HIV/AIDS Programming for MSM in the Greater

Mekong Region

Nithya Mani, MPHFebruary 19, 2009

Chennai, India

Presentation OverviewPresentation Overview

Context of HIV/AIDS among MSM in the Context of HIV/AIDS among MSM in the Greater Mekong Region Greater Mekong Region

USG strategy: hotspots and development USG strategy: hotspots and development of technical assistance-based modelof technical assistance-based model

Minimum Package of Services (MPS) for Minimum Package of Services (MPS) for PreventionPrevention

Enabling Environment as a component Enabling Environment as a component of the Comprehensive Prevention of the Comprehensive Prevention PackagePackage

Significant Emerging MSM Epidemics in SE Asia

Van Griensven, Frits; 2008

Who are MSM?Who are MSM?

Two dynamics: gender and sexual Two dynamics: gender and sexual expression expression

MSM is an umbrella termMSM is an umbrella term Transgender (TG)Transgender (TG) Male Sex Worker (MSW)Male Sex Worker (MSW) Other MSMOther MSM

Different sub-populations of MSM Different sub-populations of MSM may need different approachesmay need different approaches

Technical-assistance based approach with Technical-assistance based approach with focus on capacity building to ensure focus on capacity building to ensure sustainability and facilitate integration of sustainability and facilitate integration of activities into routine systemsactivities into routine systems

Four components:Four components: Develop Develop replicable modelsreplicable models for prevention and for prevention and

carecare Improve the Improve the qualityquality of prevention and care of prevention and care

programsprograms Increase the collection and use of Increase the collection and use of strategic strategic

informationinformation Share successful modelsShare successful models and provide TA to and provide TA to

other PEPFAR programsother PEPFAR programs

USG strategyUSG strategy

Geographic FocusGeographic Focus

Regional (regional MSM and PLHA Regional (regional MSM and PLHA networks and SI activities)networks and SI activities)

Non-presence countriesNon-presence countries

- Burma- Burma

- China- China

- Laos- Laos

- Papua New Guinea (PNG)- Papua New Guinea (PNG)

- Thailand- Thailand

Comprehensive Prevention Comprehensive Prevention PackagePackage

PLHA

Interventions

Most-at-risk Populations

MSM (including TG, MSW)

IDU

FSW

Clients of FSWs

Other vulnerable populations

Minimum Package of Services

• Behavior change communication

• Condom distribution

• STI screening and treatment

• HIV counseling and testing

• Substitution therapy and safer

injection practices for IDU

• Linkages to care and treatment

Supportive interventions

• Strategic Information

• Capacity Building

• Community Mobilization

• Policy & Advocacy

• Stigma and Discrimination

• Income Generating Activities

Targeting MSMTargeting MSM

Identifying key Identifying key hotspotshotspots Peer informants and Peer informants and

other input as part of other input as part of program designprogram design

Formative behavioral Formative behavioral researchresearch Understanding Understanding

population and tailoring population and tailoring appropriate messagesappropriate messages

MSM, MSW, TG may MSM, MSW, TG may require different require different messages and messages and messengersmessengers

Behavior Change Behavior Change Communication & Condom Communication & Condom

DistributionDistribution Peer outreach: criticalPeer outreach: critical

Innovative approaches (mid-Innovative approaches (mid-media such as media such as “edutainment”, website) “edutainment”, website)

Targeted IEC materials Targeted IEC materials Drop in centersDrop in centers

Peer activities, including Peer activities, including skills development, training, skills development, training, and services available at and services available at drop in centers and on-site drop in centers and on-site access to VCT and STI access to VCT and STI servicesservices

Targeted Condom Social Targeted Condom Social MarketingMarketing Ensuring access to condoms Ensuring access to condoms

and lubricants is key, either and lubricants is key, either by the program itself or by the program itself or through targeted condom through targeted condom outletsoutlets

Training Peer Leaders Training Peer Leaders

Community / grass-Community / grass-roots mobilization and roots mobilization and ownership is essentialownership is essential

Systems with Systems with incentives where incentives where community volunteers community volunteers can move up into can move up into part-time staff, later part-time staff, later full-time staff and full-time staff and then leadership roles then leadership roles encourage continuityencourage continuity

Important to target Important to target peers from sub-peers from sub-populations (MSW populations (MSW including TG SW as including TG SW as well as both feminized well as both feminized and masculine MSM)and masculine MSM)

Approaches to Delivering Approaches to Delivering the MPS Model for MSMthe MPS Model for MSM

Community-based Community-based servicesservices Drop-in Centers; one stop Drop-in Centers; one stop

shopshop Mobile clinicsMobile clinics Services at community Services at community

eventsevents Referrals to VCT and STI Referrals to VCT and STI

servicesservices GovernmentGovernment Private (can be subsidized Private (can be subsidized

with coupons, etc)with coupons, etc) Follow up is criticalFollow up is critical

Need strong linkages to Need strong linkages to care and support care and support servicesservices Desire for tailored Desire for tailored

programming for positive programming for positive MSMMSM

Barriers to Clinical Barriers to Clinical ServicesServices

Stigma and discrimination by providersStigma and discrimination by providers Need sensitization and MARP friendly servicesNeed sensitization and MARP friendly services

Lack of knowledge on MSM-specific STI Lack of knowledge on MSM-specific STI screening (i.e rectal exam for screening (i.e rectal exam for asymptomatic infections)asymptomatic infections)

Lack of anonymityLack of anonymity Names-based eligibility for services and Names-based eligibility for services and

reporting in some countriesreporting in some countries Cost: test and transportationCost: test and transportation Loss to follow-up: must have rapid tests!Loss to follow-up: must have rapid tests! Need to link STI and VCT servicesNeed to link STI and VCT services

Minimum Package of Services Minimum Package of Services in the Past 12 Months, in the Past 12 Months,

Bangkok, 2007Bangkok, 2007

0

20

40

60

80

100

Outreach TargetedMedia

Condom& Lube

VCT STI MPS

%

MSM MSW

Source Data: Thai MoPH, BoE, 2007

Consistent Condom Use with Consistent Condom Use with Casual Partner Casual Partner

& the MPS& the MPS

828180

76

61

0

20

40

60

80

100

1 2 3 4 5

Number of Interventions of the MPS

% C

CU

wit

h c

asu

al m

ale

par

tner

pas

t 3

mo

nth

s

OR: 1.8; CI 95%: 1.0 - 3.5

Source Data: Thai MoPH, BoE, 2007

Supportive Interventions Supportive Interventions for MARPsfor MARPs

Strategic InformationStrategic Information Capacity BuildingCapacity Building Community MobilizationCommunity Mobilization PolicyPolicy Stigma and DiscriminationStigma and Discrimination Income Generating ActivitiesIncome Generating Activities

Fostering an Enabling Fostering an Enabling EnvironmentEnvironment

Establishment of a Regional MSM Network: Purple Establishment of a Regional MSM Network: Purple Sky NetworkSky Network USG and UN support USG and UN support Community and government involvementCommunity and government involvement Country level technical working groupsCountry level technical working groups Regional Technical BoardRegional Technical Board Regional Coordination SecretariatRegional Coordination Secretariat

Goal: To enhance and strengthen the capacity of the Goal: To enhance and strengthen the capacity of the regional and in-country MSM working groups in regional and in-country MSM working groups in developing and advocating for appropriate and developing and advocating for appropriate and effective programs, services and policies for reducing effective programs, services and policies for reducing HIV and STI transmission among MSM in the Greater HIV and STI transmission among MSM in the Greater Mekong Sub-region.Mekong Sub-region.

Successes of The Purple Sky Successes of The Purple Sky NetworkNetwork

An MSM HIV prevention component is now An MSM HIV prevention component is now in every national/provincial AIDS plan in the in every national/provincial AIDS plan in the regionregion

Working groups including government Working groups including government organizations, CBOs and NGOs in all countriesorganizations, CBOs and NGOs in all countries

Opportunity for sharing experienceOpportunity for sharing experience Regional advocacy trainingRegional advocacy training Behavior change communication trainingBehavior change communication training Development and monitoring of a two-year visionDevelopment and monitoring of a two-year vision Regional network capacity building plan (in Regional network capacity building plan (in

progress)progress) Network newsletter and website (in progress)Network newsletter and website (in progress)

Challenges in the Creation of Challenges in the Creation of Purple Sky NetworkPurple Sky Network

Lack of epidemiological dataLack of epidemiological data Different political structures and Different political structures and

circumstancescircumstances Securing government buy-inSecuring government buy-in Varying levels of CBO and NGO Varying levels of CBO and NGO

engagement and human resource capacityengagement and human resource capacity Linguistic barriersLinguistic barriers

Key Lessons Learned in Key Lessons Learned in Supportive InterventionsSupportive Interventions

Regional multi-level Regional multi-level partnership approach can partnership approach can facilitate tangible national facilitate tangible national commitment by various commitment by various stakeholdersstakeholders

Donor, government and non-Donor, government and non-government participation government participation important in driving agendaimportant in driving agenda

Data is important but don’t Data is important but don’t wait for “enough”wait for “enough”

Regional coordination Regional coordination mechanism is a key mechanism is a key component in facilitating component in facilitating regional collaborationregional collaboration

Structured response can Structured response can expedite mobilization of expedite mobilization of resources and actionsresources and actions

Challenges to Implementing Challenges to Implementing the MPSthe MPS

Resource requirement to develop, Resource requirement to develop, evaluate, and disseminate replicable evaluate, and disseminate replicable modelsmodels

Limited funding available to scale up Limited funding available to scale up prevention services for MSMprevention services for MSM Government and donor funding very limited Government and donor funding very limited GFATM HIV grants were limited in GFATM HIV grants were limited in

prevention, but increasing with Round 8prevention, but increasing with Round 8 Weak linkages between community and Weak linkages between community and

clinical servicesclinical services

AcknowledgementsAcknowledgements

Cameron Wolf, Senior Regional Cameron Wolf, Senior Regional Technical Advisor, USAID/RDMATechnical Advisor, USAID/RDMA

Patchara Rumakom, Strategic Patchara Rumakom, Strategic Information Advisor, USAID/RDMAInformation Advisor, USAID/RDMA

Clif Cortez, HIV/AIDS Team Leader, Clif Cortez, HIV/AIDS Team Leader, USAID/RDMAUSAID/RDMA