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.

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Falling Through the Net No More: Community Advocacy Expands Sexual & Reproductive Health Services for PLHIV

Alliance India’s Koshish programme supports advocacy to improve sexual & reproductive health services for PLHIV and other key populations at government facilities. (Photo © 2012 Peter Caton for India HIV/AIDS Alliance)

Alliance India’s Koshish programme supports advocacy to improve sexual & reproductive health services for PLHIV and other key populations at government facilities. (Photo © 2012 Peter Caton for India HIV/AIDS Alliance)

Sexual & reproductive health (SRH) services must become responsive to the specific needs of people living with HIV (PLHIV). Unfortunately, this is typically not the case in India. PLHIV face barriers in accessing basic SRH services or they have needs that go beyond mainstream services. These challenges are compounded because HIV services do not target the holistic needs of PLHIV and these patients are not encouraged to demand expanded access to suitable SRH services. As a result, PLHIV frequently ‘fall through the net’ of HIV and SRH services.

Facing these difficulties, what has Alliance India’s Koshish programme done to improve the SRH of PLHIV and fulfill their basic human rights claims such as the right to health? With funding from the European Commission, Koshish has supported the formation and growth of four state-level advocacy coalitions in Andhra Pradesh, Gujarat, Maharashtra, and Tamil Nadu. These coalitions are organised by PLHIV and comprise of stakeholders representing key population networks, media, mainstream development organisations and civil society. In each state, the coalition identified SRH and rights needs of PLHIV and charted out advocacy strategies targeting these unfulfilled needs.

A state-level meeting organised by the coalition in Andhra Pradesh highlighted the urgent need for the government health system to ensure the availability and accessibility of testing and treatment for cervical cancer among women living with HIV. A similar initiative was undertaken in Tamil Nadu and Maharashtra. The effort in Maharashtra also advocated for initiating Pap smear tests at government hospitals for eligible women living with HIV. To achieve these goals, the advocacy event began by recognising and appreciating the work of healthcare providers in providing care for PLHIV and then sensitising them about the value of the Pap smear test for women living with HIV and requesting their support.

Press conferences in Maharashtra and Andhra Pradesh helped get coverage of the unmet SRH needs of PLHIV in the popular media. A workshop in Gujarat in December 2012 also trained 77 print and electronic media representatives. Workshop participants learned about Koshish and actively interacted with PLHIV community members, discussing their SRH needs, service availability, and the frequency of rights violations.

Community advocacy supported by Koshish has helped draw state and national level attention to the SRH and rights needs of PLHIV. And this is just the beginning. PLHIV are essential partners is India’s response to AIDS. By empowering PLHIV with advocacy tools, Koshish and our state partners continue to promote policies and strategies to improve the lives of PLHIV in India and build them as the natural leaders of these efforts.

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The author of this post, Kumkum Pal, is Programme Officer for Alliance India’s Koshish programme.

 Alliance India works closely with PLHIV in India through its Koshish programme which aims to strengthen civil society organisations and networks that represent and work with PLHIV and other marginalised groups, such as MSM, transgenders, sex workers and IDUs, to effectively advocate for policies to improve the sexual & reproductive health and rights (SRHR) of PLHIV in India. This project is funded by the European Commission  and is implemented in partnership with MAMTA, PWDS, VMM and CHETNA, along with state-level networks for PLHIV in Maharashtra, Tamil Nadu, Andhra Pradesh and Gujarat.

 

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.

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.

Mark your calendars for AIDS 2012 sessions on Sex Workers & HIV

India HIV/AIDS Alliance has been working closely with partners worldwide to make sure that the issues of sex workers are heard at the upcoming International AIDS Conference in Washington, DC. If you are attending, we encourage you to participate in the events below.

In conjunction with AIDS 2012, the Global Network of Sex Work Projects (NSWP) is hosting the Sex Worker Freedom Festival, a conference hub in Kolkata, India. The programme will focus on a variety of freedoms such as the freedom of movement and to migrate; the freedom to access quality health services; freedom from stigma and discrimination; and many more. Staff from Alliance India will participate in the Kolkata hub.

All events below take place at the Walter E. Washington Convention Center, Washington, DC, unless otherwise indicated.

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Alliance Exhibition Booth (#102)
Come visit booth #102 to learn about the Alliance’s work in India and around the world, pick up copies of our publications and find out more about the Alliance Regional Technical Support Hubs.
All week, Exhibition Hall, 10:00am-6:30pm

Satellite Session
Reaching Key Populations through SRH/HIV Integration: Opportunities for Impact
Organised by India HIV/AIDS Alliance and chaired by UNAIDS, this session will present programming experiences highlighting the challenges and successful approaches used in integrated programmes specific to key populations, including sex workers. Panelists include the Alliance’s Sunita Grote, USAID’s Clancy Broxton, CAMNAFAW’s Nathalie Nkoume, and NEPHAK’s Rahab Mwaniki.
Sunday, July 22, Global Village Session Room 1, 3:45-5:45pm

Poster Presentation
Non-Commercial Partner Relationships and HIV Risk Outcomes, HIV among Female Sex Workers in Andhra Pradesh, India (MOPE249)
Monday, July 23, Exhibition Hall, Level 2, 12:30-2:30pm

Poster Presentation
Public private partnership as a sustainable model for STI service delivery: Evidence from Avahan-supported interventions in Andhra Pradesh, India (WEPE638)
Wednesday, July 25, Exhibition Hall, Level 2, 12:30-2:30pm

Oral Poster Session
Expanding Covering and Quality: Approaches to Scaling-Up
Alliance’s Sunita Grote will present recommendations on reaching Key Populations in SRH/HIV integration, including guidance on services for sex workers, MSM, transgenders, IDUs and PLHIV. (WEPDE0102)
Wednesday, July 25, Mini Room 3, 1:00-2:00pm

Poster Presentation
Strengthening case finding through verbal TB screening among most at risk populations in concentrated epidemics: Experience from Avahan in Andhra Pradesh, India (THPE627)
Thursday, July 26, Exhibition Hall, Level 2, 12:30-2:30pm

Poster Presentation
Mobilizing community collectivization among female sex workers (FSWs) to promote STI service utilization from the government health care system: Experience from Avahan in Andhra Pradesh, India (THPE305)
Thursday, July 26, Exhibition Hall, Level 2, 12:30-2:30pm

Press Conference
Turning the Tide: Addressing SRH Needs of Key Populations in AIDS Programs
This press conference will include remarks by Daxa Patel, the Board Secretary, Gujarat State Network of PLHIV, and by Sunita Grote from the Alliance.
Thursday, July 26, Media Center, Press Conference Room 2, 3:30-4:00pm

If you have any questions, please contact us at info@allianceindia.org. You can also view our AIDS 2012 Roadmap for all India HIV/AIDS Alliance sessions at the International AIDS Conference. We hope to see you at AIDS 2012!