Keeping Violence at Bay in Andhra Pradesh: International Day to End Violence against Sex Workers 2013

Violence, stigma and discrimination decrease the capacity of sex workers to access health care and other social services. (Photo by Peter Caton for India HIV/AIDS Alliance)

Violence, stigma and discrimination decrease the capacity of sex workers to access health care and other social services. (Photo by Peter Caton for India HIV/AIDS Alliance)

“I filed an application for a ration card in the mandal (block) administrative office. The clerk made me come to office 15 times, and every time he slept with me,” rues Meena  (name changed), a sex worker from Andhra Pradesh. “Wherever we go – offices, schools, hospitals or banks – we are sexually exploited and discriminated against.”

Sex workers across the world are easy targets for violence and discrimination at work, at home and in society at large. Data show that violence faced by sex workers ranges from slapping to sexual assault, physical and psychological torture, and sometimes even murder. HIV programmes across the world are grappling with this reality of sex workers facing high levels of stigma, discrimination, gender-based violence and other human rights violations, which prevent them from accessing HIV information, health care and needed social services.

To tackle the problem, India HIV/AIDS Alliance has worked through our Avahan programme to develop community-led strategies for prevention and mitigation of violence among female sex workers and other sexual minorities. Working in a total of six states, the Avahan India AIDS Initiative is funded by the Bill & Melinda Gates Foundation. In Andhra Pradesh, our programme covered over 40,000 sex workers in 14 districts. Programme strategies on violence include: community mobilisation and empowerment, crisis response systems and teams; and sensitisation of police and other law enforcement agencies, media personnel and service professionals. The crisis response teams respond within 24 hours to any violence reported by liaising with legal services in the event of unlawful arrests, sexual assault, violence and other rights violations against sex workers.

Since 2006, our team has successfully sensitized around 7,000 police officials at state, district and block level. Over 700 community members have received training on law and human rights and have been recognized by the District Legal Cell Authority as para-legal volunteers (PLVs). PLVs from sex-worker communities provide support to those in need. In addition, community collectivization and legal education has empowered sex workers to recognize and address cases of violence against them.

Routine monitoring on violence and crisis response including data collected from Targeted Interventions for HIV prevention and from special Behavioural Tracking Surveys (BTS) among 2,000 female sex workers in five districts in Andhra Pradesh between 2009 and 2012 showed an improved response to violence in sex worker communities. The number of cases of violence against sex workers has declined by 68 percent, from 900 cases in 2009 to 288 cases in 2011. The BTS data indicate that there has also been a reduction in violence by police (from 29% in 2009 to 19% in 2011-12). The perception of fair treatment by police has increased from 14% (2009) to 29% (2011-12), and around 70 percent of sex workers now experience what they consider to be fair treatment at public institutions.

“Earlier we shuddered at the sight of police. Not anymore. We now know our rights and what to do in a crisis,” says Meena with confidence.

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The author of this post, Dr. Parimi Prabhakar, is Director of Alliance India’s Regional Office in Hyderabad.

The Avahan India AIDS Initiative (2003-2014) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, notably female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

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Strengthening STI Services for Key Populations: Alliance India’s Mythri Mainstreaming Model

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Providing STI/HIV services in rural areas with fewer and scattered key populations (female sex workers, men who have sex with men, transgenders) is a challenge for HIV prevention programmes in India. In such scenarios, project-supported static clinics are not a sustainable option because of the limited availability of skilled health professionals and operational costs involved. Realising this need for sustainable approaches for providing STI services to key populations, India HIV/AIDS Alliance in collaboration with Andhra Pradesh State AIDS Control Society (APSACS) conceptualized the Mythri Mainstreaming Model in March 2007 as part of programming it supported under the Bill & Melinda Gates Foundation-funded Avahan India AIDS Initiative.

Alliance India initiated the model through a public-private partnership (PPP).The model used infrastructure and personnel of existing government healthcare facilities. Capacity building of staff, provision of STI drugs, and syphilis screening kits were provided by Alliance India to enable the provision of an essential package of STI services. STI services were provided after regular outpatient hours to female sex workers, men who have sex with men, and transgender communities. To address stigma and discrimination in accessing government facilities, doctors and staff were trained on issues faced by these clients.

The Mythri Mainstreaming Model achieved notable success. It resulted in improved utilisation of public healthcare facilities. Within the first year of initiating these clinics, more than 60% of targeted key populations had accessed these STI services. It successfully brought these groups to mainstream healthcare services. The Mythri model serves as a ‘one-stop’ centre for HIV/STI as well as other health care needs of key populations. Considerably greater understanding on health issues of key populations developed among medical staff, and these groups reported less stigma and discrimination while accessing services. Additionally, government healthcare facilities enjoyed improved infrastructure and staff capacities.

A study done by Alliance India to identify the most effective healthcare model for the delivery of STI services found that of the three models studied—project-owned clinics, private clinics, public private partnership (Mythri) clinics—the Mythri model was the most cost-effective. The model was also found to be the most effective in leveraging the strengths of the public and private sector and was the most sustainable of the three.

Due to lower operational costs and with better performance indicators, the Mythri Mainstreaming Model offers characteristics that make it preferable to other models of HIV/STI service delivery for scattered key population groups in rural areas. Similar models should be promoted in other resource-poor settings to improve HIV prevention and overall healthcare for vulnerable populations, such as female sex workers, men who have sex with men and transgenders.

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The author this post, Dr. M. Ravikanth, was Documentation & Communication Specialist with India HIV/AIDS Alliance in Andhra Pradesh.

The Avahan India AIDS Initiative (2003-2013) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, specifically female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

Community Collectivisation to Sustain HIV Prevention: Findings from Avahan in Andhra Pradesh

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Community collectivisation empowers key populations such as female sex workers, men who sex with men and transgenders to voice their concerns and more confidently exercise their right to access healthcare and social welfare schemes. Photo by Peter Caton for India HIV/AIDS Alliance

Community collectivisation can help develop a stronger sense of purpose and interconnectedness among key populations (KPs) such as female sex workers, men who sex with men and transgenders. Sometimes known as ‘community mobilisation’, community collectivisation enables these groups to utilise their experience of vulnerability to overcome barriers they face and realize reduced HIV vulnerabilty and greater self-reliance. Collective action by KPs also empowers them to voice their concerns and more confidently exercise their right to access healthcare and social welfare schemes.

With support from the Bill & Melinda Gates-funded Avahan programme, a recent study led by Niranjan Saggurti of Population Council in collaboration with India HIV/AIDS Alliance was designed to demonstrate if community collectivisation is associated with consistent condom use and STI treatment seeking behaviours among female sex workers (n= 3,557) and high-risk men who have sex with men/transgenders (n=2,399) in Andhra Pradesh. Recently published in the journal AIDS Care, the study generated significant positive findings.

Entitled ‘Community collectivization and its association with consistent condom use and STI treatment seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India’, the study showed that high levels  of collective action and participation in public events by both populations led to higher levels of consistent condom use, increased STI treatment seeking from government facilities, and improved ability to negotiate condom use.

The findings confirm the value of sustained community system strengthening to empower communities to meaningfully engage in national HIV prevention efforts and show the key role played by community collectivisation as an essential strategy to encourage consistent condom use and health seeking behaviours among KPs.

Read the complete study here.

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The author of this post, Dr. Parimi Prabhakar, is Director of Alliance India’s Regional Office in Hyderabad.

The Avahan India AIDS Initiative (2003-2014) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, notably female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

World TB Day 2013: Reducing tuberculosis burden through verbal screening of most-at-risk populations in Andhra Pradesh, India

Under the verbal TB screening programme, peer educators and outreach workers identify clients with TB symptoms during couselling sessions and refer suspected cases for testing. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

Under the verbal TB screening programme, peer educators and outreach workers identify clients with TB symptoms during couselling sessions and refer suspected cases for testing. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

India’s tuberculosis (TB) burden accounts for one-fifth of the global cases of the disease. In 2011, there were an estimated 3.1 million Indians affected by active TB. The problem is further compounded by HIV/AIDS, which is driving the resurgence of TB not only globally but also in India. HIV increases TB risk approximately seven-fold. Of the estimated 1.42 million TB deaths across the world, 430,000 die due to HIV/TB co-infection.

Typically, the integration of TB interventions into HIV services has focused on generalised HIV epidemics, with less emphasis on key populations, including sex workers, men who have sex with men (MSM), and people who use drugs. Yet the engagement and participation of key populations can be a vital strategy to address HIV/TB co-infection and improve access to diagnostic and treatment services toward the goal of achieving zero TB deaths.

Recognising the vulnerability of key populations and the difficulties they face in accessing TB services, India HIV/AIDS Alliance under the Bill & Melinda Gates Foundation’s Avahan India AIDS Initiative has implemented a verbal TB screening programme in Andhra Pradesh since 2007. Under the screening programme, peer educators at health clinics and outreach workers in the field identify TB symptoms in key population clients and refer suspected cases for sputum testing.

Take the case of Satyanandam, a member of the local MSM community. During a regular medical check-up at one of Alliance India’s Mythri clinics, he was found through verbal screening to be suffering from symptoms of TB: cough and night sweats. He was referred to a designated microscopic centre for sputum testing. An outreach worker accompanied him to the facility where he was found positive for TB.

Satyanandam was then supported by a local non-profit organisation (NGO) to ensure he successfully completed treatment. An outreach worker kept tabs on his medicine intake and advised him to stop smoking and practice good cough etiquette. After six months of treatment, Satyanandam was cured of TB. “Thanks to the Mythri clinic, the outreach workers, and NGO staff who cared for me during my illness. Because of their support, my family and I are healthy and happy now,” he said.

In fact, there are many Satyanandams who have been cured due to early TB detection through verbal screening. To date, 54,000 people have undergone verbal screening in Andhra Pradesh and among them, almost 2,000 each year have been referred for sputum examination. The proportion of people who accessed TB treatment increased from 83% to 94% in three years.

The intervention demonstrated that integration of TB interventions into HIV prevention services for key populations is feasible and complements the Government of India’s goals and targets under the Revised National Tuberculosis Control Program (RNTCP). Partnership with most-at-risk communities, civil society organisations, healthcare providers and government should be a key strategy to realise a world with zero deaths from TB, so that every Sathyanandam can live a long and productive life without TB.

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The author of this post, Dr. Parimi Prabhakar, is Director of Alliance India’s Regional Office in Hyderabad.
 
The Avahan India AIDS Initiative (2003-2013) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, notably female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

Avahan in Andhra Pradesh: Expanded Access and Increased Impact

ai_avahan_cover_low resAvahan India AIDS Initiative is a focused prevention initiative funded by the Bill & Melinda Gates Foundation that works in six states of India to reduce HIV transmission and the prevalence of sexually transmitted infections (STIs) in vulnerable high-risk populations—female sex workers (FSWs), men who have sex with men (MSM) and transgenders—through prevention education and services. The programme’s main components are condom promotion, STI management, behavior change communication, community mobilisation, and advocacy. Avahan also supports the creation of an enabling environment through individual and organisational capacity building to increase the effectiveness of the HIV response.

India HIV/AIDS Alliance is a state lead partner for Avahan in Andhra Pradesh. Alliance India’s efforts in the state have strengthened the capacity of NGOs and CBOs to implement quality HIV and STI programming in close partnership with the State AIDS Control Society (SACS) and in accordance with the National AIDS Control Programme.

Alliance India’s work with Avahan in Phase I covered 13 districts of the Telangana and Rayalseema regions in Andhra Pradesh and reached nearly 72,000 FSWs and MSM. Now in Phase II, Alliance India is transitioning programme activities to the state government as planned and supporting efforts to further strengthen community mobilisation with beneficiary groups to ensure sustainability of prevention activities under government support.

To learn more about our Avahan work in Andhra Pradesh, please download our brochure here.

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The author this post, Dr. M. Ravikanth, is Documentation & Communication Specialist, India HIV/AIDS Alliance.

The Avahan India AIDS Initiative (2003-2013) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, specifically female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

Increasing Civil Society Involvement in the Fight Against HIV in China

Chinese delegates with Alliance India members in New Delhi

India HIV/AIDS Alliance recently hosted a study tour of the Pehchan project for the China Association of STD and AIDS Prevention and Control (AIDS Association). This tour came in the wake of a significant decision made by the Chinese Government a few years ago to support the increased involvement of civil society organisations (CSOs) in the response to AIDS in China.  To support this goal, the AIDS Association was selected by the Global Fund to handle its contribution of $18 million for Community Based Organisations (CBOs). The journey ahead for the AIDS Association is an exciting one especially given the scale of its responsibilities, which include establishing an independent grant management mechanism managed by civil society.

The visiting team, consisting of delegates from the AIDS Association, China CDC, Ministry of Health, Chengdu Gay Care Organisation (CGCO), State Council AIDS Working Committee Office (SCAWCO) and UNAIDS China, were given a complete overview of the National AIDS Control Programme in India. They met with various stakeholders in NACO, SACS, UNAIDS, and the Bill & Melinda Gates Foundation to understand the role of the government, UN agencies and big donors in promoting the participation of the CSOs in the national AIDS response. The delegates also visited a Hijra CBO in Hyderabad, supported by the Andhra Pradesh State AIDS Control Society (APSACS), which offered them the opportunity to interact with CSO members and hear their experiences about working with the government.

The team learned about Alliance India’s work, particularly the Pehchan programme, and received technical inputs on developing systems and mechanisms in the areas of M&E and finance. They also learned about the various systems which have been developed by Alliance India to provide technical support to CSOs and to build their capacities in the effective management of data and grants.

As the visit came to an end, the Chinese delegates shared a few insights gathered from their trip which resonated strongly with them. Amongst these was Pehchan’s ability to reach the hard-to-reach populations which the government would otherwise find difficult to make contact with. These interventions serve as a bridge to build the capacities of CBOs and to link communities to government supported HIV programmes. The delegates also stated that Pehchan’s ability to align the cost of the Global Fund programme with the Government’s unit costs is essential for the sustainability of the programme once the Global Fund’s support has ended.

You can learn more about the work being done on HIV and MSM by civil society organisations in China by clicking on Alliance China’s report, Community Response to HIV among Men who have sex with Men in China.

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With support from the Global FundPehchan builds the capacity of 200 community-based organisations (CBOs) for men who have sex with men (MSM), transgenders and hijras in 17 states in India to be more effective partners in the government’s HIV prevention programme. By supporting the development of strong CBOs, Pehchan will address some of the capacity gaps that have often prevented CBOs from receiving government funding for much-needed HIV programming. Named Pehchan which in Hindi means ‘identity’, ‘recognition’ or ‘acknowledgement,’ this programme is implemented by India HIV/AIDS Alliance in consortium with Humsafar Trust, SAATHII, Sangama, and SIAAP and will reach 453,750 MSM, transgenders and hijras by 2015. It is the Global Fund’s largest single-country grant to date focused on the HIV response for vulnerable sexual minorities.

How integration responds to the SRHR needs of sex workers

Sex workers have the same sexual and reproductive rights as anyone else – such as to choose who to have sex with and to have sexual relations free from violence. They also share many of the same needs for SRHR information, support, commodities and services – such as advice about family planning.

However, due to many factors, sex workers often experience greater vulnerability to SRH ill health than other community members. They may experience one or all of: specific or more complex SRHR needs; additional or stronger barriers to accessing SRHR services; and weaker capacity or opportunities to demand SRHR services . These factors are further affected – sometimes complicated – by the differences between individual sex workers, such as in terms of their gender and sexual orientation (including whether they are female, a man who has sex with men (MSM) or transgender), age, legal status, HIV status, socio-economic status and whether they use drugs.

As a result, sex workers often have significant unmet needs for SRHR. These can ‘fall through the net’ of both: HIV services (often designed to address specific risk behaviors rather than the ‘whole person’); and SRHR services (often designed for the general public and focused on mainstream services, such as family planning).

This brief specifically focuses on the importance, but also challenges, of HIV/SRHR integration for sex workers. It is based on the experiences of a growing number of groups working with such communities to put integration into practice in a range of setting. These have given important insights into ‘what works’. But they also highlight that everyone is still learning and questions remain about what constitutes good practice.

This issue brief promotes integration as a desirable goal in the long-term. However, it also emphasizes that organizations must work in a way and at pace that is appropriate and feasible for them – to ensure that the joining of HIV and SRHR services and systems enhances, rather than compromises, support for sex workers.

This review was commissioned by the India HIV/AIDS Alliance with support from the European Union under the Action Project and explores experiences and lessons from around the world including Asia and the Pacific. This issue brief is part of a series of materials resulting from a review of good practice in the integration of HIV and sexual and reproductive health and rights for key populations.

Download brief from here.

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Alliance India is a state lead partner in Andhra Pradesh for implementing the Avahan India AIDS Initiative (2003-2013) which works in six states of India and is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, specifically female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy.