Reaching the Unreached

Reaching the Unreached Service Uptake and Reten=on Among Marginalised Popula=ons

Workshop Wednesday 20th July 11:00am – 12:30pm #AIDS2016 | @AIDS_conference

Key Popula;on Sensi;sa;on Training for Health Care Workers in South Africa Zoe Duby

Research affiliate Desmond Tutu HIV Centre Cape Town, South Africa

#AIDS2016 | @AIDS_conference

Who, What & Why? •  Specific popula=ons characterised by: –  Dispropor=onate risk for HIV infec=on & consequences –  OVen s=gma=sed, excluded from society – largely due to criminalisa=on of certain behaviours, societal s=gma & discrimina=on –  Lack access to appropriate health services –  Subject to complex structural, social & individual risk factors •  For public health purposes, these socially marginalised groups are termed ‘Key Popula=ons’ (KP): –  Form part of general popula=on & have many overlapping needs –  Not epidemiologically separated but do have unique impact on both concentrated & generalised HIV epidemics •  In this presenta=on we refer specifically to:

–  Men who have sex with men (MSM) –  People who use drugs (PWUD) –  Sex Workers (SW)


A note on terminology •  MSM refers to sexual BEHAVIOUR (men having sex with men) •  Many MSM specifically in South Africa do not iden=fy as gay / bisexual / homosexual –  ‘Hidden MSM’ (i.e. married ‘straight’ men with female partners) –  ‘Situa=onal MSM’ (i.e. prisoners, miners – who iden=fy as ‘straight’ and are heterosexual but have sex with other men due to situa=ons) –  Hidden MSM are hard to reach & at risk as they will not / cannot access services / info specifically targe=ng MSM

•  While South African Cons=tu=on does not discriminate directly against anyone on grounds of sexual orienta=on, in reality, MSM con=nue to be s=gma=sed & discriminated largely because their behaviour deviates from social norm, and homoprejudice is widespread #AIDS2016 | @AIDS_conference

Commonali;es / Overlapping Risk factors


South African context •  South African HIV epidemic diverse •  Within generalised na=onal epidemic are several concentrated sub-‐epidemics •  MSM, SWs & PWUD experience dispropor=onately high burden of HIV but face mul=ple barriers accessing health care •  Limited focused services & barriers (including discrimina=on by health & other service providers) contribute to risk, onwards transmission & poor health outcomes •  Socio-‐economic factors, including poverty & marginalisa=on contribute to increased vulnerability to HIV & TB •  Exclusion of certain groups at increased vulnerability to HIV undermines na=onal HIV response •  Interven=ons addressing specific needs of key popula=ons are effec=ve in reducing HIV incidence in general popula=on #AIDS2016 | @AIDS_conference

What do we know about these Key Popula;ons in South Africa? SEX WORKERS •  • 

Es=mated 153,000 individuals in South Africa make a living in the sex industry (SWEAT, 2013) HIV prevalence among female sex workers in major metropolitan ci=es es=mated range between 39.4% -‐ 71.8% (Konstant et al., 2015; Scheibe et al., 2016)

MEN WHO HAVE SEX WITH MEN •  • 

No na=onal MSM size es=mate exits HIV prevalence is es=mated between 22.3% -‐ 48.2% among MSM in three largest metropolitan areas (UCSF, 2016)

PEOPLE WHO USE DRUGS •  • 

Popula=on of PWUD not quan=fied, but modelling study es=mated by 2010 there were 67,000 people who inject drugs (PWID) in South Africa (Petersen et al., 2013) Only mul=-‐city HIV prevalence survey conducted among PWID found overall prevalence of 14% (Scheibe et al., 2016) #AIDS2016 | @AIDS_conference

Health Care Context •  When KP manage to access health services, those provided in public sector health system oVen inappropriate / insensi=ve: –  Clinic opening hours unsuitable, par=cularly for SW –  Healthcare providers taking ‘abs=nence only’ approach to managing substance use –  Lack of standard rou=ne risk assessment tools enquiring about sex work and penile-‐anal intercourse –  Limited availability of targeted support groups –  Limited availability of harm reduc=on services including needle and syringe programmes –  Despite early focus on preven=ng HIV and STI transmission amongst SW, few scaled-‐up targeted interven=ons have been implemented in sex work sepngs, or amongst PWUD •  HIV tes=ng rates are low amongst KP and, =mely access of health services enabling viral suppression for those living with HIV is poor #AIDS2016 | @AIDS_conference

South Africa Key Popula;on Stakeholder Consulta;on 2011 •  Discrimina=on, prejudice & moral-‐ loading by healthcare workers towards MSM, SW & PWUD is major barrier to accessing health services & result in substandard healthcare provision •  KP reluctant to disclose prac=ces due to fear of: –  Discrimina=on –  Confiden=ality breaches –  Arrest

•  HCW lack professional training on specific health needs of KP, lacking appropriate skills & knowledge – inadequately equipped to provide services #AIDS2016 | @AIDS_conference

Iden;fying a need •  Advocates, service providers & researchers iden=fied need for increased HCW awareness of issues affec=ng KP •  Need to build HCW capacity to provide evidence-‐based, competent and appropriate services •  Health workers sensi=sed around issues affec=ng MSM, SW & PWUD are also empowered to appropriately engage with other key popula=ons •  Na;onal Strategic Plan on HIV, STIs and TB 2012–2016: –  Health care services need to be responsive –  KP iden=fied as being at greater risk for being infected by or transmipng HIV when compared to general popula=on

•  Opera;onal Guidelines for HIV, STI & TB Programmes for Key Popula;ons in South Africa: –  Iden=fied HCW sensi=sa=on training as essen=al interven=on to address these barriers #AIDS2016 | @AIDS_conference

Desmond Tutu HIV Founda;on’s HCW Sensi;sa;on training programmes Introductory trainings to educate & sensi=se HCWs to provide sensi=ve, appropriate, relevant, non-‐discriminatory and non-‐judgmental services focusing on: -‐  MSM -‐  Sex Workers -‐  PWUD

MSM trainings –  2 edi=ons of training manual (published 2009 & 2011) –  592 HCW trained across South Africa between February 2010 and May 2012 #AIDS2016 | @AIDS_conference

Sex Worker and PWUD trainings 388 HCW trained: March – August 2012

•  10 SW training workshops, reaching 211 HCW at 33 organiza=ons •  8 PWUD training workshops, reaching 177 HCW at 18 organiza=ons


Key Popula;on Trainings of Healthcare Workers in South Africa Organisation*

KP*focus*

Type*of* training*

HCW* Trained*

Dates*

Training* materials*used*

Training*material* editions*/* publication*date*

Anova*Health* Institute*/* Health4Men* Desmond*Tutu* HIV*Foundation* OUT*WellBeing*

MSM,$trans,$ WSW,$IDU$&$ SW$ MSM$

Clinical$ competency$

5200$ $

2013$=$ present$

ANOVA$Health$ materials$

$

Sensitisation$

592$

2010$–$2012$

DTHF$MSM$manual$ 2009,$2011$

MSM$/$LGBTI$ $$

Sensitisation$

8000$ $

Sex$Workers$

Sensitisation$

211$

SWEAT*

Sex$Workers$

Sensitisation$

2125$

2014$–$2015$

TB/HIV*Care*

Sex$Worker$ (also$MSM$&$ PWUD)$ PWUD$

Sensitisation$

244$

2012$–$ present$

OUT$MSM$manual$ &$DTHF$Integrated$ KP$manual$ DTHF$Sex$Worker$ manual$ DTHF$Sex$Worker$ manual$ DTHF$SW,$PWUD$ and$MSM$manuals$

2010,$2013$

DTHF*

2006= present$ $ 2012$

Sensitisation$

177$

2012$

$

ICAP*South*Africa* Initially$MSM$ Later$also$SW$ &$PWID$ ICAP*South*Africa* MSM$

Sensitisation$$

3002$

2012=2015$

Clinical$ Competency$$ Sensitisation$&$ clinical$ competency$ Sensitisation$

493$

2013=2015$

121$

2015$

DTHF$PWUD$ manual$ DTHF$MSM$Manual$ &$DTHF$Integrated$ KP$manual$ ICAP/MOSAIC$ materials$ $ Various$Gender$ DynamiX$materials$

405$

2012=2013$

DTHF$Integrated$ KP$(SW,$PWUD$&$ MSM)$manual$

2013$

DTHF*

Gender*DynamiX*

Transgender$

ICAP*/*DTHF*/* CoC*/*DoH*

SW,$PWUD$&$ MSM$


2012$ 2012$ 2012$

2011$ 2013$ 2013$ 2013$

‘Integrated Key Popula;ons Sensi;vity Training Programme for Healthcare Workers in South Africa’ ‘Healthcare Provision for Men who have Sex with Men, Sex Workers, and People who use Drugs: An Introductory Manual for Healthcare Workers in South Africa’ -‐  Published November 2013 -‐  Developed in partnership with Na=onal Department of Health & South African Na=onal AIDS Council -‐  Included topics: -‐  -‐  -‐  -‐ 

Social norms and values Human sexuality & sexual behaviour Legal & rights context Socio-‐structural marginalisa=on & prejudice -‐  Interven=ons to foster enabling healthcare environments #AIDS2016 | @AIDS_conference

AVAILABLE FOR DOWNLOAD

Integrated Key Popula;on Training Pilot OBJECTIVES •  Develop sustainable training ini=a=ve, including framework for on-‐going mentorship, for use by Department of Health for widespread implementa=on through regional training centres (RTCs) •  Training materials covered issues rela=ng to HIV, TB and STIs – flexible, client focused & enable HCWs to employ non-‐judgmental language and aptudes when working with MSM, SW & PWUD •  Mul=-‐partner project, led by South African Na=onal AIDS Council & South African Department of Health

ROLL-‐OUT •  Training of Trainers (TOT) October 2013 •  1 day sensi=sa=on-‐training programme for HCW •  405 HCW trained October 2013 -‐ July 2014 •  5 South African provinces: Eastern Cape, Free State, Kwa-‐Zulu Natal, Limpopo & Northern Cape #AIDS2016 | @AIDS_conference

Evalua;on of Pilot Integrated Key Pop Training •  Evalua=on of pilot sensi=sa=on training compared 2 provincial capitals: –  Bloemfontein (Free State) – training rolled out –  Mafikeng (North-‐West) – no training interven=on implemented

•  Evalua=on research conducted October 2013 -‐ July 2014 EVALUATION METHODS •  Mixed-‐methods evalua=on research to assess changes in HCW aptudes towards KPs & changes in awareness of and capacity to manage KP-‐ specific health due to training •  Qualita=ve IDIs at 2 =me points: “baseline” & “3 months post-‐training” with sub-‐sample of HCW who had received training & HCW who had not received training –  Interviews explored HCW aptudes towards KP, knowledge levels around specific health needs & vulnerabili=es of KP, as well as awareness of barriers to KP accessing health services.

•  FGDs with members of SW, MSM & PWUD •  HCW who par=cipated in training completed pre & post-‐training ques=onnaires – quan=ta=ve data #AIDS2016 | @AIDS_conference

Evalua;on Findings BASELINE FINDINGS: •  Discrimina=on affec=ng KP in communi=es & at health facility level •  HCW described own judgemental aptudes towards KP •  HCW lacked relevant knowledge, skills or training to manage par=cular health needs & vulnerabili=es facing KP •  Evidence-‐based HIV preven=on commodi=es aimed at KP not available in these areas •  Provides evidence for need to sensi;se HCW in South Africa to needs & health risks of MSM, PWUD & SW TRAINING EVALUATION FINDINGS: •  Increased HCW knowledge & awareness rela=ng to health needs of KP •  Reduced judgemental aptudes towards KP •  Resulted in HCW feeling more skilled to provide appropriate & sensi=ve services to KP •  On-‐going need to include in-‐service & pre-‐service training (PAPERS IN PUBLICATION) #AIDS2016 | @AIDS_conference

Self-‐perceived aatude shibs of HCW A"er… the training (we realized) that… when they come here (to the health facility) they must feel welcome. They must be like any other pa?ent, we must treat them equally. When a person comes here to share their problems they must not be scared to say that I am a sex worker because they are afraid of how I will react, what I will say to them and if I will judge them… I must listen to their story and understand what their problem is… because they are also people, we don't have to isolate them in society, we must treat them like all the other people. (HCW, Free State, follow-‐up IDI) I can welcome them (KP) properly because I used to think that they are just naughty before the training. I found out that they are not naughty, at ?mes as a woman you get feelings for other women and as a man you get feelings for other men… I can welcome them because now I know what the problem is. They did not choose… I have learned… not to discriminate them, to end s?gma, social s?gma. (HCW, Free State, follow-‐up IDI (The training) opened my eyes, (before) I would see them but I didn't understand them…my aJtude has changed. (HCW, Free State, follow-‐up IDI) #AIDS2016 | @AIDS_conference

Challenges of pilot programme •  Limited support from DoH -‐ training only took place when external funding was in place, most work & impetus by CSOs and donors •  No clearly defined criteria for par=cipa=on used to select par=cipants •  No clear tool/ guidelines developed to assess competence of trainees •  RTC trainers not equipped / sensi=sed themselves: limited =me to TOT properly: training =me taken up with ground level sensi=sa=on and informa=on provision – rather than facilita=on skills •  Limited to in-‐service training, pre-‐service curriculum unchanged •  Once-‐off training, no commitment to on-‐going support •  Poor representa=on from RTCs (especially Limpopo and Northern Cape) •  Very full classes •  Commitment by TOT trainees limited, lixle support from RTCs provided •  Pulling trainers from all provinces together challenging for travel logis=cs #AIDS2016 | @AIDS_conference

Successes •  Efficiency of coordinated, mul=-‐partner approach to develop evidence-‐based, appropriate materials •  HCW sensi=sa=on fostered enabling environments & increased health service access for MSM, SW and PWUD •  KP community members have reported improvements in HCW aptudes towards KPs in areas where sensi=sa=on training provided •  Linking of sensi=sa=on training with peer-‐based outreach & preven=on ac=vi=es increased KP community trust & use of health facili=es working with KP-‐focused civil society organiza=ons •  Integra=on of issues affec=ng MSM, SW and PWUD enabled HCWs to engage with trainers around cross-‐cupng issues •  Established forum where partners can par=cipate in coordina=ng and standardising sensi=sa=on training #AIDS2016 | @AIDS_conference

Recommenda;ons •  Bexer coordina=on needed between training planners & provincial departments of health (e.g. HAST) to ensure correct target audience axend trainings •  Training should include skills development around clinical management as well – this training was only ‘sensi=sa=on’ focusing on knowledge and aptude •  Government training structures (RTCs) are ideally suited to provide on-‐going sensi=sa=on training, however capacity needs to be built and supported #AIDS2016 | @AIDS_conference

Conclusions •  KP need to be successfully engaged in health system to improve uptake, access & u=lisa=on of services, by crea=ng enabling environments where non-‐discriminatory services are provided •  High degree of support & commitment from government, AIDS structures, development partners and civil society organisa=ons can enable successful sensi=sa=on training programmes •  Criteria for par=cipa=on in TOT workshops can increase the likelihood of selec=ng and training the right people •  Partner coordina=on & stakeholder commitment can enable skills, knowledge sharing & standardisa=on -‐ essen=al for scale-‐up & sustainability •  Building capacity of sensi=sed HCWs to competently provide appropriate services for MSM, SW and PWUD (inclusive of mentorship & on-‐going support) is next step towards mee=ng HIV preven=on, treatment, care & support needs of MSM, SW and PWUD #AIDS2016 | @AIDS_conference

Partners & Acknowledgements

Development & pilot of integrated training: AMSHeR, Bonela, COC Netherlands, Desmond Tutu HIV Founda=on, ICAP Columbia University Mailman School of Public Health, the United States Centers for Disease Control and Preven=on (CDC)/ United States Presidents Emergency Plan for AIDS Relief (PEPFAR), FHI360, Mainline, the Na=onal Department of Health, NACOSA, OUT LGBT Well Being, South African Na=onal AIDS Council and Sex Workers Educa=on and Advocacy Taskforce (SWEAT). The pilot project built on the tools and experience of: OUT LGBT Well Being, Desmond Tutu HIV Founda=on, ICAP, ANOVA Health Ins=tute, SWEAT and the Na=onal Department of Health

Zoe Duby, PhD Research Affiliate Desmond Tutu HIV Centre University of Cape Town

[email protected]


Reaching the Unreached

Reaching the Unreached

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