HIV GTZ Models of Care by IPPF

Models of Care Project Linking HIV/AIDS treatment, care and support in Sexual and Reproductive Health care settings: Examples in Action

Abbreviations and acronyms AIDS ARVs ARBEF ART CCM FPAs FPAK GFATM GIPA GTZ HIV IPPF LGBT MAs MoC MSM NGO OIs PLHAs PMTCT SRH STI UNAIDS VCT

Acquired Immunodeficiency Syndrome Antiretrovirals Association Rwandaise pour le Bien-être Familial (Family Planning Association of Rwanda) Antiretroviral Therapy Country Coordinating Mechanism Family Planning Associations Family Planning Association of Kenya Global Fund to Fight AIDS, Tuberculosis and Malaria Greater Involvement of People living with HIV/AIDS Deutsche Gesellsschaft fur Technishe Zusammenarbeit (German Technical Cooperation Agency) Human Immunodeficiency Virus International Planned Parenthood Federation Lesbian, Gay, Bisexual and Transgender Member Associations (of IPPF) Models of Care (Project) Men who have Sex with Men Non-Governmental Organization Opportunistic Infections People Living With HIV/AIDS Prevention of Mother-To-Child HIV Transmission Sexual and Reproductive Health Sexually Transmitted Infection Joint United Nations Programme on HIV/AIDS Voluntary Counselling and Testing

Cover: Clients being weighed at an FPAK clinic in Nakuru, Kenya

ACKNOWLEDGEMENTS & CREDITS Project consultants: Debra Jones (Dominican Republic and Colombia), Farst Africa (Rwanda), Marcela Rueda (Colombia) Katinka de Vries (Youth course evaluation), Brian Griffin (Youth course evaluation) Editing and development of booklet: Derrick Fine Published in December 2005, London, United Kingdom © 2005 International Planned Parenthood Federation For more detailed information on the case studies or for more copies of this booklet, please contact: International Planned Parenthood Federation 4 Newhams Row, London SE1 3UZ, United Kingdom tel fax email web

+44(0)20 7939 8200 +44(0)20 7939 8300 info@ippf.org www.ippf.org

Contents SECTION 1: Introducing the Models of Care Project

What does the project aim to achieve? What are the different project components? What is the aim of this booklet? What have the projects achieved?

5 5 6 6

SECTION 2: Case studies

DOMINICAN REPUBLIC

KENYA

RWANDA

COLOMBIA

SECTION 3: H IV/AIDS: Vulnerability, Rights and Young People

Models of Care Project

What were the aims of the course? How was the course and its evaluation designed? What were the key results of the course?

Models of Care Project

Introducing the Models of Care Project What does the project aim to achieve? In 1987, the International Planned Parenthood Federation (IPPF) was one of the first organizations to recognize the importance of HIV/AIDS in sexual and reproductive health (SRH) and development, and to propose integrating HIV/AIDS responses into a wider health and SRH setting. Integration is one part of IPPF’s commitment to enable Member Associations (MAs) to mainstream HIV/AIDS into all aspects of their work at grassroots level. For IPPF, mainstreaming HIV/AIDS means that all sectors and organisations should determine: • How the spread of HIV is caused or contributed to by their sector or operations. • How the HIV/AIDS pandemic may affect their aims and programmes. • How their sector has the opportunity to limit the spread of HIV and to mitigate the impact of the pandemic. • How they can use all this information to take action. The experience of IPPF MAs and others working in the field shows that integrating HIV/AIDS responses has been the most effective method of reducing the rate of HIV transmission. Programmatically, IPPF believes that this is the most appropriate response to the HIV/AIDS epidemic, and the most cost-effective way of meeting the Millennium Development Goals around poverty alleviation, maternal and infant mortality, and HIV/AIDS. Working through its extensive network of local organizations, IPPF has access to local knowledge and experience, ready-made infrastructure, and the fundamental ingredient of legitimacy and trust with people in communities benefiting from services Strengthening SRH non-governmental organizations’ (NGO) involvement in HIV/AIDS prevention, treatment and care programmes will contribute to the success of global alliances and partnerships to fight HIV/AIDS. This approach aims to ensure that effective strategies are adopted across sectors at community level to tackle the HIV/AIDS pandemic. Supported by an 18-month grant by the Deutsche Gesellsschaft fur Technishe

Zusammenarbeit (GTZ), the project ran from June 2004 until the end of 2005. It aims to produce knowledgeable and sustainable HIV/ AIDS models in different SRH settings that can be adapted and implemented by IPPF MAs worldwide. The project aimed to strengthen and link the delivery of HIV/AIDS care and treatment to already existing family planning and SRH services, together with developing the HIV/AIDS skills and competencies of MA staff.

INTRODUCTION

What are the different project components? The main project outputs of the Models of Care (MoC) Project are: • Developing a global course for SRH professionals on vulnerable groups, young people and HIV/AIDS to support the SRH movement as it redirects its focus to the challenges of the HIV/AIDS pandemic. • A systematic process of sensitizing MAs to enable them to recognize themselves as partners in meeting HIV/AIDS challenges. • An advocacy pack for MAs, setting out the work of the Country Coordinating Mechanism (CCM) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and detailing suggestions of how MAs can become involved. • Undertaking four pilot projects to develop models of best practice for member associations to increase their involvement in various aspects of HIV/AIDS programming and strengthen the work of the CCM. For the pilot projects, IPPF focused on four countries using different entry points to target HIV/AIDS through traditional SRH organizations: the Dominican Republic, Kenya, Rwanda and Colombia. The countries chosen for the pilots were a diverse mix of socio-economic and cultural realities, and thus presented the opportunity for useful lessons that can be applied elsewhere. Three key questions were addressed while implementing these pilot projects: • The MoC approach examined ways for SRH organizations to implement antiretroviral (ARV) treatment to SRH clients. • The pilots assessed how and to what extent integrated SRH services can contribute to lessening stigma around HIV and AIDS. • The pilots highlighted the main practical implications of integrating ARV treatment within SRH services.

Models of Care Project

SECTION 1

INTRODUCTION

What is the aim of this booklet? IPPF wishes to showcase different models using a variety of entry points to bring SRH closer to HIV/AIDS. The three types of examples in action covered in this booklet use these entry points: • Better linking of prevention and care through providing ARVs and opportunistic infection (OI) services (our case studies on the Dominican Republic, Kenya and Rwanda). • Working with and developing programmes to reach specific populations (our case study on Colombia). • Strengthening programming to address HIV/AIDS vulnerability and young people (our youth course). We will summarise the four case studies under these questions: • W hat needs did the project respond to? This part reflects on the country context and the aims of the pilot project. • H ow have these needs been addressed? Here we set out the process followed and some of the key activities that have been implemented. • What has been achieved? We highlight the main results and outcomes to date. • What lessons have been learned? We examine responses to successes and difficulties. • What challenges are being addressed? We explore project challenges and pointers for addressing them. We share some of the content of progress made in training and capacity-building through the course on HIV/AIDS: Vulnerability, Rights and Young People. We document the course under these headings: • What were the aims of the course? • How was the course and its evaluation designed? • What were the key results of the course? • What improvements can be made?

Models of Care Project

What have the projects achieved?

The pilot projects to create models of practice have been implemented successfully. In the Dominican Republic, an effective ARV delivery programme is well underway. The MA, Asociacion Dominicana Pro-Bienestar de la familia (PROFAMILIA), has achieved a quality service offering antiretroviral therapy (ART), medical care, education, counselling and emotional support for people living with HIV and their families. Multi-disciplinary teams have been formed and trained in two clinics and

negotiations are taking place for PROFAMILIA to provide training to government officials. In Kenya, the staff capacity of the MA, the Family Planning Association of Kenya (FPAK), has been greatly improved as a result of the pilot. Clinics have provided HIV/AIDS services to an increasing number of people and, after a site assessment, FPAK is already delivering ART. Ongoing meetings are being held with government HIV/AIDS structures, local organizations and the GTZ country office to build support for the programme. In Rwanda, the MA, Association Rwandaise pour le Bien-être Familial (ARBEF), did a site assessment and is preparing to link HIV prevention and care more comprehensively. In the meantime, it continues to refer clients to access ART from government. The assessment recommended that ARBEF should draw on its lengthy experience in family health and strong community links. ARBEF is continuing to strengthen its staff capacity. In Colombia, the MA, Asociacion Pro-Bienestar de la Familia Colombiana (PROFAMILIA), has moved from its very productive first phase and is carrying out a number of activities, such as a series of far-reaching sensitization workshops with 35 PROFAMILIA clinics. PROFAMILIA developed a variety of creative materials to reach vulnerable populations, including men who have sex with men (MSM) and their partners. In the training and capacity-building component of the project, IPPF held an innovative two-week HIV/AIDS: Vulnerability, Rights and Young People course in South Africa in November 2004. The course focused on the policy and programme links between HIV/AIDS, vulnerability, human rights and young people. At the end of the course, participants from MAs developed action plans, based on lessons from the course. Funding was made available for selected small-scale projects to: • Promote the participation of young people living with HIV/AIDS in Kenya and Nigeria. • Mitigate stigma and discrimination against people living with and affected by HIV in Uganda. • Reduce barriers and improve SRH and HIV/AIDS links in Sudan. • Increase HIV voluntary counselling and testing (VCT), and improve pre- and posttest counselling in Colombia.

Dominican Republic

Members of HIV+ support group at Santiago Clinic

DOMINICAN REPUBLIC

SECTION 2

Case studies DOMINICAN REPUBLIC

Models of Care Project

What needs did the project respond to?

The IPPF-affiliate PROFAMILIA Dominican Republic (Asociación Dominicana Pro-Bienestar de la Familia) has been engaged in a GTZ-funded pilot project to provide comprehensive HIV/AIDS care and treatment, including ART. About 29% of the population of the Dominican Republic live below the poverty line, according to World Bank statistics. In 2001, the Government of the Dominican Republic included a strong population perspective in its Poverty Reduction Strategy Paper, and several successful programmes on adolescent reproductive health have operated over the last few years. Today, poverty and domestic and gender-based violence remain enormous challenges. The Dominican Republic is among the countries with the highest prevalence of HIV in the Caribbean – 120,000 people are living with HIV/ AIDS, nine times the total number of reported cases. In particular, the prevalence of HIV is rising in the 15–24 age group (Presidential Commission for HIV/AIDS). HIV/AIDS is the leading cause of death among women of reproductive age. Prevalence is highest (5% of adults) among low-income groups that include many Haitian immigrants living in rural communities and working on sugar cane plantations. Prevalence among female sex workers is about 8%, reaching 12% in some cities. PROFAMILIA has a lot of experience in working with youth aged 13 to 20, providing them with education and services in SRH through a network of more than 600 trained youth peer educators. PROFAMILIA does awareness-raising in local and national media on reproductive rights, teen pregnancy, and the importance of sex education in schools. Since the early 1990s, PROFAMILIA’s SRH project began including HIV/AIDS, health rights, and HIV and sexually transmitted infection (STI) prevention in its clinical and community outreach work. When its youth programme included HIV prevention in its health promotion activities, PROFAMILIA clinics saw an immediate increase in new people needing VCT. By the late 1990s, there was a need for PROFAMILIA to train its staff to be able to respond to the clinical management and treatment needs of people living with HIV/AIDS. The pilot project in the Dominican Republic aimed to: • Increase access for people living with HIV/AIDS (PLHAs) to comprehensive services

for managing and treating HIV/AIDS through two clinics in the Dominican Republic. • Improve the awareness and attitudes of PROFAMILIA staff on care around HIV infection and treatment, including stigma reduction. • Expand advocacy efforts that target influential people and decision-makers in the health sector in order to promote the right to timely, quality care and access to ARV medicines for PLHAs.

How have these needs been addressed? Getting started In early 2004, PROFAMILIA’s Santo Domingo Clinic trained a core HIV/AIDS team. With the donation of ARVs from government and training support from Columbia University, the clinic began offering treatment to a small group of people living with HIV. The IPPF/GTZ initiative has allowed PROFAMILIA to: • Pilot a model to integrate HIV care and treatment more systematically into existing SRH services. • Expand integrated services to a second clinic in Santiago.

HIV/AIDS treatment programme approach The treatment pilot rested on seven key elements: • Health care worker training – IPPF and a variety of institutions have assisted with training. • Laboratory tests – the percentage of people testing HIV positive rose to 5.4% in the first half of 2005. • Pre-test counselling – there is education in clinic waiting rooms and one-on-one counselling before HIV testing. • Post-test counselling – this can include communicating test results, giving more information on HIV/AIDS and an invite to a support group. • Support group – groups at both clinics meet monthly to give each other support and discuss topics like self-care. • Multi-disciplinary team – this usually comprises a doctor, a nurse and an educator (often a psychologist). • Monitoring treatment adherence – this includes ongoing education, individualized explanations of medicines, identifying adherence barriers and solutions, and regular visits, interviews and emotional support.

The Santo Domingo clinic decided not to have a separate HIV/AIDS section of the clinic. HIV/AIDS counselling takes place in the general counselling and emotional support section of the clinic. A family planning office had to relocated to ensure confidentiality in the counselling area. At the start of the treatment programme, people qualified for ART if they had a CD4 count lower than 200 or a series of OIs at the time. Before starting ART, clients receive vitamins and Bactrim in a weekly pill container to prepare them for regular pill taking, and to strengthen them and prevent infections. Once clients are stable on their ART, they meet monthly with the nurse, and every three months or on a needs basis with the doctor.

Developments in Santiago Following the success of the model in Santo Domingo, PROFAMILIA decided to expand treatment to the Santiago Clinic in mid-2005. Here health service options include hospitalization and extend beyond SRH services. Yet, PROFAMILIA was keen to ensure that new HIV/AIDS treatment services would integrate into the clinic’s other services, rather than creating a separate area of service. People who do not qualify for ARV treatment receiving general counselling on HIV/AIDS, and

return every six months for a general check-up and laboratory tests. All clients living with HIV are invited to attend monthly support group meetings, where nurses lead discussion on topics such as self-esteem and nutrition.

What has been achieved? Saving lives Staff at both clinics highlight that the programme has saved lives and there is a renewed hope for people living with HIV. At present, the Santo Domingo Clinic has nearly 100 clients with HIV, including 41 people on ART. The Santiago Clinic is providing ART to 26 people, while 39 people living with HIV are being monitored. According to educator, Ana Gloria Garcia, after almost nine years of HIV prevention efforts that still left patients dying: “PROFAMILIA has compensated in one and a half years for the impotence of the past decade. We are saving lives.”

Empowerment of clients People living with HIV become empowered and independent in taking responsibility for improving their health. Additionally, they realize that HIV/AIDS is a chronic disease that they can manage. Clients arrive with little hope and in time learn to live with HIV/AIDS.

Members of HIV+ support group at Santo Domingo clinic

According to educator, Ana Gloria Garcia, after almost nine years of HIV prevention efforts that still left patients dying:

“PROFAMILIA has compensated in one and a half years for the impotence of the past decade. We are saving lives.”

Models of Care Project

Developments in Santo Domingo

DOMINICAN REPUBLIC

A client on ARVs in Santo Domingo captures the sense of hope that treatment and adherence can bring:

“After I started on ARVs, my life has dramatically changed… these medicines are marvellous because they make miracles possible… Thanks to God and to you who facilitate these medicines… I know that with these medicines, I can live a long life… when they are taken as prescribed.”

Adherence The pilot project has achieved good levels of adherence, with 95% of clients staying on ART for six months or longer. The team attributes this to the multi-disciplinary team approach, especially the in-depth counselling and education sessions. A client on ARVs in Santo Domingo captures the sense of hope that treatment and adherence can bring: “After I started on ARVs, my life has dramatically changed… these medicines are marvellous because they make miracles possible… Thanks to God and to you who facilitate these medicines… I know that with these medicines, I can live a long life… when they are taken as prescribed.”

Confidentiality and integrating HIV/AIDS services The integrated service structure for the HIV/ AIDS programme, without a separate physical structure, has reduced the disruption that incorporating new services had the potential to cause. More importantly, confidentiality is high and clients receive the support and services, but are not identified as ‘HIV/AIDS clients’. People living with HIV/AIDS do not feel isolated and all clients are treated equally.

Multi-disciplinary team approach Case study analysis and weekly meetings to review difficult cases have been a good strategy to build the capacity of the HIV/AIDS team and clinic administrators. A key component of the success of the team approach is the mutual respect and open communication of all team members.

Reduced stigma and discrimination Important advances have been made in raising HIV/AIDS awareness among PROFAMILIA staff and in training the multi-disciplinary team in key competencies of HIV/AIDS care. Clinic staff is now bringing relatives and friends for HIV counselling, care and treatment.

Models of Care Project

National treatment model: alliance with Dominican Government

Two PROFAMILIA clinics have been incorporated into the Dominican National AIDS Care Network of 18 health care centres as model programmes to be replicated nationally. This network membership will ensure access to and cover the costs of ARV medicines and certain laboratory tests. Network benefits have yet to be fully evaluated as they only began in Santo Domingo in September 2005, and the

first ARVs were requested for the Santiago Clinic in November 2005.

What lessons have been learned? PROFAMILIA’s HIV/AIDS treatment programme has had its share of successes and challenges. The experience gained can serve as valuable lessons for other NGOs focusing on SRH in developing countries that are trying to launch their own ART programmes.

Starting an HIV/AIDS treatment programme Useful tips from the Dominican experience are: • The executive level should support an HIV/AIDS treatment programme. • Choose a proven model and adapt it. • HIV/AIDS services should be just another service in the package of SRH services offered, rather than converting a clinic into an ‘HIV/AIDS centre’. • Select staff that are committed and passionate about HIV/AIDS. • Focus early activities on staff awarenessraising to address myths and prejudices about HIV/AIDS, and to build their confidence. • Try to establish individual and group counselling services. • Consider a sliding-scale approach to cover certain client costs. • Establish and strengthen partnerships with government and other organizations in the field.

Training and mentoring of staff Staff will learn by doing. One-on-one training on-site with clients and supervision is critical. PROFAMILIA teams in Santo Domingo and Santiago have developed greatly with direct supervision. Clinic staff have learnt through practice and over time, and benefited from onsite visits in the United States and South Africa.

Integration with other sexual and reproductive health services SRH centres are a setting to reach sexually active people and to promote HIV/STI prevention, VCT and unwanted pregnancies. It is possible to offer HIV/AIDS services in a contraceptive clinic, without segregating clients with HIV from clients for other services. Treating clients the same way is highly valued by people seeking HIV/AIDS services. “I feel like any other person in the waiting room. We sit in the same seats and share the same room as everyone else, and thus, I do not feel pinpointed. No one knows in the waiting room that I am HIV positive”.

that offer medical services for people with HIV have rejected PROFAMILIA clients with OIs needing hospitalization. PROFAMILIA in Santiago initially covered hospitalization for HIV clients, but found that the cost was too high. Clients in both clinics highlight the inhumane treatment that people living with HIV/AIDS often receive at public hospitals.

Publicizing of services Publicity about HIV/AIDS services at PROFAMILIA clinics has been discreet because of their capacity limitations. If demand for PROFAMILIA’s HIV/AIDS services dramatically increased, the clinics may not be able to meet the demand.

Building alliances Multisectoral approaches should be promoted with the involvement of, for example, government, NGOs and academics. Programme sustainability depends on broadbased commitment and resource mobilization. Local government plays an important role in mobilizing funds and medicines, as well as creating an enabling policy environment. Universities and international agencies offer crucial technical assistance that is often lacking.

Monitoring and evaluation A clear monitoring and evaluation plan, with checklists and indicators, is important to the success of any treatment programme. In particular, monitoring plans must assess and ensure adherence to drug regimens.

Gender-based violence Women living with HIV often ask how to tell their husband or partner about her HIV status. The Santo Domingo clinic’s counsellor is interested in studying the different patterns in partner response, based on whether the partner is male or female. This will test the theory that male partners tend to react violently and abandon their female partners with HIV, while female partners tend to remain with and care for their male partners with HIV.

Training within PROFAMILIA Initially, the pilot programme observed discrimination and stigma by health care providers within PROFAMILIA clinics. However, these fears subsided through awareness-raising and staff training. One obstacle to continuing education is that HIV/AIDS teams at both clinics have full work schedules and do not have much free time for training. Examples of areas for ongoing training are: • Patient rights to confidential services. • The HIV/AIDS rights of workers. • HIV and the rights of pregnant women.

Referrals and stigma among health care providers There is still a lot of stigma and discrimination in Dominican health centres and within the medical community. Public clinics and hospitals

“I feel like any other person in the waiting room. We sit in the same seats and share the same room as everyone else, and thus, I do not feel pinpointed. No one knows in the waiting room that I am HIV positive”. HIV Positive client, Santiago Clinic

Information, education and communication There is a lack of adequate educational materials for PLHAs. Most materials come from the United States and have not been adapted to be culturally appropriate for the Dominican setting. Additionally, most clients have a low educational level and low reading skills. Counsellors create visual tools to use in workshops and one-on-one counselling sessions. PROFAMILIA is currently developing brochures and information sheets on subjects such as: • HIV/AIDS prevention. • Having an HIV test.

What challenges are being addressed?

DOMINICAN REPUBLIC

• Living with HIV.

Improved health of people on treatment Improved well-being of programme participants is an achievement as well as a challenge around issues such as adherence and possible drug resistance. The Santo Domingo nurse, Flor Benitez, says: “Once people feel physically better, they see less reason to have the physical exam at the clinic. Some even begin to question the need to continue with the treatment programme.”

Access to essential medicines Access to ARV medicines has been inconsistent and costly in Santo Domingo. Initially, the Clinton Foundation provided ARVs and now these come from the Dominican Government. However, there have been gaps in availability. Consistent access to ARVs is critical to ensure adherence, avoid viral resistance and achieve high quality service.

“Once people feel physically better, they see less reason to have the physical exam at the clinic. Some even begin to question the need to continue with the treatment programme.” The Santo Domingo nurse, Flor Benitez

Models of Care Project

HIV Positive client, Santiago Clinic It is critical to address gender inequity in HIV/AIDS services. Once a woman’s HIV status is determined, her primary concern is how her partner may react. Her HIV status has the potential to lead to gender-based violence in various forms.

DOMINICAN REPUBLIC

Expense issues Analysis is costly, as only three machines exist in the country to measure CD4 counts and viral loads. All are in Santo Domingo. PROFAMILIA is currently negotiating the donation of a CD4 machine for Santiago, as well as the payment of CD4 tests for five years.

Institutional protocol for HIV/AIDS services and treatment In order to guarantee quality HIV/AIDS services and facilitate the expansion of HIV/AIDS services in other clinics, PROFAMILIA has started a process to develop an institutional HIV/AIDS care protocol. The process will be participatory and the protocol will be based on national norms of HIV/AIDS care.

Models of Care Project

Members of the monitoring programme at the clinic in Santiago

Kenya

Food for a nutrition programme at FPAK

KENYA

KENYA What needs did the project respond to? The Kenyan pilot MoC project was a GTZfunded initiative of IPPF MA, the Family Planning Association of Kenya (FPAK), to integrate comprehensive HIV/AIDS care into its existing network of SRH services. The Joint United Nations Programme on HIV/AIDS (UNAIDS) says that: “AIDS is an extraordinary crisis – it is both an emergency and a long-term development issue. More than 20 years and 20 million deaths since the first AIDS diagnosis in 1981, almost 38 million people are living with HIV.” (UNAIDS Global Report, 2004).

Historically, the FPAK has complemented the efforts of the Government and other agencies to improve a national family planning and reproductive health programme. FPAK has also focused on specific issues such as youth services, the status of women, the involvement of men, and developing its own services. FPAK has played a key role in integrating HIV prevention into national SRH services. The pilot project built on HIV/AIDS prevention and care work already present in FPAK services, including: • Peer education and behaviour change communication. • Voluntary counselling and testing (VCT). • Prevention of mother-to-child transmission (PMTCT). • Support groups to promote positive living and psychosocial care. The pilot aimed to increase access to and use of HIV/AIDS care and support services for people living with HIV/AIDS (PLHAs) in Kenya. Specific aims were to: • Strengthen the capacity of FPAK to provide HIV/AIDS care and support services. • Gradually increase the level of access to HIV/ AIDS care and support services for PLHAs in four FPAK clinics.

How have these needs been addressed?

Models of Care Project

The waiting room at an FPAK clinic in Nakuru

The project was initially designed as a one-year pilot process to introduce ART into the services of four out of FPAK’s nine SRH clinics. Two clinics were already providing PMTCT services and seven had VCT services. AIDS was first reported in Kenya in 1984 and by January 2005, an estimated 2 million Kenyans were living with HIV (Ministry of Health, 2005). The HIV prevalence among women, who make up 65% of adults, is 8.7%, while among men it is 4.5% (Kenya Demographic and Health Survey, 2003). Kenya was the first country in sub-Saharan Africa to adopt a family planning programme. Since the late 1970s, total fertility per woman has decreased by nearly one half and contraceptive prevalence has doubled. The MoC project took place against the reality of limited access to high quality, affordable and comprehensive HIV/AIDS services and the need to integrate these services into existing SRH services. The pilot project was part of the global and national process to scale up access to ART. Current estimates indicate that between 33,000 and 46,000 Kenyans were on ART by the end of June 2005, meaning that about 233,000 people needing ART were still without access (UNAIDS/ World Health Organization, 2005).

Project approach The project’s approach was based on four main elements: • Building the capacity of FPAK. • Actual delivery of services. • Demand for the services, and participation of people living with and affected by HIV/AIDS. • Research, monitoring and evaluation.

Site preparedness assessment The site assessment aimed to evaluate current site and programme preparedness (strengths and gaps) to start, manage and sustain ARV programmes using VCT and PMTCT as entry points in selected FPAK clinics. It also began to develop site- specific strategies for starting, managing and sustaining ARV programmes. The assessment was carried out in February 2005. Following a comprehensive literature review, assessment tools were developed. They considered six key areas of ART:

• Leadership and management experience and capacity. • Services and clinical care.

service and health care providers, and HIV/AIDS support groups. Examples of methods are: • One-on-one dialogue.

• Monitoring and evaluation.

• Health education talks in the clinic setting.

• Human resource capacity.

• Brochures and posters.

• Laboratory capacity.

• Stakeholder meetings.

• Drug management and procurement.

Research, monitoring and evaluation

Staff training A core service delivery team (one from each of the four sites and three from FPAK head office) was trained in a six-day HIV/AIDS care course in South Africa. With other Kenyan HIV/AIDS care training professionals, the core team then designed and facilitated a ‘step-down’ training for other FPAK staff in two six-day sessions. This was also an opportunity for participatory development of service delivery tools, such as guidelines and procedures for client selection and follow-up. Further training initiatives focused on: • Training in HIV/AIDS programme management.

Key areas of monitoring and evaluation are project development and roll out, the service delivery person, the process to integrate the different service elements, client monitoring and the projects impact on FPAK and its services. The pilot included a specific component of ‘action research’, initially focused on

KENYA

“Reproductive health, HIV and poverty are so interconnected and must be addressed in an integrated way.” Dr Joachim Osur, FPAK

• Training in other specialist skills, such as adherence counselling. • Experiential training and mentoring. • Training community-based resource people, including distributors of contraceptives, peer educators, and PLHAs as mobilizers and supporters of other PLHAs.

Delivery of expanded services pharmacovigilance – detecting, assessing, understanding and preventing drug adverse effects. This examines issues such as the use of ARVs by pregnant women, potential interactions between ARVs and contraceptives, and nonadherence to prescribed regimens.

HIV positive counsellor explaining PMTCT to support group in Nairobi West

What has been achieved? Service delivery The pilot aimed to provide ARVs to 100 clients annually at FPAK’s clinics in Nairobi West, Thika, Nakuru and Eldoret. October 2005 statistics indicate that since January 2005: • A total of 1,722 clients receiving VCT – 223 people tested HIV positive.

Creating awareness about the ART programme

• Out of 328 pregnant mothers receiving PMTCT counselling and having an HIV test, 20 women tested HIV positive – they all received nevirapine-based PMTCT treatment.

FPAK aimed to increase the visibility of and demand for FPAK HIV/AIDS care and support services with existing clients, other HIV/AIDS

• ART started in June 2005 – by the end of October, 25 people were eligible and had started ART.

Models of Care Project

FPAK has had to modify its existing service delivery to accommodate commencing ART. This has included more integrated counselling and psychosocial support, more sophisticated client monitoring, and introducing procedures for buying ARVs and additional equipment, such as refrigerators and computers. FPAK charges nominal fees for regular SRH services as a way of motivating users to value and adhere to the service. ART is not free, but provided at the current rate of about one-tenth of the market rate, under the Government’s subsidized programme. Treatment for STIs and OIs is integrated into the regular medical care and fees charged at the clinics. “Reproductive health, HIV and poverty are so interconnected and must be addressed in an integrated way.” (Dr Joachim Osur, FPAK doctor).

KENYA

“Among Kenyan youth today, it is seen as ‘cool’ to know your HIV status. Those who don’t go for VCT sometimes feel out of step.” Rufus Murerua, youth centre coordinator

“Among Kenyan youth today, it is seen as ‘cool’ to know your HIV status. Those who don’t go for VCT sometimes feel out of step.” (Rufus Murerua, youth centre coordinator)

Innovation and promising practise The project demonstrates innovation in the way that it has begun to: • Address the acute need for access to ART within and beyond the traditional clients of FPAK, largely based on existing service facilities and contact opportunities. • Pioneer in pharmacovigilance, a largely under-developed aspect of ART monitoring in Kenya. • Reposition HIV/AIDS as an integral component of SRH, and pioneer a model for HIV/AIDS care and support integrated into SRH services. • Establish increased capacity within FPAK to deliver a critical service.

“HIV has opened debate about things that were never discussed before. People are now willing to sit down and say: okay, let’s talk.” Rufus Murerua,

Models of Care Project

youth centre coordinator

Home Based Care group providing food and advice on nutrition in Nakuru

“HIV affects almost every area of sexual and reproductive health work, so you can’t avoid dealing with it.” (Dr Winifred Mwangi, Nakuru Clinic)

ongoing education and treatment support groups. These needs are vital for people on ART, those considering ART, and clients not yet needing ART. The experience in FPAK is that only 10% or less of the PLHAs under care actually need ARVs. “HIV has opened debate about things that were never discussed before. People are now willing to sit down and say: okay, let’s talk.” (Rufus Murerua, youth centre coordinator)

Empowerment and participation of PLHAs Greater involvement of clients and their empowerment for more effective and sustained participation is as important in HIV/AIDS services as it is in other traditional services of FPAK. This approach also supports the international GIPA Principle (the Greater Involvement of People living with HIV/AIDS in policies and programmes affecting them). Participation of PLHAs has been taken beyond token involvement as volunteers: • PLHAs have been employed as paid staff, included on the site advisory committee, and integrated onto the management and advisory board for FPAK.

A wider view of HIV/AIDS treatment and care

• Greater involvement has given PLHAs a stronger sense of commitment to this as long-term work, with possibilities of career development, and it has reduced stigma and discrimination from other staff.

HIV/AIDS care and support demands much more than just providing ART and management of STIs and OIs – the initial project design did not fully address the full range of care and support needs, such as psychosocial support,

• PLHAs have added much credibility to the HIV/AIDS services of FPAK within the communities served, among other HIV/AIDS service organizations, and most vitally among other people living with HIV/AIDS.

What lessons have been learned?

KENYA

FPAK clients receiving advice on nutrition in Nakuru

Meeting costs and needs

The cost of care

Comprehensive HIV/AIDS care is very expensive – it demands careful planning to address all elements, time to adapt facilities and services as necessary, and significant resource investment to start and maintain all services required. It calls for referral partnerships, expanded resource mobilization, and participation of all stakeholders in the process of care and support. Some clients are still not able to afford the FPAK’s subsidized services, and there is a high level of unmet need. There has been a very strong commitment to this project by IPPF and FPAK. Resources were well invested in a detailed site assessment, a participatory project design process, and into committing existing and new resources to modify clinics for delivering the full package of integrated services.

A continuous challenge is to find ways of covering the routine costs of HIV/AIDS treatment and care, such as laboratory costs, nutrition needs, transport to care centres, and running support groups. Collaboration with government services, referrals and attracting more donors are seen as possible solutions.

Limited laboratory service capacity A critical challenge is limited laboratory service capacity within FPAK, especially the lack of a CD4 counting machine and a haematology analyzer. Efforts to use external services have been frustrated by frequent breakdowns of the machines (especially in government hospitals). Also, patient monitoring over time is not possible when laboratories doing CD4 tests are using different counting methods. While World Health Organization guidelines say that CD4 counting machines are not necessary in resource-constrained settings, FPAK is exploring alternatives for improving the laboratory capacity and strengthening patient monitoring.

FPAK will continue to improve programme development guidelines, and training curricula and materials that properly integrate SRH and HIV/AIDS prevention and care, for nationwide application. A weaker area has been the limited opportunities for practical hands-on training. Mentoring relationships have addressed this to a certain extent, although the distances between mentors and staff needing support are often a problem.

Competition There has been a degree of competition and a lukewarm reception to FPAK from other HIV/AIDS service providers. For example, some existing ART services do not accept FPAK staff attachments for training, while others question the role of a ‘family planning and SRH service agency’ in HIV/AIDS care.

Scaling up from the pilot Lessons from this initial implementation period have informed the process to develop a threeyear consolidation and scale-up proposal. This provides for consolidating services in the current four sites, and expanding to all the other five FPAK clinics (two in the second year and three in the third year).

Models of Care Project

What challenges are being addressed?

Programme and training development

Rwanda

One of the income generating activities organized by the HIV positive support group in Rwanda

What needs did the project respond to? The Rwandan pilot MoC project was an initiative of IPPF MA, Association Rwandaise pour le Bienêtre Familial (the Family Planning Association of Rwanda), and was funded by GTZ. The project’s aim was to increase access to and use of HIV/ AIDS care and support services by people living with and affected by HIV/AIDS. Rwanda’s civil war of the 1990s left a million people dead and a tragic legacy that has affected all areas of the country socially, economically and politically. The war destroyed infrastructure, caused huge psychological trauma and led to a very high degree of population mobility. Estimates are that 60% of the population currently live below the poverty line. People’s health has severely deteriorated due to the genocide. Child mortality has risen dramatically, with almost one child in five (19.6%) dying before the age of five. HIV/AIDS prevalence has risen rapidly and is at 5.1 % (UNAIDS Report, 2004). As part of the Government’s HIV/AIDS strategy, groups at high risk of HIV infection will be targeted for sensitization, for example young men and women, truck drivers, sex workers, soldiers and other public servants who travel frequently. A high number of people living with HIV/ AIDS (PLHAs) need to be hospitalized, and this has placed much stress on health service structures. There is limited access to ART and treatment of OIs, especially in rural areas. The few service points are confined to urban areas, especially around Kigali. The costs are high and unaffordable by many PLHAs. The Government has put some resources into reducing drug prices and developing strategies to expand access. However, even with government subsidies, most people who are eligible are not yet receiving treatment. The role of ARBEF has been to complement government efforts in family health by mobilizing public opinion, reinforcing family health service delivery facilities and developing its own institutional capacity. ARBEF provides comprehensive and integrated SRH with VCT and care in its clinical service package. Of the clients that joined its integrated VCT services, 14.8% were HIV positive. At this stage, ARBEF lacked the technical, logistical and human resource capacity to include ART in its SRH service package. The one-year pilot project was set up in September 2004 to address these inadequacies, and thus to improve ARBEF’s core SRH work and also to help provide a holistic package of care. People who tested HIV positive would be referred to government hospitals for CD4 testing

and ART. ARBEF would do follow-ups to ensure adherence and monitoring of clients. The specific aims of the pilot were to: • Strengthen the capacity of ARBEF to provide HIV/AIDS care and support services for PLHAs, including treating OIs and providing ARVs.

RWANDA

• Increase access to HIV/AIDS care and support services for PLHAs in two ARBEF clinics.

How have these needs been addressed? ARBEF already had several clinics throughout the country that had been providing care and treatment services alongside VCT and SRH in different parts of the country. The pilot project targeted ARBEF’s clinics in Kigali and Butare. This association is one of the few organizations in Rwanda with access to a large proportion of the rural communities. ARBEF has several outpatient clinics but also reaches the community through community based distributors and volunteers. A new category of volunteers are associations of PLWHA that offer home visiting, nutritional support and counselling to PLHA.

Partnerships As part of incorporating VCT services and care in its clinical care package, ARBEF selected four of its existing partner associations of PLHAs to be part of the pilot project. The pilot also formed partnerships with Central Hospital University Kigali and Butare University Hospital. Both provincial hospitals are responsible for providing supervision to all health facilities in each province. In addition, the Treatment and Research AIDS Centre (TRAC) was to serve as a referral for laboratory service and ARV management.

Site assessment A site assessment exercise was conducted in the Butare and Kigali clinics in March 2005 to assess their viability for initiating, managing and sustaining ART programmes. This included assessing ARBEF’s clinics in the following areas: • Leadership and management experience and capacity. • Services and clinical care. • Monitoring and evaluation. • Human resource capacity. • Laboratory capacity. • Drug management and procurement. The site assessment indicated that both clinics were generally in the planning phases for

Models of Care Project

RWANDA

the provision of ART services. Major barriers existed in the areas of infrastructure, staffing, capacity building and logistics. However, the vast experience of ARBEF in family planning programme implementation, and the links with the community through community based distributors, associations of PLWA and the NGO forum on HIV/AIDS, were important assets on which to build this project. The Model of Care project brought some improvements in the facilities including better reception rooms for SRH and VCT, extra counselling rooms and new laboratory equipment. In addition, two doctors were recruited to respond to the increased demand for services.

Training Training and capacity-building activities included: • An IPPF training workshop in South Africa focusing on Clinical Management of HIV/AIDS, attended by four ARBEF staff (two doctors and two nurses from Butare and Kigali). • A workshop on managing ART, attended by two Kigali staff.

“Until I came to ARBEF I did not know my HIV status. When I got tested, I was told that my CD4 count was so low that I must take medicines urgently. I was then referred to TRAC (Treatment and Research on AIDS Center) where I got the required medicines and now I have a new hope in life.” HIV positive woman,

Models of Care Project

now working for ARBEF

Clients waiting for VCT in Kigali

• Training on ART, and managing STIs and OIs for 12 staff members, including nurses and counsellors. • Training on providing integrated services (SRH and HIV/AIDS) for 18 staff. • Training for 60 volunteers from PLHA partner associations on home based care.

What has been achieved? Impact of a referral community-based model ARBEF has been operating since 1986, and introduced community-based services in 2001. According to ARBEF Staff, the programme became more effective in 2005 when the MoC Project started. As a result, the number of clients attending has more than doubled. The MoC approach introduced a referral community-based model of prevention, care and treatment of HIV/AIDS and related conditions. The referral network meant applying both client-based and clinic-based care. ARBEF continued to collaborate with associations of PLHAs who had worked previously on issues such as HIV/AIDS awareness, behaviour change communication, developing materials, and income-generating activities. In the pilot, PLHA associations have helped identify community volunteers, who are trained to do follow-up home visits and maintain information flow between clinic-based counsellors and nurses and rural communities. These visits address treatment of OIs and drug adherence for people introduced to ARVs. “Until I came to ARBEF I did not know my HIV status. When I got tested, I was told that my CD4 count was so low that I must take medicines urgently. I was then referred to TRAC (Treatment and Research on AIDS Center) where I got the required medicines and now I have a new hope in life.” (HIV positive woman, now working for ARBEF). The referral network and home-based care has led to reducing the number of people who would otherwise need to be admitted to hospital.

The two clinics were improved through developing and enhancing their human resource capacities to integrate HIV/AIDS care and support services, and to treat OIs. A part-time doctor visits the Butare Clinic three times a week and a full-time doctor has been recruited to work at the Kigali Clinic. Full-time laboratory technicians have also been recruited. Outreach was strengthened by training and deploying community volunteers in home care-related activities.

Improved public response 150 health education sessions on ARVs and OIs were conducted in the two sites, and 200 OI leaflets, 250 ARV leaflets and 50 ARV posters were distributed. As a result, there has been an increased demand for VCT and other related services at both clinics. For example, ARBEF Kigali has witnessed a 53% increase in the number of clients it handles from 160 clients originally to the current 300 clients handled at the centre. This increase would be higher if the demand for the services was not restricted due to logistical constraints.

Health insurance support The MoC Project supported families of people living with and affected by HIV/AIDS to access treatment and care: • In 8 sectors in both Kigali and Butare, communities are involved in identifying needy families who cannot afford health services. • The project caters for 85% of all health costs for up to seven members of a family using the pre-payment health insurance (mutuelle) introduced by the Government to reduce domestic health cost. • Clients get health insurance cards after visiting the ARBEF clinics so that they can access free health services at any government unit using the pre-payment health insurance. There is a need to develop and apply clear criteria for selecting beneficiaries since the demand is higher than the supply. The medical insurance support provided by the pilot project has kept most PLHAs on treatment for OIs, and enabled some people to be introduced to ARVs at the Treatment and Research AIDS Centre.

What lessons have been learned? Limits on monitoring There is limited monitoring of clients who reside in sectors where there are no partner associations or trained volunteers. Follow-ups

in these cases are virtually absent. In addition, the referrals to TRAC lack a proper feedback mechanism. The referral forms are not returned to ARBEF, which relies on clients who come back to the clinic or on the reports from the community volunteers.

RWANDA

Benefits of community-based outreach ARBEF’s community-based approach has led to increased coverage and more efficient services. Involving the community has been fundamental to determining the success of the programme – for example, it has: • Contributed to reducing stigma against PLHAs in communities. • Increased the use of STI services due to the effective distribution of contraceptives like condoms, distributed by community associations. • Resulted in a strong partnership with local leaders, who contribute in the monitoring of project activities. “If ARBEF had not referred me for ARV treatment, I would be history by now. Who would have looked after my children?” (HIV positive man, rural area).

Project sustainability For the sustainability of the project, there is a need to have sufficient supplies of equipment and drugs. The project’s progress seems to rely on the fact that it fitted within the already existing ARBEF structures. However, a successor project will have to be considered to ensure continuity at the end of the pilot project period. Ultimately, the success of the project will depend on increased staff capacity to manage ART. There is also a need to train more staff in community-based care and management, in addition to clinical training in managing OIs. The pilot has shown the importance of appropriate, hands-on skills. For example: • While non-medical coordinating staff is able to ensure the success of the community approach, they are unlikely to be fully able to supervise project staff with medical and clinical expertise.

“If ARBEF had not referred me for ARV treatment, I would be history by now. Who would have looked after my children?” HIV positive man, rural area

• A coordinator based at the Kigali Clinic may be limited in supervising the Butare Clinic.

What challenges are being addressed? Human resource and infrastructure shortcomings A factor hindering implementation has been the limited investment in human resources. Apart from the laboratory technicians and doctors, the project relied on already existing staff, although

Models of Care Project

Increased human resources

RWANDA

A client attending a counselling session with a nurse, Kigali

the site assessment pointed to staff capacity gaps as a barrier to introducing the ART-related programme. ARBEF has experienced insufficient space to provide services to meet the demand for a range of services from an increasing number of clients â&#x20AC;&#x201C; for example, the lab and counselling rooms are small, and can compromise confidentiality. High rental costs of additional office space have also been a challenge draining potential sources of funding away from priorities like staff development.

Improving the referral system

Models of Care Project

A more effective referral system will depend on more committed involvement of all stakeholders in its planning and implementation. The Treatment and Research AIDS Centre needs to provide consistent feedback to ARBEF to ensure more efficient follow-up of clients.

The possibility of providing ART from ARBEFâ&#x20AC;&#x2122;s clinics The pilot has significantly scaled up the education, care and support activities of ARBEF, rather than introducing the direct provision of ART. Although there are follow-ups and improved treatment of OIs, project staff feel that providing ART would assist in ensuring closer client monitoring.

Colombia

IEC material developed by PROFAMILIA for their MSM campaign in Colombia

COLOMBIA

COLOMBIA What needs did the project respond to?

El hombre MAS hombre

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¡VIVE su sexualidad!

Profamilia Para una vida sexual plena

PROYECTO COLOMBIA DIVERSA

Línea de Información Gratuita 01 8000 110 900 www.elhombremashombre.com / www.profamilia.org.co Correo: info@profamilia.org.co

------------------------

Models of Care Project

Recorte este cupón, preséntelo en Profamilia y reciba un descuento del 10% en cualquiera de los Servicios para Hombres

Promoting Sexual Rights and HIV/AIDS Prevention among Men who have Sex with Men (MSM) in Colombia was an innovative pilot project funded by the GTZ and run by the IPPF MA, PROFAMILIA Colombia (Asociación Pro-Bienestar de la Familia Colombiana). In many parts of South America, sex between men and drug use are the most common routes for HIV transmission. While the adult rate of HIV infection in Colombia is at a relatively low 0.4%, the MSM population has an incidence rate of 18% (HIV Prevalence Study, Instituto Nacional de Salud, 2000). PROFAMILIA Colombia, an IPPF MA, began HIV/AIDS prevention activities in the 1980s, including educational activities and condom distribution at a wide range of venues. In 1991, PROFAMILIA began providing HIV tests with VCT. Most of the first group of people living with HIV was gay men and sex workers. The epidemic later affected groups not initially considered vulnerable – heterosexual men and women. The ratio of women compared to men with HIV increased from 1:20 (1980s) to 1:10 (1990s) to 1:3 currently (Instituto Nacional de Salud, 2003). PROFAMILIA studies show that women (young and old), for cultural reasons, do not demand that their male partners use condoms, especially when in stable relationships. Colombian youth under 19 have difficulty in discussing sexuality, negotiating condom use, and often choose not to use condoms as a ‘sign of love’ (PROFAMILIA, 2002). In 2002-2003, PROFAMILIA’s HIV/AIDS strategy shifted to adolescents through a video series highlighting responsible sexuality around issues like STI/HIV prevention, condom negotiation and preventing pregnancy. PROFAMILIA diversified its HIV/AIDS strategy in 2004 with a programme to integrate HIV/AIDS in all its services. This was the start of a Sexual Health and Gender Programme to coordinate projects and activities related to HIV/AIDS, STIs, gender and sexual diversity, including a focus on MSM. The GTZ/IPPF-funded pilot project’s aim, as part of defending SRH rights, was to reduce stigma and discrimination, improve access to health services for MSM, and to reduce mortality due to HIV/AIDS. Specific aims were to: • Increase the availability of quality HIV/AIDS/STI information at 35 PROFAMILIA health centres, including the needs of MSM populations. • Improve the strategies for the provision of quality HIV/AIDS/STI services in 5 PROFAMILIA centres, including the specific needs of MSM. • From lessons learnt, adapt and develop services for the special SRH needs of MSM populations.

How were these needs addressed? Project planning PROFAMILIA made contact with Colombia Diversa, a partner organization working on sexual diversity, and reviewed Colombian and Latin American literature on masculinity, sexuality, sexual practices, eroticism and HIV/AIDS. A concept document was drawn up to guide the content of training, materials development and strategies for improved service delivery. PROFAMILIA gathered information on staff knowledge, attitudes and practices around HIV/AIDS through checklists and questionnaires. For example: • Most centres did not have sufficient information on people most vulnerable to HIV/AIDS in their communities. • Staff still had many fears about working with people living with HIV.

Sensitization training and protocol development PROFAMILIA held 14 workshops for over 200 service providers in its 35 clinics. The three-day workshops were designed and facilitated with the support of Colombia Diversa and Mujeres al Borde (Women on the Verge). They aimed to: • Train staff on integrating HIV/AIDS in service provision. • Promote sexual rights and HIV prevention among MSM and their partners. • Sensitize staff on sexual diversity and gender sensitivity. Workshop recommendations were consolidated to produce an SRH protocol: Gender, Sexuality and Sexual Diversity in the Provision of SRH Services and a guide on HIV/AIDS Prevention Strategies in PROFAMILIA Clinics.

Information, education and communication PROFAMILIA collaborated with a local advertising agency, focus groups and its workshop participants to develop informational and promotional materials. Training and media efforts aimed to promote higher service use by MSM in its clinics. The materials were designed to reach a variety of audiences, including: • Men who identify as gay. • Men who gather in homosocial spaces, such as prisons, armed forces and boarding schools. • Female partners. PROFAMILIA designed materials for each population, for example: • Promotional postcards with service coupons and publicity in magazines for gay and

Creative and targeted messaging

• Men in homosocial spaces: The most manly man takes care of his health and protects his life! The idea was to reach men who first think of themselves before thinking of their partners. • Women: The most manly man says YES to protection! The message aimed to encourage women to suggest the use of condoms to their partners. In Spanish, the ‘umbrella phrase’ the most manly man (El hombre mas hombre) has two meanings. It alludes to the topic of masculinity, but would also make it possible to think of two men together.

Analyzing risky practices The project helped to explore risky practices underneath traditional gender roles. For example: • Many MSM relations take place clandestinely and are often denied, with few means of protection. • In homosocial spaces, many men feel they are ‘forced’ to have sex with men as a defence mechanism. • Some MSM consider themselves playing an ‘active’ role in sex with their male or female partners, and do not think they put their partners at risk.

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Specific, appropriate messaging was developed to educate each target group on HIV/AIDS and to attract them to PROFAMILIA’s services. Messages for gay men expanded the concept of prevention and offered integrated SRH services. Publicity targeting men in homosocial spaces addressed gender identity, SRH and HIV/AIDS prevention. Messages for women promoted empowerment to demand protection in sexual relations, and explored sexuality and what it means to be a woman. Creative slogans were developed for each population: • Gay men: The most manly man LIVES his sexuality! The word ‘live’ was used to mean ‘enjoy’, but also to say “to live I must protect myself”.

ra te ntía de Pro

¡Cuida su salud y protege su vida!

Developing partnerships PROFAMILIA developed a close relationship with the lesbian, gay, bisexual and transgender (LGBT) population. This linked LGBT groups to PROFAMILIA’s services and helped with strategic planning and project implementation. In particular, the participation of Colombia Diversa in focus groups facilitated an understanding of the particular needs of the MSM population and encouraged a broader panorama of themes around sexual diversity, sexuality and rights. The project also achieved a close working relationship between male prisons and battalions, and PROFAMILIA services. This partnership strengthened the understanding of this population and risk factors for HIV transmission.

Profamilia Para una vida sexual plena

PROYECTO COLOMBIA DIVERSA

Línea de Información Gratuita 01 8000 110 900 www.elhombremashombre.com www.profamilia.org.co Correo: info@profamilia.org.co

Project monitoring and documenting This project was monitored and documented with the aim of learning from it, strengthening interventions and replicating it as a model in other MAs of IPPF. This allowed PROFAMILIA to report on project progress, and to share successes, difficulties and technical assistance needs. A protocol and guide were developed, based on the results of the training workshops. In addition, as a way of sharing the project experience, PROFAMILIA will soon publish a book entitled: Gender and HIV, prevention of HIV/AIDS in Men who have Sex with Men in Colombia (Género y VIH, prevención del VIH/SIDA en hombres que tienen sexo con hombres en Colombia) .

What lessons have been learned? Reaching men who have sex with men Work with men who have sex with men goes far beyond sex. In the Colombian context, it is important to incorporate gender, gender roles, sexual identity, socio-cultural context, peer

Models of Care Project

What has been achieved?

El hombre MAS hombre

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• Radio spots on condom negotiation and VCT materials for women.

COLOMBIA

• Brochures and postcards with service coupons for men in homosocial spaces.

The experiences of women using PROFAMILIA services point to the risks faced by women who are possible partners of MSM: Question: “Why do you say, apparently you know when your husband is faithful?” Response: “Well let’s say in my case, he is far away, over there he is surrounded by many men… I say that most men have their adventures… I don’t know, anyway how God created you, you for the man and the man for the woman, anyway you are somebody who accepts things. Unfortunately especially (for) women, that is the law and that is the tradition and that is how we are, and the tradition will go on and on.”

bisexual venues.

COLOMBIA

“For the workshops with Profamilia staff, we used Latin American films. We selected films illustrating five situations which are part of the MSM experience, including the experience of a married man who is having relations with young men, the situation faced by men in a homosocial space like the prison and different experiences of young people who have been sexually exploited – which opens a discussion about who are the potential clients”. José Fernando Serrano,

Models of Care Project

Proyecto Colombia Diversa

pressure, power relationships and rights. These topics require careful analysis of the practices and rights of MSM, and consultations with organizations that work with LGBT and people living with HIV. The MSM population is not located in a specific place. It is very diverse and includes groups such as gay men, bisexual men and men in homosocial contexts. Recognizing this diversity makes it possible to establish different strategies to reach MSM.

Sensitive communication The communication strategy should be based on rights, gender and the experience of sexuality in everyday language. For example, any woman could be the partner of a MSM, but few think that it could happen to them. For this reason, a message directed to women has to explore issues of gender, condom negotiation and promoting HIV testing, rather than suggesting that their partner could be involved with another man. The development of a project of this nature should be supported by LGBT organizations, as their previous knowledge will enrich the communication strategy. PROFAMILIA’s ability to adapt slogans and messages, and to develop conventional and non-conventional materials, enabled the project to appeal to and reach diverse populations. For example, a web page was developed with the stories of three characters, depicting issues like their sexual practices and identity, and their perceptions of risk.

Listening to people’s experiences and needs It is vital to ground workshop discussion and the content of materials in local experiences and the realities of LGBT people and others living with HIV. Projects like this should determine key moments to measure the stigma and discrimination experienced by users when they come into contact with service providers. Their personal experiences can then inform improving of future service delivery. “For the workshops with Profamilia staff, we used Latin American films. We selected films illustrating five situations which are part of the MSM experience, including the experience of a married man who is having relations with young men, the situation faced by men in a homosocial space like the prison and different experiences of young people who have been sexually exploited – which opens a discussion about who are the potential clients”. (José Fernando Serrano, Proyecto Colombia Diversa)

Responding to difference The perception of sexual practices among men is not the same in all parts of the country.

There is clear resistance in some areas, where models of masculinity are more rigid and heterosexist. Therefore, it is vital to consider regional trainings when thinking of addressing topics related to sexuality, sexual diversity and gender. PROFAMILIA also has to respond to the particular needs of different target groups, for example, transgender people. HIV/AIDS education for MSM and for women who are partners of MSM should be complemented by appropriate services and trained staff to address their counselling, education and service needs.

What challenges are being addressed? In response to challenges identified, PROFAMILIA has begun to: • Develop new approaches and strategies to reach MSM-related target groups that feel powerless or disempowered in different ways. For example, to respond to: • Limited access to education on prevention and condoms. • Guilt around sexual identity, leading to self-destructive behaviour. • Perceptions of no or limited risk in various sexual acts. • Pressure to perform sexually or to return sexual favours in environments like prisons. • Limited space for negotiation around safer sex. • Deeply rooted values about masculinity and femininity. • Create a strategy to link the transgender population to the project and to engage transgender people in a way that is sensitive to their social identity. • Improve monitoring systems to track the HIV/AIDS epidemic and the project’s progress in meeting the education, care and treatment needs of its target audiences. • Work towards financial sustainability in longterm planning to ensure project continuity. The project has generated expectations about PROFAMILIA’s commitment to working with people living with HIV/AIDS and with the LGBT population.

COLOMBIA

El hombre MAS hombre

Siempre

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CONDÓN

¡Cuida su salud y protege su vida!

Profamilia Para una vida sexual plena

PROYECTO COLOMBIA DIVERSA

Línea de Información Gratuita 01 8000 110 900 www.elhombremashombre.com www.profamilia.org.co Correo: info@profamilia.org.co

Models of Care Project

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YOUTH COURSE

SECTION 3

HIV/AIDS: Vulnerability, Rights and Young People What were the aims of the course? Of the estimated 38 million people living with HIV/AIDS at the end of 2003, over a quarter (10 million) were young people between the ages of 15 and 24 (UNAIDS Global Report, 2004). Young people are vulnerable to HIV infection for cultural, structural and biological reasons. In order to develop programmes that effectively prevent HIV transmission, we need to understand what it is that makes some young people more vulnerable to HIV, and to be able to identify and reach populations of young people who are most vulnerable. IPPF and GTZ responded to this need with a training course aimed at field professionals working specifically with young people. Using 12 years of experience organizing similar training courses, IPPF and GTZ developed a dynamic two-week curriculum for participants from around the world. The title – HIV/AIDS: Vulnerability, Rights and Young People – reflected the goals at the heart of the course, held in Johannesburg, South Africa, in November 2004. The 28 participants came from diverse backgrounds, but held a common interest in the SRH and rights of young people. The course aimed to: • Give participants a framework for understanding young people’s vulnerability. • Encourage them to look at adolescent sexuality through a rights-based lens.

Models of Care Project

• Build their capacity to address young people’s vulnerability to HIV/AIDS in different settings and parts of the world.

Two evaluation consultants facilitated an external evaluation of the course in the second half of 2005 to document the impact of this course on participants and their MAs, and to direct the IPPF on the future development and improvement of the course.

How was the course and its evaluation designed? Before the course, a training needs assessment was conducted to inform the content and

methodology of the course. As a result, the course content tried to enable participants to: • Improve their understanding of the global context, trends and impact of the HIV/AIDS pandemic. • Understand vulnerability and how to start comprehensive programmes to address it, while ensuring the full participation of vulnerable groups. • Strengthen their commitment to addressing the SRH and development needs of the most vulnerable individuals and groups. • Develop skills to create gender-sensitive and rights-based programmes to lessen stigma and discrimination against people living with HIV/AIDS. • Explore approaches and challenges to mainstreaming HIV/AIDS into SRH and rights. • Understand and improve access to services on the HIV/AIDS care continuum. • Share experiences of and visit innovative projects that address vulnerability. Four key questions guided the evaluation of the course: • What changes were there in participants’: • Knowledge about HIV/AIDS vulnerability? • Skills for responding to HIV/AIDS vulnerability? • Support for responding to HIV/AIDS vulnerability? • How did the design and implementation of the course impact on participants’ achievement of the course’s learning objectives? • As a result of the course, what changes were there in the programmes and policies of MAs in responding to HIV/AIDS vulnerability? • What further capacity-building do MAs need to be able to respond to HIV/AIDS vulnerability? The consultants developed a questionnaire for participants with closed questions measuring changes in key course competencies. Open questions asked participants how various course elements could be improved, and how they had applied the course learning in their work. The questionnaires were followed up with some telephone interviews with participants working as HIV/AIDS programme managers in MAs to determine how course learning was operationalized in MA programmes and policies, and what additional capacity-building they needed to work with vulnerable young people.

Overall, course participants appreciated the pilot course’s innovative approaches to working with young people on HIV/AIDS. Some of the more specific findings from the course evaluation were: • The course helped participating MAs to target their HIV/AIDS programmes at their most vulnerable populations. Participants said they needed to target young people most vulnerable to HIV/AIDS, and then work to involve those young people and develop programmes to meet their needs. • Course modules on risk versus vulnerability, and stigma and discrimination, made strong impressions on participants: “For me it was amazing to see that… there are different factors affecting vulnerability, and that you need to work on these factors because they can be connected with risk.” (participant) Participants were less easily able to link their work to the modules on entry points to HIV/ AIDS mainstreaming, and on strengthening youth advocacy: • Participants experienced changes in attitudes about people living with HIV/AIDS and sexual diversity: “For me, a person with HIV was someone who was sick, had some problems. But when I saw, realized, based on their stories, what the problems in their life are… it wasn’t the same after.” (participant) “The first time I discovered that one of the course participants was gay, I was shocked. By the end of the course my perceptions had changed completely – I understood that participants have their own choice about their sexuality.” (participant)

• The geographic mix of participants created some tensions, but these tensions helped participants to examine their own values. Some participants said that the sharing of experiences gave them new perspectives on their values and their work.

YOUTH COURSE

• After the course, participants succeeded in passing on their learning to their MA colleagues. In smaller MAs, this meant debriefings to colleagues on what participants learned. In a larger MA, this could mean first training ‘front-line’ service providers and later on the ‘middle-management’ staff. • Participants want more follow-up to the course, particularly through electronic media. They felt that a more interactive, electronic follow-up medium would make even more of an impact. • The course helped participants identify capacity needs on vulnerability. IPPF needs to provide participants with the competencies to do their work differently, such as techniques for strengthening participation, and more specific methods to reduce stigma and discrimination. • The vulnerability pilot projects supported after the course helped MAs generate new learning and strengthen their reputations in HIV/AIDS work: “After developing a partnership with people living with HIV/AIDS, we gained the trust of the community, and people are more interested in participating and collaborating with us.” (participant) “We had been concentrating more on prevention... now we are workikng more on care and support, and stigma and discrimination, and HIV vulnerability. I think this is a major success.” (participant)

Youth in Action:Sentinental group from Lovelife Youth Centre in Johannesburg

Models of Care Project

What were the key results of the course?

International Planned Parenthood Federation 4 Newhams Row London SE1 3UZ United Kingdom

tel +44 (0) 20 7939 8200 fax +44 (0) 20 7939 8300 email info@ippf.org web www.ippf.org