its appointment as PR for Global Fund Round 1 (Phase 2) enabled resources to reach communities quickly and efficiently. ANCS’s current programme funded by the Global Fund Round 6 (Phase 1) is one of the most comprehensive prevention interventions supported by the Alliance in sub-Saharan Africa, and has consistently achieved ‘A’ grade ratings. The objective is to strengthen prevention of HIV transmission. This includes participatory prevention activities within the general population (such as peer education and support groups); mainstreaming of gender within HIV interventions; positive prevention with PLHIV, including among vulnerable groups; promotion of prevention of mother-to-child transmission (PMTCT) at community level; and intensification and decentralisation of voluntary counselling and testing (VCT) services. In 2009, the second year of ANCS’s Round 6 grant, ANCS scaled up the number of its Sub-Recipients and increased the number of people reached by 114%. There are long term economies of scale in channelling more resources through more CBOs and reaching more people – ANCS succeeded in lowering the cost per person by nearly 57%, from $14.42 per person to $6.23. Thus far, Global Fund support to Senegal through ANCS and the public sector PR, Conseil National de Lutte Contre le Sida (CNLS), has ensured that 8,484 PLHIV and 6,448 OVC have benefited from community care and support; 14,543 sex workers and MSM have been reached and mobilized; 6 VCT centres have been renovated and fully equipped, and

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a mobile clinic established; and 316,085 pregnant women have been mobilised at the community level for PMTCT. In July 2010, Global Fund Round 6 (Phase 2) was consolidated with Round 9, for which ANCS is PR together with CNLS and the Ministry of Health. Round 9’s goals include reduction of new HIV infections, and improvement of the quality of life of people infected and affected by HIV. Over the next five years, the project expects to reach 12,915 sex workers; 2,650 MSM; 636,264 youth; and 272,684 women. 688,342 people will have been tested for HIV; 603,655 pregnant women will have received a comprehensive package of PMTCT services; and 8,937 PLHIV will be supported with antiretroviral therapy. To strengthen Senegal’s health system, 234 health structures will be rehabilitated, and 100 nurses and midwives will be recruited. Due to the concentrated nature of the epidemic in Senegal, ANCS has a special focus on vulnerable and most-at-risk populations. It supported Senegal’s first pilot community initiative to prevent HIV among MSM. Through the Alliance’s Africa Regional Programme (ARP), ANCS is carrying out training, awareness-raising and advocacy activities to reduce stigma and discrimination towards MSM. ANCS has also supported the development of a new programme to reach IDU in Dakar, including those involved in commercial sex. In the border areas and conflict zones of the Casamance region it has been particularly active in reaching other highly vulnerable and underserved groups, such as mobile populations and the military, through peer education.

SD2: Increase civil society capacity to implement effective community responses ANCS supports many PLHIV groups in Senegal. Its experience in community participation has also been heavily drawn upon to develop tools and implement training for medical staff on a local, regional and national level. Examples of community capacity building includes leadership training for more than 80 people in 2008 and 2009, in order to increase the level of engagement, efficiency and performance of those involved in the response to AIDS in Senegal. The training was carried out in partnership with the Association Leadership et Citoyennete, an organisation that brings together international coaches in transformational leadership. Specific objectives included strengthening leadership, promoting a sense of ownership of the national HIV response and encouraging the formation of new partnerships. Training took place over three sessions in July and October 2008 and January 2009, each of which

lasted three days. The gaps between sessions allowed participants to adapt the skills learnt and apply them in their work. The first session taught how to nurture leadership talents, with participants identifying which skills could help them achieve challenging goals. In the second session, participants learnt how to develop initiatives and activities to bring about change. The final session aimed to strengthen participants’ capacity to make their results sustainable. It involved presentations, individual reflection and group work followed by plenary discussions. With funding from ARP, ANCS has also built the capacity of eight MSM organisations to enable them to position themselves as effective SubSub-Recipients in the implementation of Global Fund or other programmes. The training covered the background to the Global Fund programme; Global Fund policies and procedures; CCM and PR proposal submission process; the current institutional framework; procedures for SubRecipients and for Sub-Sub-Recipients, and the implications for MSM organisations who want to be considered. Alongside this, ANCS increased the organisations’ capacity in monitoring, evaluation, reporting, financial management and good governance.

SD3: Strengthen communities influence in national programming and in national and international policy ANCS has a strong policy presence, and works closely with networks of parliamentarians and journalists to maintain a positive policy environment for HIV work. It is a member of several key national committees for steering policy and strategy development. A key achievement has been the establishment of the Observatoire de la Reponse au VIH/SIDA au Sénégal (Watchdog of the Response to HIV/AIDS in Senegal). This is comprised of 5 major national NGOs including ANCS together with Africa Consultants International (ACI), Environnement et Développement du Tiers Monde (Enda), SIDA Service and Synergie pour l’Enfance. The Observatoire acts as a national watchdog by critically examining the response to HIV in Senegal and developing constructive proposals and recommendations to improve the response. It is an informal network that meets as the need arises. The Observatoire has made a significant contribution to the strengthening of the national response to HIV in Senegal. This includes developing positive and productive relations between government and civil society; meaningfully involving civil society in key aspects of planning and managing national action; and incorporating strategic inputs from civil society (for example, about the needs of key populations

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at higher risk) into the national response. A major success was its contribution to negotiations with the Global Fund that re-secured the country’s grant. At the end of 2008, nine members of AIDE (a partners of ANCS) were detained and sentenced to eight years in prison after they were found guilty of ‘indecent acts against nature’. Early in 2009 the conviction was overturned following interventions from civil society organisations, including ANCS with support from donors and the National Aids Council. Because of the heightened atmosphere of homophobia, there were concerns for the safety of

these men and a media inspired public backlash that threatened HIV programming. ANCS stepped up its advocacy efforts to create an environment of greater tolerance for key populations and associated HIV programming. Recently ANCS has started a two-year project with the Society for Women and AIDS in Africa (SWAA) and UNIFEM. Through coalition building, advocacy and education, the project aims to include provisions in the draft national HIV legislation that would strengthen the rights, entitlements and empowerment of women living with HIV in Senegal.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

South Sudan

Having recently emerged from 45 years of civil war, South Sudan has weak health systems and limited human, organisational and technical capacity to respond to HIV. The Southern Sudan AIDS Commission and the Ministry of Health estimate the region’s HIV prevalence to have been 3.1% among adults at the end of 2007. Small-scale surveys indicate that rates vary from as high as 10% in areas bordering Uganda to less than 1% in more central parts. Populations most at risk of HIV infection include refugees, internally displaced people, soldiers, truckers, sex workers and tea sellers, as well as women and young girls more generally. The Alliance opened a Country Office in South Sudan in 2005, and works with 70 communitybased organisations (CBOs) in Central and Eastern Equatoria states and a further 20 CBOs in Western Equatoria and Bahr El Ghazal States. Through its partners, it provides services such as HIV prevention, condom distribution, referral for voluntary counselling and testing and care and support. A national team of ‘stigma trainers’ help combat HIVrelated stigma and discrimination. Alliance Sudan strengthens emerging civil society organisations through grants and organisational and programmatic support, and has signed a memorandum of understanding with the government to be the lead agency to strengthen the capacity of civil society in the HIV response. Also, it builds the capacity of County AIDS Committees to strengthen coordination and service provision to adults and children in the Equatoria states, and it played a key role in the development of the Government of South Sudan HIV and AIDS strategy.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved 2007

2008

2009

Number of people reached through HIV prevention activities

Data unavailable

40,330

41,785

Number of individuals reached with care and support

Data unavailable

970

Alliance Sudan contributes to HIV prevention by training at-risk groups to be peer educators. Peer educators distribute and demonstrate condoms, and increase the knowledge of their peers about HIV and AIDS so that they can protect themselves. For example, Alliance partners South Sudan Women’s Effort Fighting AIDS and the Southern Sudan Older People’s Organisation train sex workers and street

boys respectively. Another project has trained secondary school pupils and out of school youth as peer educators, working through local partners the Change Agency Association and YMCA. 25 teachers from five secondary schools in Yambio also received training to manage and support the peer educators, as well as skills to enable them to provide HIV and AIDS education. The trained peer educators lead on HIV prevention activities in their schools and communities. As the military is the highest risk group in Sudan, Alliance Sudan runs a military HIV programme addressing behaviour change, prevention, care and support, treatment and voluntary counselling and testing (VCT). At the barracks, men receive HIV awareness education and are taught how to use condoms correctly and consistently. People who test positive receive treatment and counselling on how to live positively. Those with advanced HIV symptoms are referred to hospitals. Alliance Sudan focuses on provision of community based basic HIV-related care for individuals living with HIV and their families, aimed at extending and optimising their quality of life. For example, it supports groups for people living with HIV (PLHIV) such as the Star Group and the Rainbow Association in Yambio and Nzara to carry out activities that include the prevention and treatment of opportunistic infections and other HIV related complications such as malaria and diarrhoea. It ensures that such groups can access commodities such as treated mosquito nets, safe water interventions, pain relief and nutritional support. A UNDP-funded income generation project has been the first of its kind for PLHIV groups in South Sudan,

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empowering them with income generating skills to become self sufficient. four groups (Friendship Club; Rainbow Association; Widows, Orphans & People Living with HIV/AIDS; and Association of People Living with HIV) received an average grant of $13,000 to undertake income generating activities benefiting the groups and their members. By accessing loans, members have been able to set up a range of business ventures in carpentry, small scale retail and hospitality. Loan repayments are agreed according to affordability, and in a participatory fashion together with all group members.

SD2: Increase civil society capacity to implement effective community responses To strengthen organisational capacity, Alliance Sudan has conducted training in grants management, planning and use of strategic information in planning and decision-making. It has provided ongoing technical support to grant recipients on USAID compliance, record keeping, reporting and performance expectations as well as the basic principles of the project cycle. Evidence of effective capacity building of partners is reflected in their scaled-up programmes, strengthened systems and procedures, increased financial management capabilities, engagement in longer-term strategic planning and increased participation in national and local HIV service delivery. For the income generation project, the four PLHIV groups were supported to develop business plans, and then undertook training in small business management over three days. The training included basic marketing skills, stock taking, recording sales, protecting capital and developing tools for monitoring the success of the business and documenting lessons learnt. It aimed to support the maximisation of sales and development of the businesses into sustainable ventures. In addition, Alliance Sudan helped the groups and members to plan their finances. Because stigma and discrimination are primary barriers to access to HIV treatment, care, and prevention, Alliance Sudan trained a total of 22 people to become trainers themselves in stigma reduction. Those trained represented the governing Sudan People’s Liberation Army (SPLA), Southern Sudan AIDS Commission (SSAC), local CBOs and FBOs, and the network People Living with AIDS in Southern Sudan (PLASS) – and were therefore well placed to reach out to a wider audience. SSAC, for example, developed an action-plan to roll out a programme of stigma training to various groups nationwide, including the State Legislative Assembly, religious leaders, women’s groups, youth groups and teachers. In addition, the SPLA trainers pledged to carry out work with senior commanders who would be able to address stigma issues within the

army. Alliance Sudan also supported participants to include stigma training components in their proposals for community HIV work and to integrate anti-stigma activities within their work. As well as increasing CBO capacity, Alliance Sudan has also helped strengthen the institutional capacity of the Juba and Yambio County AIDS Commissions (CACs) to enable them to coordinate and manage effectively the multi-sectoral response to HIV and AIDS within their respective counties. It supports the organisation and running of the regular meetings of the CACs and provides appropriate technical support as required. Finally, Alliance Sudan has been instrumental in the creation of the South Sudan Network of People Living with HIV (SSNEP+). It is helping to build the network’s capacity to influence national HIV-related policies through training, mentoring and provision of grants to carry out its coodination activities.

SD3: Strengthen communities influence in national programming and in national and international policy Alliance Sudan partners – CBOs and PLHIV networks – have advocated for the rights of people living with HIV to access treatment and other related services, and to be represented in all HIV and AIDS-related decision making foras. In 2008, they carried out a ‘Week of Action’, during which a letter highlighting issues with access to services was presented to the President through the Chair of the HIV/AIDS Commission. This led to recognition of South Sudan Network of People Living with HIV (SSNEP+) by the country’s leaders and a promise to help facilitate their activities. Alliance Sudan collaborated with USAID and the Ministry of Health on assessment of home-based care programming. Following discussions, it has started developing national guidelines on the provision of home-based care in collaboration with the Southern Sudan AIDS Commission (SSAC). A stakeholders meeting will be held later in 2010 to finalise the guidelines, which will then be used by all stakeholders engaged in home-based care. Alliance Sudan has previously been involved in the development of several national guidelines, including the prevention of mother-to-child transmission (PMTCT) guidelines and the national M&E framework for HIV/AIDS. It was able to influence these documents to ensure that they represent the interests of communities and vulnerable populations. This year, in preparation for World AIDS Day, Alliance Sudan will hold a one day session with parliamentarians on HIV and AIDS with a view to forming an HIV/AIDS caucus within the parliament.

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

COUNTRY STUDY Summary of country programme

uganda

Uganda has made progress in its response to HIV and AIDS. HIV prevalence was much higher in the early 1990s, as much 18% in rural areas and 25-30% in urban areas. Political leadership, commitment and openness, as well as community action, has helped reduced the rate of new infections. But Uganda is still severely affected; 5.4% of all adults are HIV positive, services are not well coordinated and often don’t reach rural communities. With 950,000 people living with HIV (PLHIV) and over 1.2 million orphans and vulnerable children (OVC), a burden of care and support exists that is not being addressed. The Alliance has been working through a Country Office in Uganda since January 2005, to increase access to HIV prevention, care, support and treatment services including support for OVC. From 2005 to 2009, Alliance Uganda implemented two USAID funded projects with a total combined budget of $10 million. The Networks project focused on strengthening networks of PLHIV, and the CORE Initiative strengthened the Ugandan government and civil society response to OVC and HIV prevention among youth. Currently the Country Office is transitioning to become a Linking Organisation known as Community Health Alliance Uganda (CHAU) with expertise in HIV/AIDS, TB, sexual and reproductive health (SRH), policy, advocacy, research and programming.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved

2007

2008

2009

Number of people reached through HIV prevention activities

82,399

Data unavailable

352,304

Number of individuals reached with care and support

39,219

401,902

17,550

In 2009, Alliance Uganda achieved 34% of the UNGASS national target for most at risk populations reached by prevention programmes – making an impact on the national epidemic in Uganda. An evaluation of the Networks project (2006-2009) concluded that it had succeeded in empowering PLHIV to access services effectively at the facility and community levels through community referral systems. Alliance Uganda trained a network of more than 1,300 PLHIV as peer outreach workers, known as Network Support Agents (NSA), who were seconded to 628 health facilities across 40 districts in the country. NSAs operated the community referral

system to identify those in need of prevention, care and support, linked them to appropriate service providers and provided ongoing pyschosocial support. NSAs were also trained on counselling, treatment literacy, family planning methods, condom distribution, mobilisation of communities around family planning linked to the prevention of mother to child transmission (PMTCT) services, and referrals to family planning clinics. This approach ensured provision and access to comprehensive prevention, care and support, including family planning and SRH services. The project also succeeded in referring a number of PLHIV to income generating activities. NSAs were trained in basic nutrition, livelihood skills and basic advocacy, and used these to support local PLHIV networks in negotiating with local government and other service providers. In three years, over 1.3 million people accessed services. In addition, a total of nearly 147,000 referrals were made and 19,832 OVC were supported. Initially focusing on just 12 districts, the Alliance’s work expanded to 40 districts – well exceeding its target to cover 28 districts by July 2009. This remarkable scale up was achieved at the lowest cost per person of any Alliance programme, with an average cost of $2.46 per person. Key factors were the significant involvement of local communities and PLHIV networks, with the Alliance playing a coordination role. Costs were also minimised due to the effective use of referrals to existing health services. This low cost, scalable model is being replicated by the Alliance in Ethiopia and Malawi and other organisations have also adapted the model. It is recognised by the Ministry of Health as a model of good practice in Uganda. Through the CORE (Communities Responding to the HIV/AIDS Epidemic) initiative, the Alliance and its partners provided care and support to over 88,760

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OVC between 2005 and 2009, and 17,969 OVC care givers where trained – with the aim of improving quality of care, especially for the youngest and most vulnerable children. Recently, the Alliance was awarded funding from USAID for a five-year project (SUNRISE), worth over $22 million, to build on the CORE initiative and scale up to reach over 1,000,000 children with high quality comprehensive care in 80 districts by 2015. The aim is to improve access to and quality of services for vulnerable children in Uganda. It is anticipated that through the SUNRISE project, the Alliance will make a bigger contribution toward reducing child mortality in Uganda.

SD2: Increase civil society capacity to implement effective community responses Alliance Uganda hosts the Eastern, Central and Southern Africa Technical Support Hub. By drawing on expertise across the Alliance, it provides evidencebased, context specific and timely technical support to Linking Organisations, non-governmental organisations, community-based organisations, umbrella organisations, coordinating bodies, governmental organisations, Country Coordinating Mechanisms (CCMs), UN agencies and private sector organisations. For example, in 2009 the Hub held training sessions on PMTCT for 51 healthcare workers from across southern Sudan. The training helped to address the huge practical challenges in delivering effective PMTCT services in South Sudan, and get more staff trained. The CORE Initiative provided technical support to Uganda’s Ministry of Gender, Labour and Social Development (MGLSD) to expand the delivery of quality services through strengthened partnerships between the Ugandan government and civil society organisations (CSOs). Within the CORE Initiative consortium, the Alliance led on technical and capacity building assistance to the MGSLD, local governments, technical services organisations and CSOs. The Alliance built the capacity of the MGLSD by helping to establish and institutionalise its operational structure – the National Implementation Unit for OVC – which supports the implementation of the national OVC strategic framework and plan. It also built the capacity of 48 subgrantees of the Uganda Civil Society Fund. The project worked with each CSO to create an individual assessment and capacity building action plan, and all grantees were trained in monitoring, evaluation, financial management and communication skills. On-site visits were conducted to resolve project start-up issues, support implementation of monitoring and evaluation systems and identify and solve management issues. The support was greatly appreciated by the CSOs, as many had been carrying out activities without knowledge of national HIV and AIDS guidelines and standards. The Alliance also led on the development and roll out of national quality standards for OVC services. The standards provide practical tools to guide the government and CSOs to plan OVC services; to identify service gaps; to articulate

consistent and quality care; to manage and evaluate projects and to build collaboration across sectors. The development of the standards made Uganda one of the first African countries to take such an initiative.

SD3: Strengthen communities influence in national programming and in national and international policy Through the CORE Initiative, inter-ministerial coordination mechanisms for OVC support were strengthened and it helped position the MGLSD as a key standing member of the Civil Society Fund Steering Committee. This meant that the MGLSD was able to improve representation of OVC issues in a key multi-sector decision-making forum for the first time in Uganda. In consultation with MGSLD and district Community-Based Service Departments, the Alliance developed several key technical resource materials to inform and guide MGLSD to lead the national response to OVC. Throughout the life of the Networks project, there were widespread and persistent stock shortages of Septrin, ARVs, drugs for TB treatment, and Coartem in health facilities in many parts of Uganda. This threatened to reduce the effectiveness of the referral system, as people are discouraged from going back to health facilities if they have to travel long distances with considerable expense and no guarantee of supplies. It also posed challenges to treatment adherence, increasing the likelihood of affected individuals developing drug resistance. The Alliance and its partners used national advocacy to push for improved stocks and supply chains. In addition, PLHIV groups and communities were supported to lobby for services at district level. This work has now taken on a larger national dimension through the recently concluded CSO-led Citizens’ Manifesto, which has become a major lobbying tool for all CSOs in Uganda and targets all political parties. The health section of the Manifesto was written by the Alliance. It demands the prioritisation of health and HIV funding by the next successful party to form government after the national election in March 2011. In the lead up to the election, CSOs will mobilise on health policy issues such as the need for renovation of the present dilapidated health infrastructure; to invest in human resources, equipment and medicines; and to seriously rethink priority investments to strengthen prevention in public health. Alliance Uganda hosts the country’s National Partnership Platform (NPP), a space for effective dialogue between civil society, government and other stakeholders. An important part of the NPP are Key Correspondents – citizen journalists – who ensure that people who are not normally heard are empowered to tell their stories. The NPP and Key Correspondents will be central to this national advocacy initiative. The Alliance has also been a key member of the CSO coalition advocating against the current HIV/AIDS Bill and lobbying parliamentarians against the Anti-Gay Bill.

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ukraine

Summary of country programme In Ukraine, around 1.6% of adults are living with HIV. The epidemic is largely concentrated among most-at-risk populations such as injecting drug users and their partners, sex workers, and men who have sex with men. The country’s southern and eastern regions are the most affected by HIV. Historically, the national response to HIV in Ukraine has been compromised by political instability, frequent changes of leadership, low political commitment and weak capacity. Recognition of the epidemic’s importance has grown in recent years, accompanied by important changes in legislation. The Alliance began work in the Ukraine in 2000. A Country Office was established in 2003, and in 2009 it became an independent Linking Organisation known as International HIV/AIDS Alliance in Ukraine (Alliance Ukraine). Alliance Ukraine was one of the first civil-society Global Fund Principal Recipients A client of support services with her social worker, Ukraine © Natalia Kravchuk for Alliance Ukraine (PR) and played a leading role in the Ukrainian National AIDS response. As a PR of the Global Fund Round 1 grant (20042009), it led the expansion of 2007 2008 2009 antiretroviral treatment (ART) access in Ukraine. In 2007, Number of people reached 101,163 139,453 216,348 Alliance Ukraine and the Allthrough HIV prevention Ukrainian Network of People activities Living with HIV/AIDS (referred Number of individuals 11,220 6,920 103,030 to as the PLHA Network) tested for HIV at VCT became co-PRs of the Round centres supported by the 6 grant. Supporting the scale organisation up of prevention programmes is a particular emphasis of this Round, which will likely be extended until prevention services for most-at-risk populations. By mid-2012. Due to the success of their Global Fund the end of September 2008, 6,070 people (including programme, the Ukrainian government appointed 911 children), had received ART through the Alliance Ukraine as one of the main implementers of programme. In 2008, 80% of pregnant women living the National with HIV had received treatment to prevent motherHIV/AIDS Response Programme for 2009-2013. to-child transmission (up from 35% in 2003). Further funding for prevention programmes comes from the USAID-funded project, Scaling Up the National Response to HIV/AIDS through Information and Services (SUNRISE). This project was initiated in 2004, and was granted a two-year extension in 2009. Alliance Ukraine’s work is expanding to include TB/HIV programming. In early 2010, Ukraine was awarded a Global Fund Round 9 grant to address TB, and Alliance Ukraine is one of the civil society SubRecipients (SR) within this national programme.

SD1: Scaled up quality community programmes delivered and access to health and HIV services improved The success of the Round 1 Global Fund supported programme included the rapid scale-up of ART and a comprehensive package of care, support and

Effective partnerships across the statutory and private sectors and civil society were a key achievement of the programme. As a result, State AIDS centres and NGOs are working together to operate a well-developed referral system. While it has sometimes been challenging to connect different sectors of the national health system, this is being addressed through Round 6 and Round 9 which is funding STI/HIV and TB/HIV integrated programming respectively. The scale-up of HIV prevention services for mostat-risk populations has been a particular focus of Alliance Ukraine. A comprehensive external evaluation of the national AIDS response in Ukraine by UNAIDS (2009) reported that the prevention programme among people who inject drugs – implemented by the Alliance, through a network of

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NGOs in nearly all the regions of Ukraine – is the largest in Eastern Europe. One of the objectives of the SUNRISE project is to strengthen the preventioncare continuum, with a particular focus on improving the quality and reach of VCT services. While the roll-out of substitution maintenance therapy (SMT) initially came up against legal barriers, scaleup is now taking place at the national level. A priority area of Round 6 includes increasing access to SMT in order to improve HIV prevention and care among people who inject drugs. A key strength of Alliance Ukraine has been its ability to adapt to the changing social profile of the epidemic, especially with regard to the drug user population. Through Round 6 grants and the SUNRISE project, Alliance Ukraine has responded to this change by developing prevention programming designed to reach street children and female drug users.

SD2: Increase civil society capacity to implement effective community responses Alliance Ukraine hosts the Eastern Europe and Central Asia Technical Support Hub. By drawing on expertise across the Alliance, it provides evidencebased, context specific and timely technical support to Alliance Linking Organisations, non-governmental organisations, community-based organisations, umbrella organisations, coordinating bodies, governmental organisations, Country Coordinating Mechanisms (CCMs), UN agencies and private sector organisations. In 2009, Shell made a request for short-term HIV and workplace policy awareness training for its employees. During three training days, nine sessions were conducted in Russian and in English for over 200 employees. A subsequent evaluation of knowledge and attitudes proved that the training had achieved its aims. This assignment became the first successful experience of providing training support to private companies. The capacity of Alliance Ukraine has grown substantially. In 2004, the Alliance Secretariat in conjunction with Alliance Ukraine was the PR of Global Fund Round 1. For Round 6, however, it was important that the co-PR was an independent organisation, based locally. Alliance Ukraine’s transition to the status of Linking Organisation within the Alliance global partnership enabled it to take on this role. Strengthening civil society – as implementers and as advocates – was noted by the comprehensive external evaluation as one of the key contributions of Alliance Ukraine to the national AIDS response. In particular, Alliance Ukraine supported the development of the PLHA Network, which went from an SR in Global Fund Round 1 to a co-PR in

Round 6. Alliance Ukraine also contributed to the capacity development of 150 new and existing NGOs, which in turn provided services, a voice and a platform for those affected by HIV. The external evaluation reported that the Alliance’s ‘impressive’ performance as PR in Round 1 and 6 ‘demonstrates that direct financing of Global Fund grants to civil society recipients can improve the speed of grant implementation and help mobilise additional implementation capacity.’ Ukraine is facing a shrinking donor base, and in response Alliance Ukraine is aiding NGOs to become financially sustainable. Five NGOs have set up small businesses, using profits to fund their work. Alliance Ukraine has secured funds from businesses such as the Levi Strauss Foundation to support its HIV prevention projects.

SD3: Strengthen communities influence in national programming and in national and international policy Policy and advocacy activities of Alliance Ukraine have led to distinct achievements. For example, a campaign organised by Alliance Ukraine, the PLHA Network and their partners resulted in the government decision to take over responsibility for administering ART. The 6,070 patients who received ART through the Alliance Ukraine’s Global Fund programme were handed over to the government in January 2009 for continued treatment, supported by the state budget. Furthermore, in 2006 the criminalisation of sex work was repealed, due to advocacy efforts of Alliance Ukraine and its partners. Alliance Ukraine also developed and led an advocacy campaign which introduced SMT into the country for the purpose of promoting adherence to ART and prevention of HIV among people who use drugs. However, methadone-based SMT, which is cheaper than buprenorphine, remained illegal. Therefore, the next phase of the campaign focused on removing barriers to methadone-based SMT. Restrictions were lifted in May 2008, representing a major policy breakthrough. However, sustained opposition to SMT within the state hindered scale-up, but eventually progress was made when the Minister of Health signed an order for the expansion of SMT. The National Programme for 2009-2013 now includes SMT with methadone. Nevertheless, there have been ongoing challenges in SMT provision, as some doctors and other health and social professionals involved in SMT provision and work with drug users in Ukraine have been subject to criminal prosecution, harassment and intimidation by law enforcement officers in Ukraine. In the face of political instability and frequent changes in government, Alliance Ukraine’s flexible approach enabled ongoing dialogue with government. This strategy was complemented by its work with more

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stable middle-level decision makers. A partnership with the Ministry of Education and Science brought about life skills-based HIV education. In 2008, 57% of schools were staffed with appropriately trained teachers and 27% of pupils had access to quality prevention course. With life-skills education now included in the National AIDS Programme 2009-2013, government funding in this area is safeguarded. Lastly, in response to an environment of declining funding, Alliance Ukraine and its partners lobbied the government to increase funding for HIV/AIDS with the result of a new national programme that is the bestresourced to date.

Injecting drug users receiving peer support, Kiev, Ukraine ÂŠ Natalia Kravchuk/Alliance Ukraine

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

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zambia

Summary of country programme HIV prevalence in Zambia is 14.3% among adults and one million people are living with HIV. HIV in Zambia is mainly transmitted through unprotected sex. The epidemic is fuelled by multiple concurrent partnerships and transactional, commercial and intergenerational sex. Of the 416,333 in need of antiretroviral treatment, 68% were receiving it at the end of 2009. Treatment access is much lower among children. Due to poor coverage of programmes to prevent motherto-child transmission, approximately 95,000 children are living with HIV in Zambia. The country is also home to an estimated 600,000 AIDS orphans. The Alliance opened a Country Office in Zambia in 1999. This office is currently in the process of becoming a Linking Organisation – an independent A game of tag designed by Sports in Action in Zambia to educate youth about HIV national NGO known as Alliance for Community © Gideon Mendel for the Alliance Action on HIV and AIDS in Zambia. Over the last 10 years, Alliance Zambia has mobilised community responses on HIV by providing technical support, SD1: Scaled up quality community programmes training, mentoring and funding community-based delivered and access to health and HIV services organisations (CBOs). The key focus of its work is improved community and government health systems strengthening. It has developed significant 2007 2008 2009 experience in the following Number of people reached 10,363 7,023 1,530 programme areas: promotion through HIV prevention of comprehensive treatment activities access and adherence Number of individuals Data 12,408 17,492 and positive living, stigma reached with treatment unavailable reduction, orphan and and adherence support vulnerable children protection and youth prevention. More Number of individuals 2,908 21,476 49,226 reached through stigma recently, Alliance Zambia has and discrimination developed policy experience reduction initiatives in broader health issues. Number of orphans and/

354

1,191

5,701

or vulnerable children A major programme was the receiving care and support Antiretroviral Community within the community Education and Referral (ACER) Programme, funded in part by the Global Fund, which championed people The ACER programme ran from 2004-2009. The living with HIV as agents to increase referrals and model involved training people living with HIV to be adherence to treatment. In 2009, Alliance Zambia the treatment support workers, who acted as agents introduced a whole school site approach to improve for reducing stigma and discrimination in the wider the sexual, reproductive and psychosocial health community, and encouraged others to get tested and of young people 10-20 years of age in Zambia and helped them to adhere to antiretroviral therapy (ART). Swaziland. It scaled up to work with 550 treatment support workers in five of Zambia’s nine provinces. Initially the government only piloted ART provision at certain health centres. The involvement of treatment support workers at these centres helped the government agree to scaling up the decentralization of ART provision. The ACER programme subsequently became the largest adherence programme in Zambia, and went on to get funding from the Global Fund. It also became a model for the Alliance’s referral

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programmes in Uganda, Ethiopia and Malawi. The four key outcomes of involvement of openly HIV positive treatment support workers were: increased ART adherence; increased referrals between organisations in the community to health facilties and from health facilities back to the community for care and support; reduction in health centre workers’ workload (as health facilities often only have 50% of the staff needed); and a reduction in stigma and discrimination. The programme has used drama, dance and radio to raise awareness of HIV services. It has trained health workers, traditional healers, birth attendents on making referrals. In November 2007, Alliance Zambia started a programme to strengthen government and community support systems for orphans and vulnerable children (OVC), which has reached over 8,000 vulnerable children through seven CBOs. The CBOs are able to take advantage of recent a government led social protection scheme (Public Welfare Assistance Scheme) aimed at the most vulnerable children to ensure their basic needs are met, including education, healthcare and good nutrition. Selected households receive a holistic package of support, including educational support, nutritional support, livelihoods support and psychosocial support. For example, children receive books, uniforms and shoes, and their school fees are paid. Nutritional support includes food packets, and cooking demonstrations to help parents and carers cook nutritious foods. Households are supported through various economic strengthening initiatives such as cash grants, agricultural inputs and small livestock. The Alliance’s Regional Stigma and Discrimination Programme is based at Alliance Zambia. The aim of the programme is to train trainers on HIV stigma who can then support scale-up of anti-stigma interventions – at individual, family, community, national and institutional levels. By reducing stigma and discrimination, access to HIV services is increased. By 2009, over 600 trainers had been trained through the programme. Through integration and roll out activities, each trainer reaches hundreds of others. For example, in just six months, 20 Zambian trainers had reached more than 4,000 people. A major achievement of the programme has been training of policy makers, who are then able to support anti-discrimination policies at a national level.

SD2: Increase civil society capacity to implement effective community responses Supported by the Global Fund, Alliance Zambia has strengthened leadership and capacity of CBOs to implement prevention, treatment, care and support activities. Technical support is provided through regular technical visits, mentoring and skills building workshops. Alliance Zambia uses its own toolkits on

community engagement for anti-retroviral treatment, stigma and discrimination, gender and sexuality, positive prevention and life skills to share knowledge at CBO and community level. In addition, Alliance Zambia facilitates learning exchanges between communities and organisations. Alliance Zambia’s stigma team have trained national teams of anti-stigma trainers across 24 African countries since 2004. The stigma team carries out training around the continent, using the manual ‘Understanding and Challenging HIV Stigma: Toolkit for Action’ to support organisations and communities develop strategies to tackle HIV-related stigma. The training is coupled with ongoing technical support to ensure it is integrated into the activities of participating organisations, and into national responses. Alliance Zambia strengthened the capacity of 7 CBOs to engage communities they planned to serve in deciding what should be supported, using the Alliance’s OVC toolkit ‘Building Blocks’. This led to the development of proposals that incorporated ideas from households and children. Alliance Zambia also helped them in the use of the government’s social welfare beneficiary identification matrix, report writing and data collection, and engaging with beneficiaries with a view to identifying success stories. A major impact has been recognition by the CBOs that the matrix for identifying the most vulnerable children is extremely effective. Based on this, other CBOs in the area have decided to work with the government and use this matrix for their targeting of beneficiaries. Alliance Zambia is building the capacity of government structures to take a pivotal role in coordination of support for OVC at community and district level. It has built the government’s capacity to collaborate with civil society organisations (CSOs) at district level, funding coordination meetings to share information and develop trust. As a result, district level partners have become aware of which other organisations are working with OVC and the areas of support each is providing. Alliance Zambia is also developing an OVC database with the Ministry, and it has trained CSOs to understand the government’s social welfare mechanisms, such as the Public Welfare Assistance Scheme, and how to work with them. The approach aims to ensure that CSOs avoid duplicating work and are able to distribute limited resources fairly, including to more remote, rural communities.

SD3: Strengthen communities influence in national programming and in national and international policy The National Partnership Platform (NPP) is a policy initiative currently being hosted by Alliance Zambia, spearheading coordination of civil society around HIV and TB. Officially launched in 2007, the NPP is a

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partnership of 19 national CSOs that has stimulated unity and focus in advocacy while also opening up dialogue and improved accountability of government stakeholders. It has played a critical role generating dialogue between communities and policy makers around UNGASS reporting. The NPP continues to monitor national HIV, TB and more recently sexual and reproductive health rights targets and milestones. Based on assessment by partners and stakeholders, the NPP adopted Sexual Reproductive Health and HIV for the advocacy agenda in 2010. An e-forum of the NPP has built up a membership of 1,000 subscribers and recently held a debate on the issues of multiple concurrent partners. Contributing to the e-forum are a cadre of community-based writers, called Key Correspondents (KCs). Two Zambian KCs are ambassadors for the Here I Am campaign, launched in advance of the Third Replenishment Conference of the Global Fund to Fight AIDS, TB and Malaria, which presents the personal stories of those who are alive today thanks to programmes supported by the Global Fund. A project supported by Oxfam-NOVIB through the Centre For Economic Governance And Aids In Africa aims at improving participatory budgeting and budget monitoring for health (particularly HIV/AIDS services) by civil society organisations or coalitions in Southern Africa. With Zambian civil society, Alliance Zambia is tracking funding and monitoring budget

support for HIV treatment. This includes analysing how ART budgets are developed, how they are allocated, disbursed and utilised at health facility and community levels. The information gained will help measure progress towards universal access targets, the Abuja Declaration and the Millennium Development Goals. It will be used by civil society for advocacy, by government for health planning and by donors for effective resource allocation and distribution. In late 2009 Zambia held its first national HIV prevention convention, with significant support from Alliance Zambia. Over 250 delegates came for the three-day event from across a wide range of stakeholders including the NAC, UNAIDS and other UN agencies, USAID, INGOs and national civil society. The high profile event was opened by Zambian President Rupiah Banda, closed by Vice President George Kunda, and led to national television, radio and newspaper coverage. The convention identified six key drivers of Zambiaâ&#x20AC;&#x2122;s epidemic. These included multiple concurrent partnerships, low and inconsistent condom use, low rates of male circumcision, the mobility of Zambian workers to find jobs, mother-to-child transmission, and poor services for women and other vulnerable populations who are not protected by the law. A series of resolutions was taken to the Vice President on the final day, increasing pressure for policy change to address them.

Children playing in George compound, Lusaka, Zambia ÂŠ Liza Tong for the Alliance

Alliance country studies: a global summary of achievements, progress and challenges under IMPACT 2010

Acknowledgments This series of country studies was developed and compiled by the Alliance secretariat. The two authors are Maresa Pitt and Julia Ross. Special thanks to Field Programmes geographic teams for their support and constant supply of key documents.

About the International HIV/AIDS Alliance Established in 1993, the International HIV/AIDS Alliance (the Alliance) is a global alliance of nationally-based organisations working to support community action on AIDS in developing countries. To date we have provided support to organisations from more than 40 developing countries for over 3,000 projects, reaching some of the poorest and most vulnerable communities with HIV prevention, care and support, and improved access to HIV treatment. The Allianceâ&#x20AC;&#x2122;s national members help local community groups and other NGOs to take action on HIV, and are supported by technical expertise, policy work, knowledge sharing and fundraising carried out across the Alliance. In addition, the Alliance has extensive regional programmes, representative offices in the USA and Brussels, and works on a range of international activities such as support for South-South cooperation, operations research, training and good practice programme development, as well as policy analysis and advocacy.

International HIV/AIDS Alliance (International secretariat) Preece House 91-101 Davigdor Road Hove, BN3 1RE UK

Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901 mail@aidsalliance.org www.aidsalliance.org Registered charity number: 1038860

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