HIV in Asia and the Pacific

INCORPORATING GENDER IN TO MARPs-BASED SERVICE INTERVENTIONS

2009-12-26T11:56:00.001+07:00

[Authors: Scott Berry, Dave Burrows, Lou McCallum and Ruth Birgin]

After twenty years of programming to prevent and treat HIV there is growing consensus that the most effective approach involves a focus on most at-risk populations (MARPs) – sex workers and their clients, injecting drug users (IDU) and their partners, men who have sex with men (MSM) and transgender people (TG). Gender and gender inequity is a major concern for HIV vulnerability but the evidence is scant on how gender and gender inequity impacts on the HIV vulnerability of particular MARPs. This article attempts to explore gender and gender inequity in most at risk populations for HIV including issues for women IDU and sex workers, MSM and TG and female partners of MSM and men who buy sex. It presents two innovative interventions that are attempting to address gender relate issues in MARPs in the Asia Pacific.

OVERVIEW

HIV prevalence among MARPs in some major Asian cities is said to have outstripped the capacity to prevent it. As well as the behaviors that place them at high risk for HIV transmission, MARPs face high-levels of social and structural stigma and discrimination that makes them more vulnerable to HIV infection including major human rights violations. They are more likely to find themselves in situations where they are unable to get the information or resources they need to prevent HIV and more likely to be unable to, or fearful of accessing health care.

Responding effectively to HIV among MARPs requires a complex analysis of the drivers of HIV transmission and acquisition and of access to health care for people affected by HIV. An analysis of the drivers of HIV transmission makes three things clear: (a) HIV is a human rights issue – vulnerability to HIV increases where human rights are being eroded or violated; (b) HIV is a women's issue – women who are sex workers, who inject drugs or are partners of men who buy sex or MSM are especially vulnerable and are not currently well served in the HIV service system; and, (c) HIV requires meaningful involvement of MARPs – MARPs aim to stay hidden and they do not come forward for service unless there are clear indicators of sensitivity and protection of privacy and confidentiality in the service system.

The simplistic approaches that have dominated many HIV programs to date have assumed these sub-populations are homogeneous and that their risk behaviors are distinct from each other. Sex workers should use condoms, MSM should use condoms and IDU should use clean needles. The reality is more complex - these are heterogeneous populations but with a high degree of overlap between them and overlap in the behaviors which put them at risk for HIV (an apparent contradiction). HIV risk and vulnerability is not evenly spread within each sub-population. More important for HIV programming is to understand that some MSM work as sex workers and use drugs while female sex workers may also inject drugs and may be more at risk of HIV transmission from their regular male partner than from their clients.

The little we know about gender and MARPs is compelling. Women IDU and sex workers are more at risk for HIV than other women. They are more at risk than their male IDU counterparts. Female partners of sex work clients and of MSM (where MSM have female partners) are more at risk of HIV infection than other women. Yet many MARPs programs and services have yet to extend their reach in to services targeted to women. In many settings transgenders are at higher risk of HIV than MSM, but programs and services focus more on MSM as they are often thought to be easier to identify and work with. Women, TGs, and MSM are punished for their transgression of socially constructed gender norms and expectations. They may stay hidden, avoiding disclosure of their risk behavior for fear of social persecution and exclusion. This in turn adds to the cycle of risk and vulnerability for all involved. Given this level of hostility in the environment, a key element of effective programming is the meaningful involvement of these groups in programming and decision making. Let's explore what is known about women who inject drugs, gay men and other MSM and transgender people.

SUB-POPULATIONS OF MARPs AND GENDER ISSUES

WOMEN IDU

Women IDU are at likely higher risk of acquiring HIV than other women (from the very limited evidence available) and are at higher risk of acquiring HIV than their male IDU counterparts. The increased social/cultural shame and punishment of women IDU compared to men means they are unrepresented in IDU services and in research on IDU and HIV. IDU services are often geared towards single client management and find the complex management of women and their children more challenging – not to say that all female IDU issues revolve around their role as mothers – but that services and programs have been particularly challenged by this. Services of all types related to drugs and HIV are often established by and for men. This is in spite of women representing perhaps 25%-35% of IDU in some Asian countries and in Eastern Europe women are thought to make up half of all IDU in some jurisdictions. Women sell sex to buy drugs, may be pimped by their male partners for drugs and are often injected by their male partners. This means they can be less powerful and less able to negotiate safe sex and injecting. Programmatic issues related to gender are rarely discussed in the literature. Evaluations of programs designed specifically to address the needs of women IDU appear to be non-existent. However, a Ukraine AIDS Alliance IDU program has increased its access to women IDU by 20% by creating a web of social networks to target women and encourage women's involvement in their program. That success offers lessons to other programs and a report is soon to be published.

GAY MEN AND OTHER MSM AND TRANSGENDER PEOPLE

Understanding the gender dynamics of sex between men and the behavioral, identity issues and concerns of TG are important factors for delivering effective HIV policy and service to them. In Asia and the Pacific, particular gender-based categories, definitions and behaviors operate in between MSM and TG but are often more complex than the definitions suggest. For example, insertive for anal sex may mean an MSM is referred to as a 'man' while receptive for anal sex can mean an MSM is referred to as a 'woman' or 'lady'. But it would be a mistake to think that these behaviors and descriptions define the social relationships, power and gender dynamics between MSM or between TG and their partners. TGs and MSM can move fluidly between these sexual and social behaviors and categories. Let's explore issues for transgender people and their risk of HIV through gender.

TRANSGENDER PEOPLE

Biological men who dress and live as women or as a third gender face criminal sanctions (as MSM or as sex workers). They face violence, rape and ridicule and social isolation, with restricted access to education, work and community life. TG who live openly as TG or as 'women' are often restricted to low paying retail and service jobs. Those who decide on gender reassignment surgery cannot raise the money required. They often have to engage in sex work to raise the cash for surgery. TG may be forced out of families and into sex work to make a living. Poverty and lack of education play a key role in poor health outcomes for transgender people. HIV and public health programs have often lumped TG into MSM populations together to make it easier for them to design and implement programs. This has not always been a successful approach and is often criticized by TG themselves, who do not see themselves as men and certainly not 'men who have sex with men'. They argue that they face a different set of challenges to MSM. They also argue that most of their sex partners are actually 'heterosexual' men who do not see themselves as having sex with another man when having sex with a TG. Many TG populations are at higher risk of acquiring HIV than MSM in Asia and the Pacific, as they are more cut off from programs and services, more likely to be discriminated against in education, employment and health services and more likely in many cases to be selling sex in environments where insisting on condom use is either not possible or financially impractical.

GAY MEN AND OTHER MEN WHO HAVE SEX WITH MEN

The very idea of anal sex between men - of a man being penetrated by another man – often triggers great hatred toward them. The neglect of emerging HIV incidence in Asia among MSM is now well documented as is the alarming rate of HIV prevalence that may have outstripped the capacity to prevent HIV among MSM and TG in a number of regions. Societies simply prefer not to deal with it.

Gay men and MSM have the power to 'transmute' or 'camouflage' their sexuality – that is, to hide their sexual orientation and to appear, act and sound heterosexual. While this strategy works well to prevent the many forms of stigma and discrimination that can affect them, it means they give up power (and importantly, their health agency) through self-censorship. They may not come forward for HIV or STI related service and, where they do, they may not disclose their sex with men to a health service provider. Loss to follow up is a serious concern across the Asia Pacific region in relation to gay men and other MSM.

Anecdotal evidence suggests that effeminate boys and young men may be targets for forced sex and a recent study by the Population Council found that one-third of boys and young men in an African study reported their first sexual encounter as a forced encounter.

FEMALE PARTNERS

Important in terms of gender dynamics is the sub-population of MSM who are married or have regular sex with women. The gender inequity and health risk for women partners of these men is obvious and concerning and mirrors the concern the sector shares for women partners of men who buy sex from sex workers. Female partners who don't know their male partners are having sex outside their relationship and/or with other men are simply powerless to protect themselves or their unborn children. The men involved are exercising a power that their female partners do not have. Protecting those women from HIV infection is a key concern. However, the most effective programs in relation to MSM who have female partners have been those with seek to educate these men about the risk of infection while making no judgments about their behavior. Other programs seek to educate the MSM and transgender people having sex with these men so they can, in turn, educate their male sex partners about HIV risk and how to avoid it. In Africa, Australia and the UK there is evidence that where MSM with female partners have the right information about HIV prevention, they do take steps to prevent HIV transmission to their partners. This includes modifying the kinds of sex they have with men and transgender partners to avoid high risk activity for HIV. But these are not gender transformative approaches to HIV prevention. They may prevent HIV but the power dynamics which keep these women uninformed remain unresolved.

INNOVATIVE GENDER-BASED MARPs INTERVENTIONS IN ASIA PACIFIC

Two interventions are presented here for their innovative incorporation or targeting of gender in MARPs-based interventions. The first is an experimental program by Kios Atma Jaya in West Java Indonesia. Kios established a program of service targeting women IDU who sold sex to maintain their drug habit. The second is The Poz Home Center in Bangkok which incorporates gender-based assessment in to its intake and case management approach to MSM and TG with HIV.

KIOS ATMA JAYA

Kios Atma Jaya is a program of the Atmajaya Catholic University providing IDU outreach education in West Java Indonesia. It began in 2002 and they service a highly marginalized population, many of whom resist going to clinics even when seriously ill – for example, in a recently published report they describe a small but significant percentage of referrals to clinic services die before getting service or while receiving clinical service.

In response to the small numbers of women IDU sex workers accessing services in West Java generally and the overrepresentation of that small number in the most complex of client presentations, they developed a program to deliver night outreach to female IDU sex workers .One key element of success in this program was the active involvement of both male and female outreach workers, some of whom were ex-IDU and some of whom were previously or presently part of the target group. The numbers of female IDU sex workers reached were small (n=341) but numbers of female IDU (who were not sex workers) was higher (n=2,471). Nevertheless, this approach has been applauded as one of the few examples of targeted women IDU service provision in the Global South and is certainly innovative for Indonesia.

The range of program activities included an outreach needle and syringe distribution program, voluntary testing and counseling for HIV, STI referral, case management, basic health services, reproductive health referral and advice, HIV and drug dependence counseling, peer education/support, advocacy, referral to peer support groups and referral to vocational training. The particular outreach activities engaged for this project included:

Promoting of reproductive health services
Condom negotiation techniques
Referral to STI clinics
Safety procedures related police raids, aggressive and abusive clients – including self defensive training

Kios Atma Jaya noted that best time to reach this group of women is at night time – they work at night and sleep during the day (another reason why they are not and do not access mainstream health services). They note that in the BCC intervention there is limited time to make a strong connection, communicate effectively and provide relevant information education. The work occurs on the street, in the middle of the crowded areas, the education is often hectic, interrupted by police raids or drunk patrons. Kios has twelve outreach workers who carry the main responsibility for reaching IDU and IDU sexual partner generally. To meet the need to target women IDU sex workers seven out of twelve outreach workers were diverted to this project.

STRATEGIES

The strategies used to make this work most effective included:

Involving women in the outreach team
Rearranging schedules for the outreach team to do late night and early morning outreach – they describe the best time to reach this group of women was before 'peak hour' (around 2-3 am)
Because of the control their male partners exerted over them, the team often had to approach female IDU sex workers through their partner and/or pimp and ensure that the partner/pimp was not threatened by their engagement
Involving local people associated with female sex work activity like venue owners, other women IDU sex workers to deliver prevention material and promote health services was a particularly successful element of this program.

PRINCIPLES APPLIED

ü Maintaining flexibility - this program worked to provide service late at night when women IDU are engaged in sex work. They provided services on the street, often in difficult circumstances and found ways to do so that made a connection and communicated needed information to their female clients.

ü Addressing the context of women IDU's lives – they didn't just respond to HIV risk, the team also provided strategies for getting away from the police, getting legal representation and dealing with aggressive and abusive clients to ensure safety. They provided referrals and support in relation to reproductive health and wellbeing for female clients.

ü Promote meaningful participation – the team involved male and female outreach workers, often IDU or ex-IDU themselves to signal safety and the meaningful involvement of IDU. In a conversation with one of the team after their ICAAP 9 presentation, she described how women IDU know if you know the language, they know if you know how to inject and the difficulties of injecting in public places as well as the difficulties with their clients and partners/pimps. Her key advice to others was "You have to speak their language".

THE POZ HOME CENTER, BANGKOK THAILAND

The Poz Home Center is a drop-in, peer-based service for HIV positive gay men & other MSM, transgender people and these individuals engaged in sex work. The center uses a 3-stage peer counseling model that is an example of one of the only programs to incorporate gender analysis in to intake and assessment and case management for gay men, MSM and TG in this region. The 3-stage model provides 1-2-1 support at diagnosis or first presentation. It is at this stage that gender-related questions and concerns are considered and dictate how the rest of the service delivery is managed. The second stage involves matching clients to peer-based buddies for ongoing 1-2-1 support and the third stage involves connecting clients to groups and networks of peers.

At intake and assessment the presenting issues of the client are filtered through the 'lens' of gender to identify particular challenges in the client's life. Then, in case planning, these issues are raised with a view to setting goals to resolve them. The Poz Home Center identifies a set of gender-based presentations that are particularly common:

Transgender people working toward gender-reassignment and diagnosed with HIV need to consider the impact of HIV on surgery and the preparedness of hospitals to complete reassignment after their diagnosis with HIV
Transgender people are often engaged in sex work to pay for gender reassignment as this is one of the few ways available to them to save the money for surgery
Kathoey (the Thai word for transgender) experience violence, intimidation, sexual violence and may be unable to negotiate safe sex in their relationships
MSM experiencing difficulties and rejection at home because of their sexuality or gender transgressions (especially young people). Young People may be particularly vulnerable to HIV infection because they have limited experience at negotiating sex and may be negotiating with adults. They are also more likely to not understanding how to manage HIV once diagnosed
MSM experience violence, intimidation, sexual violence and can be unable to negotiate safe sex in their relationships

The Poz Home Center, as one element of its service program, provides peer counselors to newly presenting clients. These peer educators/counselors are chosen because they have similar experiences to the client and have overcome similar difficulties. So a young transgender person may be matched to another, a young MSM with another and older MSM to each other.

PRINCIPLES APPLIED

ü Uses a non-judgmental approach – Poz Home works with these clients 'where they are' in their lives.

ü Fulfills rights and respect choices – a key principle is respecting the choices of each individual and supporting them.

ü Protects confidentiality and privacy – Poz Home is trusted because it has a reputation for protecting and preserving the anonymity of its clients.

ü Maintains flexibility – Poz Home provides weekend and evening services as well as weekday services.

ü Promotes meaningful participation – Poz Home uses peers, and often people who have been through their program as clients, as buddies and as staff.

ü Assists with all aspects of the client's life, not just HIV.

RESPONDING EFFECTIVELY TO THE GENDER NEEDS OF MARPs

Responding practically to the gender needs of MARPs means understanding both the service-level needs and the national-level needs of MARPs. Services need to establish proper, long term service goals that aim for 'life ong' contact with MARPs where possible. Legal and cultural impediments are getting in the way of that goal right now. Services need to consider how to effectively attract and retain MARPs in their service programs. Involving MARPs as volunteers, staff and MARPs-based groups and organizations in promoting services is a key element for success. Getting MARPs services to 'scale' remains a challenge. The gap between 'supply' and 'demand' can be wide; loss to follow up is a problem. The role of MARPs community-based groups, networks and organizations cannot be over-emphasized in the challenge to reach scale and attract and retain MARPs. Approaches relying on peer workers have been found to have a greater effect than other approaches to HIV prevention to most-at-risk-populations (MARPs).MARPs community-based organizations need to emphasize the role of women in service provision and leadership and provide specialized promotion and programming for women.

Given the formidable social hostility and marginalization of MARPs, people from MARPs find it difficult to engage in leadership, policy and advocacy or meaningful involvement in service design and delivery. A recent review of Global Fund Country Coordinating Mechanisms by Fried and Dowalski-Morton found that out of 65 CCMs they reviewed, just 5 had representatives easily identifiable as LGBT organizations or members. Another study commissioned by the Global Fund on the proposal development and review process in seven countries in Africa, Asia, Latin American and the Caribbean, found that "marginalized groups were seldom discussed as an issue per se of particular relevance" by CCMs. This means that governments are determining their country priorities without MARPs. There is insufficient strategic information about the prevalence and impact of HIV among MARPs in many countries where this should be driving programs. This means that there is little attention to what, anecdotally, is believed to be high levels of HIV transmission and burden in MARPs. Governments and national public health partners are not using Global Fund resources to deliver high intensity, targeted programs that can disrupt HIV transmission where it's needed or to improve health outcomes for MARPs living with HIV.

Fried and Dowalski found that MARPs groups often operate 'below the radar'. They stay informal because they fear the consequences of a more public presence. Their capacity to engage can be limited, especially where government programs and other formal instruments are involved. We still don't know the answers to this but what would best national government practice look like for involving and engaging MARPs in these contexts?

HIV in MARPs is a gender issue but gender activists have yet to fully grapple with the implications of gender and at-risk-behavior in women or to embrace and advocate for the gender-related issues of MSM and transgender people. Equally, MARPs-based analysis would benefit from a more sophisticated consideration of gender and incorporation of best thinking on gender and HIV vulnerability.

REFERENCES

Van Griensven, F. (2007) The epidemiology of HIV and STI among MSM and Transgender in Asia. Presentation. 8th International Congress on AIDS in Asia and the Pacific. Colombo, Sri Lanka.

Watchirs, Helen. AIDS Audit – HIV and Human Rights: An Australian Pilot. In Law and Policy, Vol 25, No 3, July 2003 p247.

Kirby, Michael. Speech at the UNDP Symposium: Overcoming Legal Impediments to HIV services for MSM and TG. 9^th International Congress on AIDS in Asia and the Pacific. Bali, Indonesia.

Amin, Avni and Burrows, Dave. Where sex work, drug injecting and HIV overlap. Practical issues for reducing vulnerability, risk and harm. WHO. Feb 2007 (unpublished).

Burrows, Dave. Summary: women IDU, harm reduction and HIV/AIDS. Unpublished.

Van Griensven, F. (2009) The epidemiology of HIV and STI among MSM and Transgender in Asia. Presentation. The 200 Forum. APCOM Pre-Conference Meeting at the 9th International Congress on AIDS in Asia and the Pacific. Bali, Indonesia.

This summary taken from Burrows, Dave (unpublished) ibid.

Van Griensven, F. (2009) ibid.

Barker, Gary. Engaging Adolescent Boys and Young Men in promoting reproductive and sexual health: lessons, research and programmatic challenges. Chapter 6. Population Council Resource on Men and Boys. 2004; p114.

Research by STIGMA (UK), UNSW (Australia) and reference from Africa not available.

Kios Atma Jaya team: Oral Presentation: Night Outreach: Addressing Female IDU Sex Worker needs in West Java, Indonesia. Presentation. 9th International Congress on AIDS in Asia and the Pacific. Bali, Indonesia

Hangzo, C et al. reaching out beyond the hills: HIV prevention among injecting drug users in Manipur, India. Addiction 92 (7), pp. 813-20.

The Global Fund to Fight AIDS, TB and Malaria. 15^th Board Meeting Decision Points. Available at http://www.theglobalfund.org/en/ September 11, 2007.

WHAT MARPs ADVOCATES CAN LEARN FROM INDIA’S SUCCESS

2009-11-04T23:42:00.001+07:00

ARTICLE: What can MARPs advocates in HIV learn from India's success in overturning s377 of the Penal Code which made adult homosexual relations punishable with a ten year prison term? APMG Asia Pacific undertook a media scan and interviewed some key Indian advocates to find out more.

[Author: Scott Berry. With thanks to Aditya Bondyopadhyay and Ashok Row Kavi for their guidance].

On July 2, 2009 the Delhi High Court annulled the law criminalizing adult homosexual relations with a ten year prison term. Section 377 as it was known was a section of the Indian Penal Code left over from British imperial rule. In subsequent years s377 had been used to persecute LGBT people and silence their human rights defenders. It had massively stifled HIV efforts in the country, making volunteers and outreach workers vulnerable to police harassment and arrest. It had been used to extort money from men who have sex with men and had forced them underground, adding to the difficulties of undertaking effective HIV prevention education for gay and other men who have sex with men and transgendered people. The Naz Foundation India Trust along with India's Lawyers Collective and other community advocates and groups worked for eight years for the decision that finally came on the 2^nd July.

The main focus of the Naz Foundation India Trust petition was to challenge the law on the ground that it violated the health rights now considered by the Courts to be covered under the fundamental rights to life as given in Article 21 of the Indian Constitution.

Indian activist and lawyer Aditya Bandopadhyay expressed the collective joy and hopes for the future of those advocates when he told the BBC "we are elated. I think what now happens is that a lot of our fundamental civil rights which were denied to us can now be reclaimed by us."

About most-at-risk-populations

Most-at-risk-populations (MARPs) for HIV are those engaged in behavior high risk for HIV transmission including commercial sex work without condoms, sharing injecting equipment and sex between men. At this point in the epidemic then, most-at-risk-populations for HIV include sex workers and their clients, IDU and their partners, MSM and transgender people. As well as the behaviors that place them at high risk for HIV transmission, MARPs face high-levels of social and structural stigma and discrimination that makes them more vulnerable to HIV infection including major human rights violations, including criminal sanctions. An example of the outcome of this sort of hostile environment was described by staff of Kios Atma Jaya at this years' International Congress on HIV/AIDS in Asia Pacific. Kios Atma Jaya is an IDU outreach program of the Atmajaya Catholic University in Indonesia. They described a large proportion of their client group who resist going to clinics even when seriously ill with HIV or Hepatitis. A small but significant percentage of the clients they refer to mainstream clinic services die before getting service or while receiving it. MARPs are more likely to find themselves in situations where they are unable to get the information or resources they need to prevent HIV and more likely to resist accessing health care.

MARPs, especially women, MSM and transgendered people are particularly shamed and punished for their transgression of social constructed norms and expectations. They stay hidden and may avoid disclosure of their risk behavior to medical and other personnel for fear of social persecution and exclusion. This in turn adds to their cycle of risk and vulnerability.

It stands to reason, given this formidable social hostility that MARPs find it difficult to engage in leadership, policy and advocacy related to HIV. Lifting legal sanctions against them is now considered an essential step in creating better health outcomes and active participation in HIV prevention and care. For example, a recent review of Global Fund Country Coordinating Mechanisms by Fried and Dowalski-Morton found that, out of sixty-five CCMs they reviewed, just five had representatives easily identifiable as LGBT organizations or members. Another study commissioned by the Global Fund on the proposal development and review process in seven countries in Africa, Asia, Latin American and the Caribbean, found that "marginalized groups were seldom discussed as an issue per se of particular relevance" by CCMs. This means that governments determine their country HIV priorities without the participation of or representation of MARPs. The result is little evidence of the prevalence of HIV among MARPs in many countries. The Global Fund represents one of the most innovative programs to scale-up and deliver high intensity, targeted programs that can disrupt HIV transmission in the 'hotspots' for HIV in many countries.

What can MARPs advocates learn from India's success?

What can advocates, whether sex workers, injecting drug users, MSM or transgender people, learn from India's success? Can the experiences of the movement to change s377 be applied to MARPs-based advocacy in other countries and the lessons learned used to change the legal, social and health-related impediments to effective prevention of HIV and support for people living with HIV (PLHIV)? We wanted to know whether the experiences of s377 advocates might help to predict the sorts of problems faced and solutions found in broader struggles for MARPs human rights. We came up with six themes posed here as suggestions for advocates taking steps to change criminal law for most-at-risk-populations in Asia Pacific:

Make a conscious, collective decision to change the law and then do it
Choose your key partners carefully and add partners strategically as the movement progresses
Expect problems, delays and setbacks
Be in it for the long term
Develop a rational, coherent and well thought through set of arguments
Educate and communicate your arguments to the broader community – especially target the legal fraternity, law enforcement, politicians, the media and relevant health and welfare sector leaders

What follows is an exploration of each of these themes to analyze and present the views of some of India's s377 advocates.

Make a conscious decision to change the law and then work collectively to do it

In 2000, HIV and LGBT advocates took a decision to work collectively to remove sanctions in the criminal code. There was opposition to the decision both from within and outside HIV and LGBT circles. Some quarters of the community didn't think it was the right time, Anand Grover, who headed the legal team explains. Some warned "the climate was not right" for this sort of fight while others outside the LGBT community were just "uncomfortable" with gay men and TGs. Others misunderstood the nature of the petition and the team leading the change to s377 needed to take time to explain and work collectively to reach consensus.

A strategy to listen to and involve stakeholders in the decision to act and facilitate change was adopted from the start. Anand explains "we involved the community from day one. In this case it was not lawyers who decided how the case would go. HIV in India and other places, it is the community who are the deciders. They decided whether we should go to the Supreme Court." In the end it was clear that "criminalization of private practices of groups vulnerable to HIV impedes HIV programs and goals. It had to be addressed."

Aditya Bondyopadhyay, a leading advocate of the movement to change s377, highlights that "the progress of the case was an opportunity for the community to mobilize cohesively, to an extent where it can now be called a viable movement."

Choose your key partners carefully and add partners strategically as the movement builds momentum

A key organizational leader in this movement was The Lawyer's Collective of India (Go to: http://www.lawyerscollective.org). The Lawyer's Collective is a CBO with a history of representing PLHIV, mounting legal challenges for HIV treatment and representing women fighting for their human rights. Its organizational principles are embedded in the emancipation of marginalized sub-groups in Indian society. The Lawyer's Collective was crucial to the success of the movement because it brought the necessary legal expertise to fight the case as well as the knowledge of key leaders in the legal fraternity to sensitize as part of the community education process.

The other key partner was The Naz Foundation India Trust, an MSM and HIV agency agency with an active role in HIV prevention, care and support in India. And it was Naz Foundation India Trust that ultimately filed the petition (Go to: www.nazindia.org).

Why was it an HIV organization that submitted the petition? Anand Grover explains that some within gay community circles were concerned that a gay group should have led the High Court petition and not an HIV organization, even if that organization was running MSM and TG programs. But, as he says, "in 2001 who would file a petition?" The answer he says is "no one". And this goes to one of the key issues in MARPs based advocacy at country level – in situations where legal impediments exist, MARPs-based groups and organizations are excluded from participating fully. They operate 'under the radar', they may not be formally organized and may be without the capacity to lead and bring about change. In India, it was possible to register a LGBT organizations before the s377 change. However, the government could theoretically de-register a GLBT organization if it was determined to be working against the law or for an illegal purpose or intent.

At different time periods, depending upon the particular needs of the time, the coalition supporting the petitioner (The Naz Foundation India Trust) involved various individuals and organizations in the sensitization process including international agencies like the International HIV/AIDS Alliance and local LGBT organizations such as the Humsafar Trust.

Expect problems, delays and setbacks

At the beginning of September 2004, the movement experienced a major setback in their campaign to annul s377 when the High Court decided to dismiss the Naz Foundation India Trust's petition. We asked Shaleen Rakesh, previously of the Naz Foundation India Trust, how he reacted to that news and he explained the High Court rejection was a deep shock. "After three years of going back and forth the High Court has thrown out our petition on the flimsiest and most baffling grounds," he told AFP. The High Court ruled that it was not legally possible for a petitioner to challenge the Penal Code when they were not directly affected by it. Aditya Bondyopadhyay explains that the decision to dismiss the petition was against the established jurisprudence of Public Interest Litigation, wherein it was the law that any third party can file and prosecute litigation for marginalized populations incapable of accessing the Courts themselves. "We are not prepared to sit back and accept what the Court is throwing at us. We are studying legal options in front of us and will file a review petition in the High Court or take the matter to the Supreme Court," Shaleen said at that time.

In response, groups against the Naz Foundation India Trust petition celebrated the ruling as a win. Government lawyers had told the Court that the abolition of the law "could result in delinquent behavior" and the erosion of "strong Indian family values."But over the following years the movement to change s377 even managed to convince government- at least the Ministry for Health – that this change was necessary. In their submission to the High Court the Indian Ministry of Health said "while the National AIDS Program has achieved some measure of success in reducing HIV among sex workers, rising sero-prevalence among homosexual men has been a cause of worry. With criminal sanctions gone, we hope to reach out better to men who have sex with men and encourage safer sex." It is significant that they put this position to the Court when other Government Ministries mounted strident homophobic opposition to any change in the law, including suggesting the affidavit from the Ministry for Health be rejected by the Court.

Raising challenges to the law will also provoke strong opposition from other corners of society. There were times when raising awareness about s377 created negative press and social reactions to LGBT across India. Immediately following the High Court's decision of July 2, the Students Islamic Organization issued a statement against it, saying it was a setback for HIV prevention and that the right to personal liberty should not be used to justify anti-social behavior. Incest and sex with animals," the Organization claimed, "would then also be legalized." Managing these kinds of civil challenges becomes part of the process for change.

Be in it for the long term

This was an eight year battle. Individuals and groups involved needed to be prepared to stay in for the long haul. Anand Grover explains that you need to be determined and focused on change. This is not a challenge for "short-term, fly by night operators" he says. A lot of people want publicity. But, Anand advises, follow the principles of the Baghavad Gita - be like a rock, and do not expect any reward or benefits. Aditya can recite parts of the Gita word-for-word and he explained that the section of the Gita is as follows: "Do you duty without any regard for consequences or rewards".

Develop a rational, coherent and well thought through set of arguments

Civil society is not one homogenous lobby group agreeing on all issues. Rather, it is a concentration of varying interests that struggle to be heard and can compete for limited resources. Nowhere is this more the case than in the MARPs-based civil society responses to HIV where limited resources intersect with high levels of discrimination and need. Expect much competition between civil society actors for these limited resources. This is democracy in action and it's what civil society is - it should be honored as such.

But in the context of India's success, the development of a rational, coherent and well thought through set of arguments appears to have been an essential element in convincing the legal fraternity, members of government and other significant community leaders that this change was necessary. The head of the Naz Foundation India Trust explains the intensive work on research and careful consideration of arguments by The Lawyer's Collective as one of the factors in their success.

Educate and communicate your arguments to the broader community – but particularly target the legal fraternity, law enforcement, politicians, the media and relevant health and welfare sector leaders

At ICAAP 9, Anand Grover explained that "as lawyers we don't take the time to sensitize all stakeholders – but this is important and particularly it's important to sensitize Judges, the legal community, the police. They also realize and understand. Police say 'Why are we trying to catch men having sex with other men or drug users when we have other issues that are more important?' Over a period of time you are able to have an impact on sensitizing stakeholders who are part of the establishment and also the opening up of situations where gay men could form into groups as HIV service providers."

Aditya Bondyopadhyay emphasizes the large amount of work done on the media so that in the end they had a sensitized and supportive media, which went a long way in transforming the position of the government too this issue. "Their contribution," he highlights, "cannot and should not be slighted."

Ex-Australian High Court Justice, The Hon Mr. Michael Kirby was one international activist invited to participate in the sensitization program. At ICAAP 9 he described how the Lawyer's Collective "organized seminars throughout India and just talked about these issues in the presence of Judges and lawyers. Often it's a matter of personifying it," he explained. "In terms of the White Australia policy, we were able to change it when people began to meet Asian Australians and this is the way to change attitudes toward MSM."

APMG Asia Pacific interviewed Ashok Row Kavi, the Executive Director of Humsafar Trust, a GLBT and HIV organization in Mumbai (Go to: www.humsafar.org). Ashok was recruited by the Lawyer's Collective to lead targeted community sensitization workshops targeting particular segments of Indian society. Those workshops were meetings between GLBT groups and Indian leaders and included the legal fraternity and law enforcement. He explains "I stood in front of Judges... people who came from deep within the wellspring of Indian society and culture – they came from deep within Hinduism – and I talked to them about being gay... the injustices perpetrated against us... the impediments in HIV work."

Shaleen Rakesh, now Director of Technical Support for the India HIV/AIDS Alliance explains that the July 2 verdict "is a major step forward but there is still much more to do in terms of engaging communities in the response to HIV." Ashok Row Kavi told the BBC "the social stigma will remain. It is still a long struggle. But the ruling will help in HIV prevention. Gay men can now visit doctors and talk about their problems. It will help in preventing harassment at police stations."

Finally, Ashok Row Kavi offers this advice to other advocates, he says "look at the turmoil of India, its tumultuous identities and how all these identities are demanding to be heard... to make the invisible visible." It is a long struggle but it is possible. The outcome in India has been good for the country he says because "the state has benefited and guaranteed for itself legitimacy and relevancy for its citizens."

REFERENCES

APMG’s WORK ON SEX WORK POPULATIONS SIZE ESTIMATION

2009-09-28T19:55:00.001+07:00

IN BRIEF: AIDS Projects Management Group is working on developing population size estimation processes for sex workers at the national level. In this short brief, APMG Director Dave Burrows reports on this important development in HIV.

While many estimation methods are available for measuring the size of sex worker population as national level most are not suited to developing and transitional countries. Population size estimation is important for a number of reasons. Most significantly, coverage statistics only make sense if we know the population size. Coverage is expressed as the percentage of a total population which receives or participates in specific services of acceptable quality on a regular basis. While there is still a great deal of debate about which services - or combinations of services - are most important, and how to measure quality and regularity, none of these is useful if we don't first have at least a general agreement on how many people are in the population being covered.

Also, national government, Global Fund, WHO and UNAIDS processes - such as applying for GF grants, scaling up existing services, "Know Your Epidemic" and Universal Access to HIV Prevention and Treatment - all require knowledge of the total population of most-at-risk populations including sex workers.

APMG is carrying out population size estimation (PSE) for female sex workers and injecting drug users in Tajikistan at present. The report on these processes is due to be released before the end of 2009, but already there have been several lessons learned:

Stand-alone PSE processes are likely to be much more effective than combining PSE with risk behavior and behavioral surveillance surveys: while it seems natural to combine these processes, the combination leads to great difficulties in PSE and less-than-ideal surveillance data
PSE in countries with less developed health systems and health statistics requires a specific group of techniques to triangulate the most likely population size
From the Tajikistan work, it appears that a combination of at least one (and, if possible, at least two) multiplier processes together with capture-recapture and local Delphi methods can provide the necessary data for the estimation exercise*
The above processes are cheaper and tend to require less technical capacity among national institutions than more sophisticated studies using social network analysis
Respondent-driven sampling is very useful for BSS and other survey work, but appear to be both expensive and less likely to lead to appropriate estimates than the above combination of methods
Any estimation process among sex workers or drug users needs to be carried out collaboratively with local, state/ province and national authorities in both the health and law enforcement sectors. The final estimates should be agreed at a national consensus workshop.

APMG is now discussing the use of these PSE processes with countries in the Asia-Pacific region.

* Multiplier processes use known statistics such as detentions or arrests of sex workers together with survey data to estimate the population size.
Capture-recapture is a method that uses an object - in Tajikistan, a pocket calendar - distributed to a population at a defined time prior to survey implementation, combined with survey data.
Local Delphi methods assemble local authorities who have some experience of dealing with sex workers and ask them to agree on the number or the range of numbers of sex workers in the local area. These are combined at state and national level.

MYANMAR MOVES TO “SUPERVISE” PLHIV GROUPS

2009-09-15T13:11:00.001+07:00

IN BRIEF - Yangon, Myanmar: On August 6 this year Myanmar's Ministry of Health moved to impose registration on networks of people living with HIV (PLHIV) forming in different states and divisions across the country. The Myanmar Health Department requires these informal groups to work under the supervision of Prevention and Control Teams for STDs and HIV in each state. Alternatively, where a group wishes to form independently, it is required to register step-by-step with first the township, province, State/Division Peace and Development Councils and finally with the Ministry of Home Affairs.

Bloggers across Asia Pacific have begun agitating online. They argue registration will impede development of the enabling environment needed to support PLHIV and to change the stigma and discrimination toward them in the country.

But Cyclone Nargis and the burgeoning non-government organization presence in-country have created a conundrum. The health and humanitarian assistance is desperately needed; but the Myanmar leadership has viewed humanitarian and health intervention as a threat to their security.

An August 24 article in The Washington Post explains the reasons why. 'Strategies of Dissent Evolving in Burma' maps the evolving ways activists are finding political momentum using humanitarian non-profit organizations. It describes the Burmese junta since 1962 clamping down on civil society and prohibiting associations of more than five people. However, immediately post-Nargis, while the government was negotiating conditional entry of international aid agencies, the article describes Burmese citizens, concerned about the lack of adequate relief aid by authorities, forming in to groups, gathering and distributing food aid, assisting with rebuilding, re-housing and providing medical care. The article describes how these national groups and some non-profit organizations are becoming undercover recruitment points for political leadership and activism. It quotes an AIDS activist: "many people say civil society is dead. But it never dies. Sometimes it takes different forms, under pretext of religion, under pretext of medicine."

While there is international consensus that political change is urgently needed in Myanmar, it's clear that humanitarian aid and medical care as political activism will be treated as a serious threat by the current regime. This move to restrict informal PLHIV groups is viewed by those with experience in Myanmar as an attempt to limit that perceived threat.

The challenge now is to determine a way forward that ensures progressive support at local level for PLHIV. APMG Asia Pacific has asked a number of Myanmar leaders in HIV for their views on the way forward – we'll present their thoughts in an upcoming post.

THAILAND EXECUTES 2 FOR DRUG CRIMES

2009-09-05T14:28:00.001+07:00

NEWS ARTICLE - Bangkok, Thailand: The execution by lethal injection of two Thai men for drug possession and trafficking last week has sent shockwaves around the world. The men, Bundit Jaroenwanit aged 45 and Jirawat Poompreuk aged 52, were given just 60 minutes notice of their executions, offered a last meal and a chance to listen to a Buddhist sermon before being led to the execution chamber manacled and blindfolded. Amnesty International immediately denounced the killings underlining "there is no evidence that the death penalty deters crime."(1) Human Rights Watch called the executions a "new low" in Thailand's anti drugs campaign (2).

At the 9^th International Congress on AIDS in the Asia Pacific this year there was universal consensus that criminalization of illicit drug use, sex work and sex between men is seriously hampering effective prevention and support programs in the region. Professor David Cooper from Australia said the international community would not reach its goal of universal access to HIV treatment for all people with HIV by 2010 (3). Prasada Rao of UNAIDS offered a reason why. He said "the main challenge is overcoming the whole issue of stigma and discrimination, repealing of outdated laws and legislation."(4) Progress being made in HIV treatment, care and prevention is of little use if stigma and discrimination is not reversed in the region.

Sixteen countries in Asia still have laws that deliver the death penalty for drug related crimes. In 2005, to mark International Anti-Drugs Day the Chinese government paraded 50 men convicted of drug crimes before a public rally, then executed them – at least one was broadcast on state television. In Malaysia, 36 of 52 executions were for drug trafficking. Vietnam, in a 2003 submission to the UN Human Rights Commission stated that "over the last years, the death penalty has been mostly given to persons engaged in drug trafficking." Since 1991, more than 400 people have been executed in Singapore, mostly for drug related crime. In spite of the application of the death penalty being applied to trafficking, cultivation, manufacturing or importing/exporting, the definition of capital narcotic crimes can be applied to those who possess illicit drugs in some jurisdictions (5).

Before their execution, Khun Bundit and Khun Jirawat were housed in Bangkwang Prison. It's called the 'Bangkok Hilton' by many Westerners but Thai's call it "The Big Tiger" because it is a man eater. In overcrowded conditions, prisoners battle to remain sane. For those convicted of drug crimes, even though they may have admitted to trafficking, even pleading guilty, they are still awarded the death penalty.

Arguments in the blog-o-sphere have been raging. Bloggers on ThaiVisa.com and Prachatai.com are engaged in a passionate debate re the merits and shortcomings of these executions. Hard line views appear sensible and practical at face value. Contrary views are easily 'argued away' as tree hugging. But experts point out there's no compelling evidence that criminalizing drug use and trafficking or administering the death penalty deters it. In fact, they argue all the evidence available is to the contrary. Dave Burrows, APMG Director, has extensive experience in harm reduction across the globe. He argues "punitive drug laws drive drug users underground away from prevention and treatment services; this then reduces the effectiveness of HIV control measures and leads to increased costs in resources - expended both on ineffective drug control programs and less effective HIV control and in the lives of drug users dying of AIDS." APMG, he says, supports the Executive Director of UNAIDS who told the ICAAP conference "many countries are changing laws that criminalize consensual adult sexual behavior (including sex work) and drug use, and courts are helping to clarify bad laws...Australia has demonstrated that law enforcement and public health goals can go hand in hand while dealing with drug use. We can remove punitive laws and policies that block effective responses to AIDS." (6)

The International Harm Reduction Conference 2009 was held in Bangkok in the hope it would pressure the Thai Government to improve its treatment of injecting drug users (IDU). Thailand's recent history on treatment of drug users has been brutal and unforgiving. Many Conference participants struggled with whether to attend given Thailand's recent past. They remembered too well that after announcing a war on drugs in 2002/3 the Thai Government executed drug traffickers and users in the thousands. The then Prime Minister Thaksin Shinawatra said "all of them [drug dealers] must be sent to the guardian of hell, so that there will not be any drugs in the country." Unsurprisingly, further violence toward drug users followed. Activists in the North East of the Kingdom reported extra-judicial killings by death squads targeting the homes of both users and dealers. Local villagers were enlisted to support the action and dead bodies left to rot in the streets (7).

With the recent change in Thailand's national government, there was optimism that a softening of national policy toward drug crime would follow. Presentations by Thai officials at the Thailand satellite workshop during the Harm Reduction Conference seemed to suggest some genuine change in the Governments' position. With the execution of these two men some are suggesting that policy and legislative reform on drugs in Thailand may be a long way away.

REFERENCES

(1) Amnesty International. Thailand Carries Out First Execution in Six Years. 26 August 2009. www.amnesty.org

(2) Thailand executions a new low. Human Rights Watch 26 August 2009. www.hrw.org

(3) Herald. Treating AIDS more difficult due to stigma, experts say. 4 Sept 2009. www.calgaryherald.com/health

(4) Ibid. 4 Sept 2009. www.calgaryherald.com/health

(5) Lines, Rick. The Ultimate Price. DRUGLINK. July 2007.

(6) http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/20090810_ICAAP_EXD_oped.asp

(7) www.stopthewarondrugs.org/chronicle-old/235/thaipolice.shtml

MSM at ICAAP 9

2009-09-04T20:55:00.001+07:00

SPECIAL REPORT - Bali Indonesia: the 9^th International Congress on AIDS in Asia and the Pacific (ICAAP) was held here from 9-13 August 2009. APMG attended and followed Congress streams on most at risk populations (MARPs). The theme for this ICAAP was 'Empowering People, Strengthening Networks". The organizing committee wanted to highlight the need for sectors to work together to expand treatment and prevention to sustainable levels across the region. ICAAP 9 was attended by almost 3000 people from 65 countries including the Asia Pacific region, but also Africa, Europe and America. Information about the conference is available at www.icaap9.org.

This article covers some, not all, sessions on transgendered peoples (TG), gay men and other men who have sex with men (MSM) at ICAAP 9 and has been developed by APMG Asia Pacific. The Asia Pacific Coalition on Male Sexual Health (APCOM) convened an MSM preconference workshop as well as a range of regional caucus meetings that are not covered in this report but which are presented on the APCOM homepage – read more at www.msmasia.org.

LIST OF PRESENTATIONS (click on titles for details of each session)

Symposium: Overcoming legal barriers to comprehensive prevention among MSM
Speech by The Hon Michael Kirby
Speech by Mr Anand Gover
APN+ - gloss on the results of the Asia Treatment Survey of PLHIV (MSM and TGs)
HIV Vaccine Acceptability among High-risk MSM and Transgenders in Thailand
Discussion Groups: an innovative strategy for gay men and Waria in Indonesia
Beach boys in Sri Lanka are they at risk of HIV transmission
Hong Kong: Drug using MSM had higher HIV risk behaviors than non-drug using counterparts
Stigma and Discrimination towards MSM in the context of HIV in Vietnam
Strategies for Increasing Migrants' Access to HIV Services in Thailand

SYMPOSIUM: OVERCOMING LEGAL BARRIERS TO COMPREHENSIVE PREVENTION AMONG MSM

The symposium 'Overcoming legal barriers to comprehensive prevention among MSM' was one of the most interesting at the Congress. In particular, the speech by Mr Anand Gover, credited with successfully leading the fight to overturn Indian legislation criminalizing sex between men, was particularly significant. The speeches of The Hon Michael Kirby and Mr Anand Gover were taken verbatim during the session for presentation here.

The Hon Michael Kirby

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Let me start by reflecting on the speech by the President of Indonesia who got his lips around those words MSM, sex workers and injecting drug user and did so with the First Lady in similar language recognizing the realities of citizens of his country and giving leadership to his country. We're luck y that the President here has done so. I want to pay my respects to UNDP in picking up the baton and recognizing the importance of prisoners, refugees, women, MSM, IDU and sex workers -vulnerable groups all. The initiative of UNDP needs to be praised.

I go back to 1983-4 when Jonathon Mann came to Australia and appointed me to the Global Commission on AIDS. I remember those Commission meetings, the great scientists who were there - how they predicted that within ten years we would have a vaccine and within twenty years we should have a cure. We have to get in to the minds of the people most at risk now to change their behavior and safer sex conduct because there is no cure coming soon. I was a judge for 34 years. Altering peoples' conduct, particularly by law, is not a successful strategy. People will continue to act in given ways. Instead, we need to get in to the minds of people themselves. And that is the challenge we have pending a vaccine and cure. A number of points were made today that remind me of the things being said at the beginning of the epidemic.

HIV is a human rights issue
That HIV is a women's issue
That it's essential to engage vulnerable groups in discussion about strategy and policy

MSM in most countries in this region are highly vulnerable. 20 of the countries here criminalize sex between men and that is a situation I grew up in, in Australia. I grew up in that situation and it makes you feel like you have second class status and it means marginalized groups can exist outside the messages of society and those messages that aim to protect them. So many will not put it [being MSM] out on the table and they will keep it to themselves. And yet by not bringing it out and by not being open about sexuality the reality is that MSM conspire in the attitudes of society toward them. If only every person who was gay identifying or MSM stood up in society – if they all stood up the whole shabby and dishonorable strategy to denigrate and put them outside the family would be over. But that's not going to happen any time soon. We have to think through the strategies to facilitate change - especially to legal sanctions.

How? Legislation. First, engaging politicians, community groups and, let it be said, mostly straight people persuading politicians to change the law. It's [the law criminalizing same sex behavior] not only wrong but in the times of HIV it's a real impediment to getting into the minds of MSM and the prevention strategies they require.

We've been talking about this for a long time and many politicians do nothing and will do nothing about this matter. In India, 60 years after Kinsey, 50 years after reform in Britain, the law remained firmly in place. The second strategy is to engage the Courts – International Tribunals and Courts. In Ireland and Cyprus the Human Rights Committee of the UN. And in respect of Tasmania in my country the Human Rights Committee of the UN again. But also Courts in South Africa and Supreme Courts in the US and the Delhi High Court.

The recent decision in India was in large part due to Anand Gover and his particular strategies. The people involved in that decision are great fighters for human rights. They organized seminars throughout India and just talked about these issues in the presence of judges and lawyers. Often it's a matter of personifying it. In terms of the White Australia policy, we were able to change it when people began to meet Asian Australians and this is the way to change attitudes toward MSM.

However, in our region we've got bad news. In Singapore, a committee of the Law Society recommended a legal change for that State, introduced it in to parliament. But a Professor of Law had become a member of a Pentecostal group and said it would be the end of civilization and so nothing was done.

In Cambodia, in the case of sex workers, the Government has engaged unfortunate steps in recent times. But we've had Hong Kong upholding the principle of equality of gay people. Nepal's Supreme Court and Delhi High Court rulings. UNDP and UNAIDS in China and Hong Kong and elsewhere also. So it's very important at this phase of the epidemic that we should have this session on overcoming legal sanctions. This session is emblematic of the need to focus on vulnerable groups. The third phase of the epidemic is prevention – the plain fact of the matter is the world won't continue to expend ARV funds to people who are infected. The whole strategy has to be on prevention and that means focusing on vulnerable groups, MSM, reducing stigma, accessing people in the vulnerable groups and giving messages for their own self protection. Infections worldwide continue to increase at 2.7 million people per year. We have to prevent this continuous epidemic.

Finally, what can we do to give a new impetus? I saw in one UNDP booklet a quotation from Dr Neil Blewett. He said, "the best way is not to crash through. The best way is to respect the fact that people are at different stages and endeavor to engage in dialogue with them". I agree but after a decade or two you then have to begin to ask 'what is a new strategy that will get a change?' What new pressure can those who are donors exert on those countries? Do you have to stand by indefinitely?

The Director of UNAIDS, Global Fund ,UNDP, the President of Indonesia, many people are saying the right thing - the planets are in alignment specifically on the MSM issue. But people like me are fed up. It's [discrimination] not scientific, not rational. We have to translate words in to action. We need to address how we can do just that.

Mr. Anand Gover

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I think the point has been made that criminalization of private practices of groups vulnerable to HIV impedes HIV programs and goals. It has to be addressed. Secondly, it should be appreciated that there is gross injustice in the criminalization of private practices. Even drug users and criminalizing their personal behavior is antithetical to the notion of having freedom in the use of your leisure time and activity. It is an imposition of western culture - I can drink alcohol and smoke cigarettes but not smoke marijuana. In criminalization, customary practices are denied. It breeds corruption and it doesn't address the real issue at all. Sex work criminalization is driving HIV transmission underground. Very few people take these issues head on. If you remove criminality then you can successfully intervene. But people are uncomfortable with them [these groups] or the climate is not right.

In India, we took at decision in 2000 that it is very important to remove the criminal sanction [of same sex behavior] in the Criminal Code. It was British and not Indian at all. In our religion Hijra are part of our culture - we have an attitude toward them but we had not criminalized it. The fact is that one must take a decision that these injustices have to be removed and only then can you progress toward it. Michael [Kirby] was quite correct when he said that when you take a decision there are a number of things you have to do. As lawyers we don't take the time to sensitize all stakeholders – but this is important and particularly it's important to sensitize Judges, the legal community, the police. They also realize and understand. Police say "Why are we trying to catch men having sex with other men or drug users when we have other issues that are more important?" Over a period of time you are able to have an impact on sensitizing stakeholders who are part of the establishment and also the opening up of situations where gay men could form into groups as HIV service providers. E.g. Humsafar group – they started not as a gay group. But now the first gay group has been officially registered [in India]. But that opened up over a period of time and HIV provided a huge opportunity and an umbrella for these issues: about HIV, injustice and how it affected HIV. Spaces opened up for gay men and other vulnerable groups. It was not an accident. It was in fact a lot of sensitization.

A lot of people said why are you taking up this issue? You need to be determined and focused on change. You have to go in for the long haul. Not short term, fly by night operators. A lot of people want publicity. But follow the principles of the Baghavad Gita - be like a rock, and do not expect any reward or benefits.

In this case [the overturning of Section 377 of the Indian Criminal Code] it was not lawyers who decided how the case would go. We involved the community from day one. HIV in India and other places it is the community who are the deciders. They decided whether we should go to the Supreme Court. Then we had to be ready for the big bats. A lot of people feel that the matter was taken up by a non-gay group - NAZ Foundation. They felt it should have been taken up by the gay groups. But in 2001 who would file a petition? So it was an HIV group. But if it were a gay group working on HIV it would have been much better.

Next we had to decide whether to change the law by an amendment process or by a constitutional process. One of the grounds that we took up was privacy. A lot of the groups don't want to take up the privacy ground because most do not want to take on the sexual issues related to privacy. The other thing was a lot of the groups said it's a gay human rights issue why take up HIV as the matter. Again, you always expose the issue of the opposition and you expose yourself. One argument in that case in privacy was that the State can come and say there is a compelling State interest to criminalize any private behavior e.g. rape. They couldn't precisely make this sort of argument because of HIV. [It was possible for HIV organizations to say] "If this law continues to be on the statute book then HIV intervention will be impeded." There is no State compelling force to keep the status quo.

In terms of the decision of the Delhi High Court - already people in Singapore want a workshop on this issue. Malaysia has expressed an interested. And judges in other jurisdictions are keenly reading this judgment. This should be followed up in other countries.

VARIOUS MSM ORAL PRESENTATIONS AND POSTERS

Oral Presentation: APN+ results of the Asia Treatment Survey of PLHIV

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This is an overview of findings in relation to transgendered peoples (TGs) and men who have sex with men (MSM) living with HIV from an APN+ Treatment Survey. Further information about sample size and recruitment of participants etc. is available on the APN+ website www.apnplus.org. The importance of the APN+ survey is that it underlines how significant education is to effective treatment and adherence (the overall survey found large numbers of people were taking ARVs while not knowing exactly what they were taking or the importance of adherence to staying well in the long term). It also underlines continued health care setting discrimination and human rights violations for some MSM and TGs in the region.

This investigation was undertaken in six countries in the Asia Pacific region and the number of MSM and TG participants was 897. Mean age of participants was 32.5 and 32% resided in urban settings such as capital city while 28.5% resided in rural settings and towns.

HIV information and counseling - 59.3% of the participants received HIV tests in government hospitals. Of these:

13% reported HIV screening without consent
81.6% received post test counseling
81% disclosed their sexuality to the service provider
41% did not receive friendly or sensitive service

Access to HIV related services – Barriers to service included:

Length of travelling times
cost of services, legal issues
travel emerged continuously as a barrier
lack of adequate information about services and treatment
stigma reported

ARV access - In total nearly half (46.4%) are in need of ART, among those who are in need 71% are taking it. Barriers include: lack of adequate knowledge about ART, fear of side effects, denial of service by doctors, unfriendly HIV service providers, lack of availability of ART services, ART out of stock in government centers, being unable to pay for treatment.

Access to OI treatment – 61% can access treatment for OIs, participants reported a variety of barriers for not accessing OI treatment but these were not reported in the presentation.

Attitude of health care providers (HCP): nearly two thirds of the participants (64.6%) had disclosed their sexuality to HCPs half of the participants reported that their HCPs encouraged them to discuss openly their sexual health issues. Some participants reported that HCPs disclosed their HIV status and sexuality to others without consent. Some reported denial of services (21.1%) and physical assault (9.6%) by HCPs.

Other issues: some fears their partners might find out their HIV status prevented accessing or adhering to treatment. Some said clinic opening hours are not suitable for them if they are involved in sex work.

Poster 135: HIV Vaccine Acceptability among High-risk MSM and Transgenders in Thailand

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HIV prevalence among MSM in Bangkok (30%) and Chiang Mai (16.9%) rivals the hardest hit regions of Sub-Saharan Africa. Thailand has enrolled more volunteers in HIV vaccine trials than any other country in the world. Based on Diffusion of Innovation theory, we assessed the acceptability of future HIV vaccines and the impact of vaccine characteristics, socio-cultural and structural factors on vaccine acceptability in order to provide empirical support advancing tailored combination prevention. The authors recommend education and social marketing interventions to increase acceptability of partial efficacy HIV vaccines. Social and community interventions to combat anti-gay and HIV stigma, and promotion of HIV vaccine uptake as a 'pro-social' behavior to support the community and nation (in contrast to individual-level approaches) are recommended.

Authors: Peter A Newman Ph.D.; Surachet Roungprakhon PhD (cand); Suchon Tepjan BA; Suzy Yim MSW. Institutions: Faculty of Social Work, University of Toronto; King Mongkut University of Technology North Bangkok Thailand; Chiang Mai University.

Methods included data collection – phase 1: in depth 45 minute semi structured interviews in Thai and English (n=40) – Phase 2: structured 3- minute Thai language survey questionnaire programmed on laptop computers (n=260) Sampling and recruitment included MSM, MSW and M2F transgendered people recruited using venue based sampling from LGBT, MSW and HIV prevention organizations as well as gay sex venues and nightclubs in 3 Thai cities. Data analysis included – phase 1: narrative3 thematic analysis with techniques from grounded theory and phase 2: conjoint analysis with a fractional factorial experimental design to assess acceptability of hypothetical HIV vaccines with different attributes, and the impact of attributes on acceptability.

Table 3: Impact of HIV Vaccine - Quotations from Participants:

"People might think we have HIV"

"If we want something to protect our bodies, it should have 100% effectiveness"

"Everybody would have doubts or be afraid for the long term; you'll never know what's going to happen after 5-1- years"

"It's worth trying. Well, at least I have that 5 years of fun (laughing)… that 5 years of, you know, miraculous fun"

"If it's 500 baht people will be ok. 1000 [baht] people will not be able to afford it."

"I don't want to be involved unless someone else proved it first"

"Not from the government hospital… I think the vaccine won't be the same as from a rich hospital"

"If they go to a public hospital, then it seems usual, nothing secretive. But if they go to an unknown clinic… people will start thinking and suspecting that person."

Conclusions and recommendations

Include education and social marketing interventions to increase acceptability of partial efficacy HIV vaccines as this may support initial HIV vaccine uptake.

Social and community interventions to combat anti-gay and HIV stigma, and promotion of HIV vaccine uptake as a pro-social behavior to support the community and nation (in contrast to individual-level approaches) may ensure the effectiveness of future HIV vaccines as a component of combination behavioral and biomedical prevention among vulnerable communities in Thailand.

Structural interventions including government and corporate vaccine cost subsidies, and dissemination of HIV vaccines through a variety of venues – both population-specific (e.g. targeting male sex workers, gay men or Transgenders) and universal (for the general population, i.e. "unmarked") – may optimize HIV vaccine coverage among populations at highest risk of HIV infection in Thailand.

Funding from this study was provided by the Social Sciences and Humanities Research Council, The Canada Research Chairs Program and Canada Foundation for Innovation. Branding for this research looks like: "Voices Thailand: HIV prevention and healthcare research".

ORAL PRENTATION: Discussion Groups: an innovative strategy for gay men and Waria in Indonesia

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This presentation underlined the need for ongoing, sustainable community-based support and education. At international level there is a debate about the best single or multiple dose interventions to sustain HIV prevention behaviors at the lowest possible cost. However, authors of this presentation point out that Coca Cola understands they must hit you over and over again for your whole life to get you to remember to drink Coke. Therefore, the challenge, they argue, is to find interventions that can be sustained over the long term, driven by the community and that support community behavior change while also being good value for money. The authors describe discussion groups called Kelompok diskusi used in Indonesia. Kelompok Diskusi are a different kind of focus group that they argue can achieve the above aims.

Authors: Tom Boellstorff and Andi Akbar Halim

THE PROBLEM

HIV has been reported in Indonesia since late 1980 but there are still many new infections among gay men other MSM (a problematic term) and Waria (male-to-female transgenders).

In Indonesia, as often in the Asia Pacific, knowledge about HIV is high at individual level but not consistently turned into sustained behavior change at community level. There is a need to integrate HIV/AIDS knowledge with other health and social issues - from STIs to discrimination. Knowledge about HIV among Waria and MSM is generally high, they know about HIV, know what it is, but it's not getting translated in to sustained behavior change and its being done at the individual level and not at the community level. The atomized individualistic approach to HIV prevention programs being pushed by donors and other folks is of concern and that atomization is characterized through the term MSM which is a problematic one.

WHAT'S NEEDED?

What's needed is not new knowledge so much as a new method for sharing knowledge that can build upon and strengthen community gay men and Waria who usually can't learn about their identities from their families. The aim is to change norms at the community level. But also to strengthen community for gay men and Waria – men that call themselves 'gay men' are not all elites; they are often low class but what gay means to them may differ.

THE BACKGROUND

The Gaya Celebes Foundation formalized in Makassar city (South Sulawesi province) in 1995. It is a community based organization for gay men, other MSM and Waria. It began with street outreach, but now engages in a range of activities.

THE IDEA OF KELOMPOK DISKUSI

Focus group: the name seems similar but kelompok diskusi are very different from traditional focus groups. The idea of focus groups originates in marketing and social science research. Also used for years in HIV research. But there are two limitations with typical focus groups: one, they meet only once. Two: they bring together people who don't know each other ahead of time.

HOW KELOMPOK DISKUSI WORK

Kelompok diskusi is a different kind of focus group that overcomes both limitations mentioned above. One, they meet regularly usually once a month for years. Two, participants come primarily from a shared social network. But kelompok discussions do not just build upon community. They create community – these groups are creating and strengthening community not just individual identity.

STEPS TO SETTING UP A DELOMPOK DISKUSI PROGRAM

Hire and train outreach workers and discussion group leaders – some staff can do both but different skills needed.
Outreach – get to know the communities first.
Identify community leaders who can take turns to host monthly meetings.
Build to hold monthly meetings – early topics HIV101 to more advanced topics stigma, relationships, support skills.
Evaluation and sustaining the KD.
KD as foundation for further activities e.g. VCT, entertainment, events, support groups. It can include bringing PLHIV in to the group.

ADVANTAGES AND LIMITATIONS/CHALLENGES OF KELOMPOK DISKUSI

Advantages include

They are relatively inexpensive,
Information can be customized, repeated over time and learned in a context of group reinforcement,
They are an excellent environment for bringing together wide range of topics and turning knowledge into action

Limitations/challenges include

Requires dedicated staff;
Organized KD every month can be time consuming (particularly ensuring attendance),
Requires sustained funding, scalable but not always easily so.

Professor Boellstorff (presenter of this session) points out that Coca Cola understands they must hit you over and over again for your whole life to get you to remember to drink Coke.

WHAT KELOMPOK DISKUSI TEACH US

Turning to community is not enough. In many cases we must build community through HIV prevention. When basic HIV/AIDS information is already well known methods like KD are effective at helping make that knowledge relevant to daily life. A need for more research on the effectiveness of KD in different contexts is indicated.

ORAL PRESENTATION: BEACH BOYS IN SRI LANKA ARE THEY AT RISK OF HIV TRANSMISSION

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Concerns about Sri Lanka and sex tourism, poverty, lack of employment opportunities and displacement have resulted in beach boys generally being viewed as a vulnerable group for HIV infection. Poor access to condoms, partners who are unwilling to use condoms and prior research indicate that beach boys had low levels of awareness of STIs and HIV. This research was attempting to answer the question 'Are beach boys at risk?' as well as the factors that help identify which men are at risk. Does HIV prevention look feasible with this group of men?

Author: Patrick Rawstorne et al, University of New South Wales, Australia

BACKGROUND

There has been tsunami damage and conflict internally for many years in Sri Lanka.
There are lots of internally displaced people and that affected the study in some regards.
It's a beautiful country.
Buddhist monks play an important role in contributing to the social norms, setting values and setting laws in the country.
We were establishing a behavioral research survey and capacity development work.
Cross sectional behavioral surveillance survey.

Formative mapping: this mapping exercise aimed to determine: where are the beach boys? What number are they? How accessible are they?

BASIC PROFILE OF BEACH BOYS

553 men/ 482 men reported which median age 25 (17-56)
Education: completed Years 0 level
Literacy: 97.3% able to read and write
marital status: married 24% and never married 74%
Monthly income: LKR 10,-20,000 (100-200 USD)

BEACH BOYS DEMOGRAPHICS

100% employed and types of work included: 74.5% tour guides; 20.7% retail 8.2% fisherman
How many of the sample were paid or received goods for sex? 16% received payment from at least one male partner; 5% received payment from at least one female partner

ARE BEACH BOYS AT RISK OF HIV TRANSMISSION?

Yes.
Almost 60 % reported unprotected sexual intercourse with at least one casual partner in the previous twelve months.
Sexual intercourse with both male and female partners
Sex with both foreigners and locals: 34% had sexual intercourse - 79% both local and foreigners while 17% with local foreign male and female partners.

WHAT FACTORS HELP IDENTIFY WHO IS MOST AT RISK?

Men who engaged in unprotected anal intercourse in the twelve months prior to the study were more likely than those who use condoms all the time to have smoked cannabis in the previous twelve months; they had sexual intercourse with both male and female non-regular partners; had more foreign male partners with anal intercourse; had STI symptoms and were more likely to believe they are hiv risk.
Men who engaged in unprotected anal intercourse in the twelve months prior to the study were less likely to work as tour guides, less likely to have heard about hiv through health services; less likely to believe that a person with HIV can be health looking; less likely to believe that people can protect themselves from hiv using condoms; less likely to have used a condom at first sexual intercourse.

DOES HIV PREVENTION LOOK FEASIBLE?

Goal to change sexual practice toward one hundred percent condom use with casual partners
Knowledge gaps around HIV transmission
Skills to negotiate sex, payments for sex and condom use with foreign partners.

CONCLUSIONS

Beach boys are at risk of HIV. Contrary to the stereotypes, they don't necessarily exchange sex for money. Their jobs often provide a legitimate way of approaching tourists. They often instigate and seek romantic relationship with male and female tourists. These data point clearly to types of health promotion/hiv prevention messages that are needed and are usable for this population.

POSTER 126: Hong Kong: Drug using MSM had higher HIV risk behaviors despite more prevention than non-drug using counterparts.

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A territory wide seroprevalence study among MSM was conducted at the end of 2006. The result has caused alarm as it suggests HIV prevalence is about 4.05% which is many times higher than other MARPs such as commercial sex workers. Recent overseas documents demonstrated drug using was positively associated with HIV infection among sexually active MSM, which could be one of the reasons contributing to rising HIV cases. Up until now the situation in HK is still not clear, although drug possession and drug trafficking are prohibited by law.

Authors: KM Mak, WL Mak, HL Ho.

METHODS

A venue based survey was conducted in bars/clubs and saunas by trained MSM interviewers, which was composed of self-administered behavioral questionnaires on the subject of sexual risk, condom usage and testing habits; together with unlinked anonymous HIV antibody (Western Blot) testing by way or urine sample collection. Stratified random sampling method was adopted to enhance representativeness.

RESULTS

859 valid samples were collected. Of these 12.3% (n=106) reported drug use - commonly these were poppers, ketamine, ecstasy and Viagra.
The seroprevalence (non-adjusted) of drug using MSM was 8.5% compared with 2\3.7% of non-drug users.
More non-Chinese than Chinese MSM (22.4% versus 11.8%) claimed to have drug use practice.
Drug using MSM tended to have more anal sex partners than non-drug users. They also engaged in more anal intercourse with casual sex partners not to mention a higher proportion of casual sex partners observed in this group (93.5% versus 81.9%).
In relation to prevention, there was a smaller proportion of consistent condom use with regular sex partners in drug using MSM (30.2% versus 44.9%).
Despite all this, the overall condom usage rate between any of the groups was not accountable (reporter: not sure what this means).
The authors of this study conclude that drug users 'fail' [reporters' quotation marks] to perform safe sex consistently (i.e. 100% use of condom) when compared to MSM not taking drugs during sex with their casual partners.
A double proportion of drug using MSM compared with non drug using ones had sex outside HK as well as drinking alcohol before or during anal or oral sex.
In view of the health promoting service delivery, it showed that drug using MSM received more HIV prevention information (free condom and HIV prevention message) and a 20% higher utilization of HIV/STI screening services that non-drug users and there was no dissimilarity regarding the location of having HIV/STI testing service.

CONCLUSIONS

Drug using MSM were covered by preventive activities and received health messages. They were also more proactive in testing behaviors. Their sexual behavior, for example, number of sex partners, multiplied their risk of contracting HIV, in addition to the effect of recreation drugs.

Hence, screening of drug use can be considered to serve as a proxy indicator of high-risk sexual behaviors among MSM. It is important to explore underlying factors of recreational drug use so that targeted interventions can be implemented that reduce the harm of substance abuse.

POSTER 318: Stigma and Discrimination towards MSM in the context of HIV in Vietnam

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This poster presentation focused on promoting a new developed training toolkit and curriculum called "Understanding and Reducing Stigma and Discrimination against MSM". The HIV epidemic in Vietnam is concentrated among key populations at higher risk, including MSM, IDU, and SW. There is high prevalence among MSM in Ho Chi Minh City (5%) and Hanoi (9%) compared to 0.43% estimated prevalence among 15-49 year olds nationally. The authors underline that the report of the Commission on AIDS in Asia projected new infections among MSM in Asia could increase from 2 million in 2009 to 5 million in 2015 and nearly 8 million in 2019 unless HIV interventions for MSM are scaled up.

CHALLENGES IN RESPONDING TO HIV AMONG MSM

The lack of strategic information including size estimation and social research
Misunderstanding of the concept of MSM and the confusion between MSM and homosexuality and between behavior and identity
Significant overlap in high risk behaviors such as drug use and sex work but limited integration of interventions for different groups and
Insufficient technical resources and lack of MSM friendly services
A Vietnam specific training toolkit "Understanding and Reducing Stigma and Discrimination against MSM" has been developed to address these challenges and to support emerging HIV interventions for MSM. It provides health and social service providers, media and policy makers with essential knowledge and skills to work effectively with MSM on gender and sexuality issues.

A WELL ADAPTED TOOLKIT TO REDUCE STIGMA AND DISCRIMINATION IN VIETNAM

The toolkit includes three main sections: gender, sexuality and sexual health; stigma and discrimination related to HIV and MSM and action plan and advocacy.

This is the first toolkit for MSM and HIV related stigma developed in Vietnam. It is well adapted to the needs and the contexts of the target groups and has received positive feedback during the adaptation and pre testing proves.

The toolkit can be used for and by difference audiences and target groups including: health and social service providers, NGO and COB staff, media, police, policy makers as well as MSM groups.
It was the first opportunity for many participants to learn about forms of stigma, MSM and the relationship between HIV and MSM.

Quote from one participant: "I am very pleased and highly appreciate [for] this toolkit. I think that the toolkit will be very effective for increasing awareness of policy makers which will lead to increasing impact for later interventions". (A workshop participant who is a staff member of the provincial AIDS Centre, March 2008).

Quote from another participant: "I think that the content is practical and the methodology is good. I enjoyed participating in the workshop. I get a better, a more through and correct understanding about homosexuality. We need to conduct more communication and disseminate information about MSM issues to society which will help to reduce self stigma as well as discrimination toward MSM" (A participant of the workshop for policemen and journalists, March 2009).

THOROUGH AND CONSULTATIVE PROCESS

The Institute for Social Development Studies and UNAIDS Vietnam developed the toolkit. In consultation with key target groups including MSM groups, health service providers, NGOs CBOs, media and policy makers. A part of the toolkit is adapted from the MSM module of the International HIV/AIDS Alliance's toolkit Understanding and Challenging HIV Stigma. The drafting process included a literature review, consultation, meetings, pilot testing and dissemination of the toolkit.

This toolkit is an innovative initiative that breaks the silence on sexuality and MSM in Vietnam. By applying participatory learning processes, the development of the toolkit empowered and equipped people with the skills to openly and confidently discuss sensitive issues. The development process in Viet Nam was unique and instructive as the MSM community was actively involved from the beginning to the end, which was itself a capacity building exercise for future training of trainers. Users need to be creative and flexible in applying the toolkit to difference audiences, durations and contexts.

Poster 119: Strategies for Increasing Migrants' Access to HIV Services in Thailand

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This poster sits outside the theme of this field report but was of interest to the author so is documented here for others who may have an interest in migrant access to HIV services in Thailand. It appears an excellent example of successful HIV prevention and support in a multi-language and multi-cultural target groups. Lessons learned are concrete, practical and have evidence and analysis to back them up. In all, a best practice example of how to undertake HIV prevention and support in a multi-cultural context.

Author: Brahm Press Organization: Raks Thai Foundation, Thailand.

Background – there are over 2 million migrant workers in Thailand, only a quarter are properly registered. Eighty percent come from Myanmar, the rest from Cambodia and Lao PDR. Migrant work in unskilled jobs is commonly described as the3D jobs – dirty, dangerous and difficult.

Migrants' Vulnerability to HIV: contributing factors include language barriers, being a hard to reach population and limitations on mobility. Migrants are coming to start work at younger ages. Improper information about HIV or limited access to condoms increases risk. Sub groups have high risk behaviors such as men working on deep sea fishing boats and karaoke women.

The PHAMIT Program

The first phase (2003-2008) of the Prevention of HIV among Migrant Workers in Thailand Program covered 21 proviences and was support by the Global Fund. PHAMIT was a collaborative project of eight NGOs: Raks Thai Foundation (Principal Recipient), World Vision Foundation of Thailand, Foundation of AIDS Rights, MAP Foundation, Stella Maris Center, Empower Foundation (Chiang Mai), Pattanarak Foundation and PATH (contracted as technical consultant), working partnership with the Ministry of Health's Dept of Health Services Support. The second phase of PHAMIT, which started as of 2009, is being expanded to cover 33 provinces.

Strategies: PHAMIT uses a combination of outreach and in-reach strategies:

Networks of volunteers provide behavior change information, condoms and referral
Behavior change materials reflect migrants life styles, cultures and situation in Thailand and are produced in a variety of mediums in migrant languages
Drop In Centers attract migrants by providing a location that migrants can go to relax and where they can access information and referral to services
Migrant Health Assistants are trained to assist in hospitals and provide VCCT to migrants in their own language
The MoPH established a module for Migrant Friendly Services' in ten focus provinces.
Outputs and Outcomes evaluation

RESULTS

PHAMIT reached over 442,000 migrants with direct activities and distributed over 6.8 million condoms.
The final impact assessment for PHAMIT shows that self reported condom use among migrants has increased considerably.
Migrants are increasingly able to access STI and VCCT services and migrants have been included under Thailand's National AIDS Plan.
PLHIV migrants are receiving ART through a special program under the MoPH.
PLHIV migrants are receiving support through PHAMIT volunteers and Migrant Health Assistants, and PLHIV support groups at some sites.

LESSONS LEARNED

A mixed strategy of outreach combined with DIC is necessary to overcome issues of accessing migrant workers.
A strategic partnership between NGOs and the health department can lead to systems that increase migrants' access to health and HIV services
HIV prevention programming for migrants needs to support migrant communities and protect migrants' rights, as well as respect language, culture and dignity through the meaningful participant of migrants in implementation.

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IDU AT ICAAP 9

2009-09-03T16:34:00.010+07:00

SPECIAL REPORT - Bali, Indonesia: the 9^th International Congress on AIDS in Asia and the Pacific (ICAAP) was held here from 9-13 August 2009. APMG attended and followed streams related to most at risk populations (MARPs). The theme for this ICAAP was 'Empowering People, Strengthening Networks". The organizing committee wanted to highlight the need for sectors to work together to expand treatment and prevention to sustainable levels across the region. ICAAP 9 was attended by almost 3000 people from 65 countries including the Asia Pacific region, but also Africa, Europe and America. Information about the conference is available at www.icaap9.org.

This article reports on presentations related to Injecting Drug Use (IDU) at ICAAP 9 and has been developed by APMG Asia Pacific.

LIST OF PRESENTATIONS (click on titles for details of each session)

IDU prevention and education

Shooting Galleries as NSP Site Partners with CARE Myanmar
Preventing HIV transmission among female addicts in Kerobokan Prison, Denpasar
Behavior Change through targeted education in Xinjiang, China - International Red Cross
PANAZABA – HIV/AIDS Prevention among drug user using critical awareness
Empowering Teachers in Penabur, Jakarta to be the agents for HIV prevention
Drug Users community based HIV prevention and Care in West Java
Using Quality Improvement Processes to Improve Program Performance

Health and wellbeing of IDUs, their partners and families

Health Status at Baseline of a Cohort of Drug Injectors in New Delhi
Family support of Jakarta and Bali IDUs receiving antiretroviral (ARV)
Factors related to Hepatitis C (HCV) prevalence among sexual partners of HIV/HCV co-infected patients

Sex and IDU

Condom Use and Sexual Networks of IDU&s in Bandung, West Java, Indonesia, A Review
Night Outreach: Addressing Female Injecting Drug User Sex worker needs West Jakarta
Sexual Networks Study among IDUs in Indonesia
Injecting and sexual risk behavior among fishermen in Kuantan, Malaysia

IDU PREVENTION AND EDUCATION

Poster 116: Innovative Approaches to Harm Reduction: Shooting Galleries as NSP Site Partners with CARE Myanmar

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One of the most interesting posters at ICAAP reported on the co-opting of 'shooting galleries' and their proprietors as NSP site partners and participants in HIV prevention for IDU in Myanmar. Care Myanmar initiated the project in 2003 with support from UNODC. They found that many IDU in Yangon were not self injecting but instead buying drugs and using the service of a shooting gallery where a 'staff member' injected them – often with equipment that had been used previously. IDU reported that ' a clean fit for every hit' was not the norm and Care changed this community norm by providing clean fits and safe disposal bins in shooting galleries which were collected daily by outreach workers. They reported a significant change in community norms with IDU reporting that they go elsewhere now if shooting galleries are not able to guarantee a clean fit. When Care supplies ran low shooting gallery owners, on their own initiative, purchased new equipment to meet client demand.

Authors: Sarah (Sally) Moore, Dr Kyaw Hlaing, Tammy Hasselfeldt: CARE Intervention in Myanmar.

BACKROUND

Injecting drug use in Myanmar is a significant route of HIV infection with estimates of up to 37.5% IDU being HIV positive. The introduction of Needle and Syringe Programs (NSP) is challenged by the legal environment and socio-cultural factors. Strategic Direction Three in Myanmar National Strategic Plan on HIV AIDS 2008-2010 focuses on the reduction of HIV related risk, vulnerability and impact on IDU. Until the Care Harm Reduction Program began it was common for needles to be shared between users in shooting galleries allowing for rapid spread of HIV and other blood borne viruses (BBVs). Following project completion, new funding was secured through the 3DF to continue NSP activity, DIC, advocacy and harm reduction training with law enforcement officials (ref: National AIDS Program: MoH and WHO 2009; Myanmar HIV Sentinel Surveillance Survey 2008).

RESULTS

In 2003 Care began advocacy to shooting gallery proprietors, educating them on HIV and safe injecting practices. Free sterile needles and syringes were distributed to shooting galleries as part of the CARE outreach work. Basically the shooting gallery staff were supported to use a new needle each time they provided a hit for drug users. One of the conveniences of shooting galleries is that drug users who come to buy drugs and get an injection do not have to carry or share any injecting equipment. CARE provided safe needle collection bins for the shooting galleries and outreach workers collected these for safe disposal each day.

IDU reported that a clean fit for every hit was not the norm and, subsequent to the introduction of this program, they will go elsewhere if there is any risk of equipment being reused. Through discussions with shooting gallery owners, feedback from clients and in collecting used injecting equipment it was clear that shooting gallery owners were responding to clients' demands. When CARE NSP supplies ran low, shooting gallery owners on their own initiative, purchased new single-use needles and syringes from pharmacies to ensure clients continued to use their services. Over a twelve month period in 2007-2008, more than 100,000 sterile needles and syringes have been distributed through shooting galleries and outreach activity.

"Now many injecting drug users no longer want to use nor will they accept non sterile needles so shooting gallery owners have to buy needles and syringes when supplies from CARE run out. Many IDU choose to attend only shooting galleries where clean needles are available and provided. IDU recap and bend the tip of the needle because they do not want their needle to be reused by another IDU" A quote from a Care Project Staff Member.

Over the life of this project IDU have been trained by CARE in peer approaches. Peer-to-peer information sharing has been conducted in shooting galleries on harm reduction topics ranging from safer injecting practice, injecting site rotation, to HIV, Hepatitis B and C risk reduction and management. Recruitment to participate in drop in centre activities such as primary health care, home based care for HIV positive drug users, referral for VCCT and information sharing on treatment options including MMT, ART and home based care for HIV positive IDU has occurred with IDU using shooting galleries.

LESSONS LEARNED

Partnerships between shooting gallery and NSP programs offer innovative opportunities to promote harm reduction site and reduce the risks of HIV and blood borne virus transmission to IDU.
Access to these sites through peer approaches can ensure that marginalized groups such as IDU are able to obtain correct information, clean equipment and referral to appropriate and client friendly primary health care services.
Continued advocacy with law enforcement agencies is required to ensure programs can build sustainable demand for safer practices. Involvement of shooting galleries represents a pragmatic approach to harm reduction along with opportunities to promote supportive services for IDU.

POSTER 111: Preventing HIV transmission among female addicts in Kerobokan Prison, Denpasar Indonesia, Bali.

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This poster reported on IDU prevention initiatives in Kerobokan Prison for women in Denpasar, Indonesia. It presents lessons learned from a series of education sessions and support/focus groups undertaken with female IDU in this prison and it used a twelve step approach. The overall aim of the project appears to be to reduce or stop drug use among participants. The poster concludes that life skills education and support programs are good methods for female IDU especially where these programs can include recovery, reproductive health and PMTCT to reduce transmission of HIV in prison.

Authors: Ni Luh Putu Ariaqstuti, Yayasan Kasih Kita, Jalan Tukad Pancoran Gang IIIA no 11, Panjer. Denpasar, Baili Indonesia.

ISSUES AND BACKGROUND

Like many other prisons in Indonesia and throughout the world, Kerobokan Prison in Bali faces the issues of drug addiction and HIV/AIDS. In 2003, an estimated 50% of all inmates were entering prison because of drug related offenses. Female addicts are considered more vulnerable to HIV. This risk seems to be higher in prison related to increased risk behavior in prisons and detention center settings.

ABOUT THE PROJECT

The project is part of "Building the capacity of prison in working with substance abusers and addicts and HIV in Bali" project involving prison staff and inmates in Kerobokan Prison. The projects aim is to increase knowledge and practical skills to prevent substance abuse and HIV transmission among female addicts in prisons.

METHODS

Prison staff and peer educators training on drugs, HIV and Hepatitis C.
Life skills education and support group program to increase knowledge and awareness about addiction, Hepatitis C, HIV and reproductive health female inmates every week
Distribution of IEC materials on addiction, HIV and harm reduction to inmates.
Life skills education
Life skill education activities takes place every Thursday from 9am until 11am. Life skill education conducted in the form of lectures and focused group discussions facilitated by YAKITA staff.

Topics discussed during the lectures and/or focus group discussions were adapted from the Yayasan KITA 6 month basic residential treatment program and six month peer training program.

SUPPORT GROUP PROGRAM

This support group program used self help and self supported groups based on twelve step programs for 'substance abusers' [reporters' quotation marks]. The meetings are held every Friday at nine to ten thirty am. In the meetings inmates share their experiences, strengths and hopes in efforts to achieve harm reduction, abstinence from drugs and to share problems relating with their life and coping with the prison environment. The meeting is facilitated and chaired by inmates themselves and also guided by other recovering addicts and NA (Narcotics Anonymous) members.

LESSONS LEARNED

Life skill education and support programs in Kerobokan Prison are a good media to give intervention to female addicts related to their behavior in prison. Comprehensive approach programs include recovery, reproductive health and PMTCT will remarkably reduce transmission of HIV in prison.

ORAL PRESENTATION: Behavior Changes through Comprehensive program approach of targeted education in Xinjiang Red Cross.

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This oral presentation delivered results achieved through a program targeting IDU in Xinjiang by the International Red Cross. Methods included workshops, outreach and referral related to HIV and IDU, relapse prevention, wound care and other basic health issues related to injecting and life skills training. While more outcome data was delivered than the reporter could record at the time the data provided here show significant improvement in general HIV awareness, access to service knowledge and reduction in sharing of equipment. The presenter attributes the success of the program to a non-judgmental approach by the team and the active involvement of affected communities and their families in the design, delivery and evaluation of services.

At the time of posting, Chinese separatists have been blamed for syringe attack violence in Urumqi, the capital of Xinjiang province. Chinese authorities dispatched riot police to the city after more than 10,000 ethnic Han Chinese marched to protest what they consider government failure to protect public safety after attacks in which hundreds of people were stabbed with syringes. Authorities said the Uighur separatists are also blamed for violent riots in July in which syringes were also used and caused over 500 injuries [Source: UNWire].

Author: Ms Hai Liman.

BACKGROUND

Xinjiang is situated in the north eastern border areas of China. It is the biggest province by area but lesser for population (19.2 million). There are 47 ethnic groups. There were 256,940 reported cases of HIV in 2008 - the fourth highest ranking in China in terms of HIV prevalence. Ethnic groups are hit hardest by the epidemic - 85% of all cases in 2003 are among ethnic minorities. The sharing of injecting equipment among drug users is the major HIV transmission mode - 79% in 2007. Double stigma of IDUs and as PLHIV is reported as a significant barrier to better health seeking behavior in HIV positive IDU.

Xingjiang Red Cross HIV Program – provides prevention, Care and Support, Advocacy, Capacity Building – peer education, targeted education, PLHIV Centre, PE Outreach Program, Drama performances, community lectures, staff capacity building.

Targeted education approach and activities:

Methods, approaches and content of targeted education are workshops, outreach, referral of which the content for these interventions includes:

Major content: understanding drugs and drug use, and introducing relapse prevention
Basic HIV information
Understanding dependence, and types of drugs
Basic skills: how to deal with overdose, basic wound dressing and syringe cleaning
Life skills for behavior change – revisiting peer pressure

PROGRAM EVALUATION 2008

Evaluation utilized UNAIDS Global AIDS Monitoring and Evaluation Framework. Knowledge and attitudes of injecting drug users: comparisons between the respondents who were beneficiaries of XRC project activities and those who were not. Evaluation Findings: 100% know where to get clean NSP 100% (n=54); 83% know where to go to get condoms (n=45); Any sharing in the last 6 months outside the program was 8% while inside the program was 12%. The presenter reported that the knowledge increase ranged from 15-32% in participants and the overall affect of the program on supporting an enabling environment was significant in terms of reducing incidents of stigma and discrimination in the province.

KEY ELEMENTS OF SUCCESS

Red Cross: non judgment, respect, empathy, equal/working together.
Close involvement of target people, IDU families, friends and their community
Provided wide information and skills which previously IDU were unable to access
Information upgraded on a continual basis.
Facilitated access to available services
Building supportive environment for family and community.

POSTER 156: PANAZABA – HIV/AIDS Prevention among drug user using critical awareness

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This poster presented on a program called PANAZABA "Drug Victims Community Bandung". (Note that some aspects of this poster were not clear as the English capacity of the author or translator was not high and some language would be considered inappropriate by IDU advocacy groups).

Name: Febby Cahaya. K. Website: www.panazaba.org.id

Government health services data from 1989 to Sept 2008 shown about 4,051 HIV cases reported in West Java. There are 132 cases in Bandung (according to this poster). This means HIV/AIDS is growing over the years. "HIV/AIDS preventions method happens not to touch the drug 'victims' [reporters' quotation marks] who became social movement subjects. Critical Education is a way that oppressive in thinking process and drug victim involvement in making avoidance in HIV spreads to themselves and their environments." (I think this means that HIV prevention doesn't reach IDUs or engage them and involve them in prevention of HIV to themselves and others).

The drug victims' community in Bandung (PANAZABA) is an organization that fights for the drug victims right through reorganizations, advocacy, and campaigns that aim to change social paradigms. Critical Education is a way to treat and to prevent HIV/AIDS because it involves key populations as Transformation Agents.

RESULTS

Results of PANAZABA are reported in the poster in a number of ways: the program has more than 100 members that have connections in their territories and provide ongoing critical education through discussions that put the PLWHA IDU point of view. They appear to engage IDU and PLHIV in critical discussions involve them in HIV/AIDS prevention interventions.

LESSONS LEARNED

PLHWHA IDU gains health access without stigma and discrimination
Treatment and preventions of HIV/AIDS can more effectively be undertaken with Key Populations involvement
ODHA IDU basic needs are more understandable by doing critical discussions (I'm not exactly sure what this means)
"Respect Drug User Right as a Human Right"

POSTER 153: Empowering Teachers of Penabur, Jakarta to be the agent of change on drug abuse and HIV prevention.

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This poster presented a teacher training pilot aimed to raise awareness of "drug abuse" [reporters' quotation marks] and HIV prevention. It argued that "the wrong paradigm on AIDS and drugs abuse in school will lead to misperception."

Author: Andreas Sigit Pamungkas

The program was a Live-In-Program for senior high school teachers (60 teachers involved). The curriculum involved mainly sharing experiences with "drug abusers" and PLHIV. It included information on how to prevent the transmission of HIV, how to get access to VCT, how to "deal with" PLHIV and "how to control the drug abuse problem." [Again, quotation marks are the reporters].

RESULTS

Results reported included increased knowledge and changed behavior towards PLHIV and drug abusers (not exactly sure how this was evaluated as information about this was not provided). The author suggests that the program empowers the teachers to be the agent of change, changing students' paradigm.

POSTER 152: Drug Users community based HIV prevention and Care in West Java

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This poster presented field analysis from community-based HIV prevention and care programs to drug users in West Java. As an introduction it presented that the number of reported cases of HIV continues to increase significantly in West Java. All districts have reported HIV infections. It reported that IDUs contribute 68% of HIV infections in West Java through needle sharing practices and are thus a high priority for intervention.

Authors: Suharni, Siswanto, Suwartini, Bayu, Mochammad

The authors reported on a project initiated in 2003. It was a community-based intervention which incorporated sensitization of local community, IDU socio-cultural norms and practices. It was established in 10 districts/cities managed by six NGOs. Project staff were trained on technical and social-cultural aspects of the interventions in which outreach was a program key component and education on safe injecting practices, use of clean needles and effective use of condoms were key interventions. IDU and their partners were "motivated" to have HIV counseling and testing (HCT) - case management for HIV IDUs was reported as part of the program of services.

RESULTS

By December 2008 7,598 IDUs were reached.
1,308 (17.2%) IDUs received HIV counseling and testing (HCT).
Case managers assisted 1,813 HIV and drug addiction-related cases.
Over 500 volunteers with drug injecting backgrounds were involved.
291,795 clean needles and 87,267 condoms were also distributed.

Authors argue that outreach is a key component in working effectively with IDUs. Participation of IDUs and local people in the program is essential. Support from local authorities and community leaders, provision of essential and accessible services are the key to program success.

ORAL PRESENTATION: Using Quality Improvement Processes to Improve Program Performance

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Presenter: Rizky Ika Syafitri (FHI Indonesia)

This oral presentation reported on an FHI program to deliver clean syringes and HIV prevention information to IDU in Indonesia. It was particularly concerned to analyze the ways that data was used to improve programming and quality of service delivery.

It found that the program reached inadequate numbers of IDU and distributed inadequate numbers of syringes. For example the frequency of contact was only 1-2 times per month in which a total of 1-15 needles were delivered to individual IDU through outreach. The key finding here was that minimum level of contact frequency needed to be at least 3-4 times per month in which 20-25 needles were delivered to individual IDU.

A concern for IDU in Indonesia is the law that prohibits the carrying of needles and makes arrest highly likely if stopped by police. However, the need to provide adequate numbers of needles is highlighted and was noted by the speaker as an essential strategy for increasing health and decreasing risk of HIV transmission. Legal change is required.

The speaker recommended that an evidence based model, guidelines and procedures and minimum standard of interventions should be in place before QI processes are undertaken.
Database systems and routine monitoring are needed to continuously monitor program performance
Technical support and encouragement are crucial.

HEALTH AND WELLBEING OF IDUs, THEIR PARTNERS AND FAMILIES

ORAL PRESENTATION: Health Status at Baseline of a Cohort of Drug Injectors in New Delhi

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An oral presentation by Luke Samson et al reported on a cohort of IDU in New Delhi, India and reported the health profile of this group with a view to better understanding the impacts of ill health and poverty on consistent use of clean injecting equipment and safe sex. The research focused on 449 IDU in New Delhi over 18 months beginning in 2004. All participants were men, mainly single (74%) although 29% reported having children. 60% of the cohort was employed as scavengers in which their daily income was around US$2.4, the majority were homeless and 62% had no access to toilet facilities. 38% of the cohort were underweight at baseline and the average BMA was 19.2. Only 66% had ever heard of AIDS and of these 65% had low functional knowledge. 45% believed they were already HIV positive. 46% believed they would eventually acquire HIV and 19% knew someone who had died of AIDS. 22% were HIV positive at baseline while 10% were Hep C positive and 50% Hepatitis C positive. 13.6% had syphilis at baseline and systemic infections affected were experienced by a third of the cohort. 85.5% initiated drug use after the age of 17 and the two drugs reported as most regular included cannabis (57%), heroin (18%). Half the cohort reported injecting for less than 5 years while 59% used injecting and non injecting drug together. The authors conclude that integrated welfare and health programs are essential to NSP success in resource poor settings.

Authors: Luke Samson, Enisha Sarin, Jimmy Dorabjee, Basant Singh, Mike Weat

BACKGROUND

The program followed a cohort of 449 IDU in New Delhi India for up to 18 months beginning in 2004 to assess the effectiveness of sequential interventions: NSP, condom access, health education, case management, nutrition, VCT, medical care, buprenorphine. The
study area and recruitment was New Delhi population. Study Site Yamuna Bazaar and this is the earliest hub of IDU in New Delhi. Eligibility – self reported injecting over 18 years; resident in area. Examine the impact of a sequential set of interventions for IDU e.g. NSP, substitution, nutrition, residential care programs. Measures included baseline survey questionnaire assessing demographics, knowledge and attitudes, sexual history, drug use history, medical history, voluntary screening for HIV, syphilis, Hepatitis B and C.

RESULTS

All participants were males from 18-64 years mainly single (74%). 29% reported having children. 66% had less than 5 years of formal schooling. 60% employed as scavengers. Average daily reported income $2.4. 92% were homeless and 62% had access to a toilet. 66% had heard of AIDS of these 65% had low functional knowledge, 46% believed they would get AIDS, 49% believed they had AIDS, 19% knew someone who had died of AIDS.88% reported having had sex in their life time but current rates were low (71% not engaged in sexual activity). 17% reported unprotected sex in the past six months. 18% reported having paid for sex in last six months. 4% reported anal sex in the last 6 months.85.5% initiated drug use after age 17. 57% were using cannabis; 18% heroin. 54% reported injecting for less than 5 years. 59% used injecting and non injecting drugs together. 22% of participants were HIV positive at baseline. 10% were Hepatitis B positive. 60% were Hepatitis C positive. 13.6% had syphilis at baseline. Systemic infections totaled 30% of the cohort. The average BMA was 19.2 with 38% clinically underweight at baseline. Mental health is abysmal (presented in another paper in this conference). Psychiatric co-morbidity not captured as it was beyond the scope of the study.

LIMITATIONS

TB status not considered in health status although the same population was treated for TB , data captured was of poor quality due to lack of resources.

OVERALL CONCLUSIONS

Ill health, poverty and homelessness present a significant challenge to the notion of a comprehensive package services to IDU. The abysmal BMI shows the need for nutritional interventions. The reality of 92% of the population being homeless exacerbates vulnerability to multiple infections (22% HIV infected = low resistance). Poor literacy and the reality that over 90% of the reported income was spent on drug use indicated little or no resources for nutrition or health related expenditure. The reality that 60% that Hepatitis C positive complicated access to ARV treatment and currently no interventions are available. 31% reported prior participation in buprenorphine substitution program that was run by Sharan. The substitution program closed two years prior to the study and only NSP was available to this population. Clients recruited were from Sharan's NSP program supported by Delhi Government of which 87% reported sharing needles accessed through the needle exchange program. This population represents the average clientele covered AIDS Control Targeted Interventions the bulk of whom are only being provided with needles and syringe.

Targeted interventions appear to be severely compromised unless they take cognizance of the need to build linkages with IDU/HIV interventions, general health interventions including Hepatitis C and poverty alleviation measure including access to food and shelter.

FLOOR DISCUSSION AND QUESTIONS

This session stimulated some questions and debate from the floor which was particularly interested and so the discussion is provided here for the reader.

Q; 87% still sharing needles is stunningly high. Are you saying that if you just give out needles and syringes, needle sharing will continue unless accompanied by a number of other services? Do you need nutrition and counseling programs to modify behavior?

A: not sure there's a clear answer. We count reduction in sharing episodes –but what is in that? Were they sharing every day? How was it happening? There's been a large amount of NSP – it's not that it doesn't work it's just that it isn't enough unless it is complemented with additional services to sustain it – simple factors, if you are spending 100 rupees a day on heroin-use then what's happening? You might have borrowed money, people will be looking for you. You may also have engaged in petty crime and so you won't go to the same NSP because people will get to know that you go there.

Q: sharing equipment 84% - what's in it? The model you're proposing includes dealing with suicidal issues, homelessness, nutrition and shelter and family counseling - are there any good examples that you know of in South Asia, in a resource poor setting, that provide a more comprehensive program?

A: We would like to think that we've spent a huge amount of time and energy on local messages and in terms of cleaning needles and syringes. I think there is hopefully a little more education. The problem is that it's a moving line – money and funding change and services change so it's difficult. I haven't found an international model that is completely acceptable. We have no integrated residential care with substitution or one stop shop concept.

POSTER 170: Family support of Jakarta and Bali IDUs receiving antiretroviral (ARV)

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This report notes that many studies support the effectiveness of ARV therapy in resource poor areas but data are sparse from areas like Indonesia where IDU is a key risk factor. Social isolation, ongoing substance use, unstable housing, depression and absence of outreach, drug treatment and other support services are potential obstacles to effective ARV use in IDUs. This report focused on analyzing the ARV and care needs IDU with HIV in Jakarta and Bali who live with their families. The authors conclude that the family context represents a useful one for promoting ARV adherence and appropriate levels of care to IDUs with HIV. In particular, they propose using family support as a key component of ARV support to IDUs and continuity of overall care.

Authors: RC Hershow, S Lenggogeni, O Kamil, M Setiawan, R Tambunan, Irwanto. Institutions: UIC School of Public Health, University of Illinois at Chicago, Chicago, USA; Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia; Keri Praja Foundation, Bali, Indonesia. Funding for this project was provided by the National Institute of Child and Health Development NIH.

OBJECTIVES

Objectives of the study were to assess and compare the availability of family and friend support, substance use treatment, other support services satisfaction with HIV care and self reported ARV adherence among IDUs receiving ARVs in Jakarta and Bali. Also the study aimed to assess the prevalence of potential obstacles to successful ARV use such as ongoing substance use, depression and social isolation.

METHODS

Included cross sectional survey of 130 HIV infected adult patients who have been receiving ARVs for at least 3 months in Jakarta (n=60) and Bali (n-70). Also participants interviewed using a structured questionnaire regarding 1. Demographics, 2. Family and friend support, 3. Use of support services including drug treatment 4. HIV care satisfaction 5. Current substance use, 6. Depression screen using CES-D instrument and 7. ARV adherence. Also 36 randomly selected Jakarta participants underwent serum HIV RNA viral load testing at enrolment.

CONCLUSIONS – HIV care and adherence

Among IDUs receiving ARVs in Jakarta and Bali, ARV adherence and satisfaction with care are reasonably high.
Although ARVs are free, nearly half of participants claimed that associated HIV clinical costs were problematic

CONCLUSIONS – Family and Friend Support of ARV Use

In Jakarta and Bali, most HIV infected IDUs live with family. For the great majority of participants, relatives are aware of their IDU and HIV status.
For married persons, spouses are the family members who offer most assistance with ARV use. For unmarried participants, mothers are considered "most helpful".
Reminding participants to take ARVs is common, but family-supervised directly observed ARV therapy is uncommon.
Participants less commonly disclose their HIV status to friends and tend to distance themselves from drug using acquaintances after starting ARVs.

CONCLUSIONS – Use of Support Services

Outreach services and case management are available in Jakarta and Bali, but only a minority report contact in the last month; HIV+ support group attendance was more common in Bali. Narcotics and Alcoholics Anonymous were only available in Bali.
Methadone and other drug treatment modalities are available in Jakarta and Bali and current heroin use is reportedly uncommon in this population.
Although 29% of participants are depressed by CES-D screening, less than 5% report recent use of mental health services.

IMPLICATIONS AND FUTURE STUDY

It may be reasonable to enlist family to play a more direct role in facilitating successful ARV use, relieving some of the burden on outreach and case management support services.
Analyses are planned to compare the clinical course of patients after initiation of ARVs to examine the effects of drug substitution therapy, depression, and ongoing substance use on clinical response to ARV therapy.
This is a highly select group of patients who have managed to enter HIV care and sustain ARV use over time. Even in this select group, almost half report that HIV care costs are problematic. More research is needed to explore cost and other factors that may impede or facilitate successful entry and retention in HIV care.

POSTER 290: Factors related to Hepatitis C (HCV) prevalence among sexual partners of HIV/HCV co-infected patients

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This poster reported upon the prevalence of Hepatitis C among a cohort of sexual partners of HIV/HCV co-infected IDU in Jakarta, Indonesia. 118 participants were enrolled in the study and the majority were female. As well as baseline health status investigation and analysis of medical histories, the research used structured individual interviews to seek information from participants. HCV prevalence was 9.3% among subjects at baseline. Non vaginal sexual contacts and HIV positive status increased the risk of acquiring HCV infection up to 8 times. The poster concludes that screening and prevention program for HCV transmission upon high risk groups should be integrated in to HIV service centers.

Authors: Sri Agustini Kurniawaqti, Teguh H. Karijadi, Rino A. Gani. Institutions involved: International Medicine Dept, Medical School, University of Indonesia; Allergy Immunology Division Internal Medicine Dept, University of Indonesia; Hepatology Division International Medicine Department, University of Indonesia.

BACKGROUND

Management of hepatitis C virus co-infection in Indonesia has become an emerging issue due to improved life expectancy of HIV patients because of the availability of free ARV by government. Prevention of HCV is an important part of management of HCV infection. Various factors related to transmission of HCV among sexual partners of HIV/HCV co-infected patients were not previously investigated in Indonesia. Thus, the research was conducted with the purpose of evaluating the prevalence of HCV infection and identifying factors related to HCV prevalence among sexual partners of HIV/HCV co-infected patients, as an important part to the better quality of health service in HIV/HCV co-infected patients.

METHODS

This was a cross sectional study among non-intravenous-drug-using sexual partners of HIV/HCV co-infected patients in the outpatient clinic Pokdisus Ciptomangunkusumo Hospital, Jakarta. Index patients were taken from medical records. Evaluated risk factors included blood transfusion, HIV status, condom use, numbers of sexual contacts, numbers of sexual partners, types of sexual contacts, and CD4+ count of HIV/HCV co-infected patients. Data was collected using structured interviews with individuals for each group. Blood samples were taken for examination of anti-HCV third generation and anti-HIV ELISA. Statistical analyses were performed using CHI square or Fisher Test and logical regression with CI 95%.

RESULTS

During May-Aug 2008, 118 eligible subjects participated in this study. The median age was 26 years (range 19-39) 96.1% were female. HCV seroprevalence was 9.3%. In univariate analysis, higher HCV prevalence was evident in subjects with HIV positive results or in subjects with non-vaginal sexual contact even though in multiple logistic regression analysis showed that only subjects with non-vaginal sexual contacts correlated with HCV prevalence.

CONCLUSIONS

HCV prevalence was 9.3% among subjects. Non vaginal sexual contacts and HIV positive status increased the risk of acquiring HCV infection up to 8 times. Based on these, screening and prevention program for HCV transmission upon high risk groups should be integrated in to HIV service centers. Total larger samples and genotype examination of HCV in both spouses were needed to evaluate HCV sexual transmission.

SEX AND IDU

Poster 169:
Condom Use and Sexual Networks of IDU&s in Bandung, West Java, Indonesia, A Review (On behalf of IMPACT Project Indonesia).

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This poster presented a literature review undertaken to report on available data related to condom use within sexual networks of IDUs in Bandung. Its importance is highlighted because the numbers of IDU is estimated at around 22,000 in West Java while numbers of IDU reported as living with HIV is 60% (UNAIDS, 2006). The literature review reports that, while risky injecting drug use is reducing from 33% in 2004 to 24% in 2007 across the six big cities of Indonesia, in Bandung 82% do not use condoms consistently with their regular partners while 72% do not use condoms consistently with their casual partners and 45% don't use condoms consistently with sex workers (IBBS, 2007).

Authors: Basar, Indriasari, Prawiranegara, Pinxten, Martodirdjo.

BACKGROUND

This poster presented some initial facts on Indonesia, HIV and IDU. Indonesia has the fastest growing HIV epidemic in Asia more than 1,000,000 HIV infected by 2005. IDU are believed to make up 52.4% of HIV-infected populations in Indonesia. There has previously been reported HIV transmission from IDUs to the general population due to high rates of unprotected sex by IDUs and their partners (including regular, casual partners or female sex workers (Pisani 2003). Condoms have a poorer reputation in both the Indonesian general population and among HIV risk groups and no improvement in consistent condom use in this group with spouses, casual partners and SWs is reported.

This poster reported on a literature review of available data on condom use within the sexual networks of injecting drug users in Bandung. Its method was to first literature search for studies on IDU and collect all statistical data related to condom use among IDU in Bandung. It then analyzed and reviewed studies on condom use among IDUs in Bandung.

RESULTS

Results included findings that analyzed the current HIV situation among IDUs. Numbers of IDU estimated at 22,000 in West Java with 60% of IDUs infected with HIV (UNAIDS 2006). Latest official data stated that 46% are already infected by HIV are IDUs (KPA, 2006). In terms of IDU Risk Behavior the study looked at injecting behavior in Bandung and said there is a positive tendency of reduce d needle sharing from 33% in 2004 to24% in 2007. In terms of sex, data from 6 big cities in Indonesia (Jakarta, Medan, Bandung, Surabaya, Semarang and Malang) show that 38-39% of IDUs have regular partners and 20-60% have casual partners. Between 9 and 54% of IDUs buy sex (IBBS, 2007). In Bandung, 60% of IDUs have multiple partners with 59% have regular partners, 59% have casual partners and 46% buy sex, 10% sold sex (IBBS, 2007) In terms of condom use – In Bandung 82% of IDU do not use condoms consistently with their regular partner, 72% do not use condom consistently with casual partners and 45% do not use condoms consistently with sex workers (IBBS, 2007). Reasons for not using condoms with regular partner included that IDUs were afraid of suspicion from their regular partners. In casual partners and female sex worker there was no plan for having any sexual relationship before (I think this means these were fairly spontaneous encounters with no pre-planning) and that they had not been in the habit of using a condom. Among female sex workers the decision to use condoms was seen as dependent upon the client's attitude and preference for condom use. There were also reported some attitudes and myths about condom use – in particular that they lessen the experience and satisfaction of having sexual relationships.

CONCLUSION

Conclusions from this study are that inconsistent condom use by IDUs having sex with multiple partners results in the "spill over" to FSWs and subsequently to the general population. Gender inequalities affected the decision to use condoms. 100% condom use enforcement is the first step to fight the spreading of the HIV. More in depths research s needed.

ORAL PRESENTATION: Night Outreach: Addressing Female Injecting Drug User Sex worker needs West Jakarta, INDONESIA.

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An oral presentation from West Jakarta reported upon night outreach to female IDU sex workers through the organization Kios Atma Jaya. They reported on the activities and results of the project which included night outreach that promoted attending to the reproductive health of the target group, educated on negotiating condoms in sex transactions, provided advice on keeping safe during police raids and referrals to STI clinics. The numbers female IDU sex workers reached were particularly small but numbers female IDU (who were not sex workers) was higher. The approach was noted as innovative for Indonesia.

Authors: Nazaruddin latief. Atma Jaya University Jakarta, Indonesia.

KIOS ATMA JAYA PROFILE

Started 2002, outreach is used as a platform for the intervention, outreach carried out in three municipality spread over in 12 sub district in west, north and center of Jakarta, Kios program focus is to prevent HIV infection among IDU and their sexual partners.

PROGRAM ACTIVITIES

The range of program activities for this particular project included outreach NSP, VCT, case management, basic health services, HIV and drug dependence counseling, peer education, advocacy, support group, vocational training.

TARGETING FEMALE, DRUG INJECTING SEX WORKERS (FISW)

KIOS identified female IDU who worked as sex workers as at particular risk of HIV infection through sex and injecting. However, no specific program and intervention was available for FISW, there is limited understanding of HIV and STI among this group, low access to condoms and a weak bargaining position with sex client regarding condom use.

The best time to reach FISW is at night time but this puts a particular stress on CBOs in terms of attracting staff to work at those hours. In the BCC intervention itself there is usually limited time to communicate and provide information education due to the work and activities in the street. The streets in which FISW work are often crowded and education occurs in a hectic environment. Police raids make it difficult to work. Kios has twelve outreach workers who carry the main responsibility for reaching IDU and IDU sexual partner generally. To meet the need to target FISW seven out of twelve outreach workers were used for this project.

STRATEGIES

A set of strategies were used to make this work most effective and they included:

Rearrange schedule for outreach team to be able to do outreach at night
The best time to reach FISW is before 'peak hour (around 2-3 am)
Approaching FISW through the pimp
Involving local people associated with FISW activities to deliver prevention material and promoting health services

The particular outreach activities engaged for this project included:

Promoting of reproductive health services
Condom negotiation techniques
Referral to STI clinics
Safety procedures on police raid situation

PROGRAM OUTCOMES

5,570 total IDU reached by Dec 2008 in which 349 were female IDU and 53 were FISW
Needles distributed to FIDU and FISW 21,986 while Condoms distributed to them totaled 13,366
FISW accessing VCT totaled 21 and IEC materials distributed to FISW totaled 2,471
Night outreach only twice per week
341 FISW were reached in the current life of the project

LESSONS LEARNED

Female IDUs who also work as sex workers are the hardest group to reach. Different approaches and strategies were needed to reach them.
Flexibility to different times (shifting)

POSTER 386: Sexual Networks Study among IDUs in Indonesia

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This poster reported on the sexual networks of IDUs in Indonesia. It began with a background on HIV in Indonesia explaining that by year 2004, it was estimated almost 50% of IDU in Indonesia have been infected with HIV/AIDS. Potential sexual transmission of HIV IN injecting drug users is increasing. Understanding IDU sexual networks, the nature of sexual relationships and sex risk is still limited. This investigation, initiated by FHI aimed to address gaps in knowledge.

Author: Octavery Kamil, AIDS Research Center, University of Atmajaya; Ignatius PraptoRaharjo, University of Illinois at Chicago, USA; Wayne Wiebel PhD, University of Illinois at Chicago; Alfred PachIII PhD, Consultant.

METHODS

The study was conducted in 4 big cities in Indonesia (Jakarta, Surabaya, Medan, Bandung and Denpasar, Bali). The study used purposive sampling design to include IDU representing various characteristics at each location. Inductive analyses revealed common themes and exceptional cases.

FINDINGS

Findings include:

Sexual relationships among IDUs in the study covered an array of relationships based on different levels of emotional intensity, social involvement, sexual activities and risk behavior. They also varied in their age, social group membership and risk profile, which reflected patterns of sexual mixing and a bridge of HIV transmission.
IDU informants found to commonly have regular casual and commercial sex partners. "Serious relationships" included emotional ties and mutual expectations and obligations. Those with regular sex partners had concurrent relations with casual and/or commercial partners. Male IDU also reported sex with transvestite and other males. Condoms were rarely used during sexual activities.

The result demonstrate that with the sharp increase in HIV infection among IDUs the substantial proportion of IDUs who buy sex, lack regular condom use and are involved with multiple partners, will lead to an increase in HIV prevalence among their different sexual partners and partners of their sexual partners. Effective and high coverage interventions aimed at simultaneously reducing injecting and sexual risk behavior among IDUs and their different sexual partners are urgently required.

ORAL PRESENTATION: INJECTING AND SEXUAL RISK BEHAVIOR AMONG FISHERMEN IN KUANTAN, MALAYSIA

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One of the most significant statements by the presenter of this paper was that, previously, alcohol use in Muslims at risk of HIV has not been a factor considered in research or education. However, given the high rates of alcohol use by participants in this study, there is a need to reconsider alcohol consumption in those at risk of HIV residing in Muslim countries.

Authors: Sumathi Govindasamy, University of Malaysia: Centre of Excellence for Research in AIDS

BACKGROUND

Fishermen account for 4% of all HIV cases in Malaysia. IDU behavioral survey findings from Kuntan Feb 2007 found 69 out of 100 were fishermen whose first IDU experience was at 23 years of age. HIV prevalence among fisherman in this survey was 42%. Port doctor use (a service that provides 'black market' assisted injecting) was 25% by participants in the sample. Polysubstance drug use is high (BPN 65%; heroin 42%; stimulants 26%). Sex with sex workers was 6%. SEP began July 2007.

OBJECTIVE

This study aimed to describe the injecting and sexual risk behavior of fisherman in Kuantan 1 year after SEP implementation.

METHOD

Sample size was 69 fisherman. Modified snowball recruitment was used in which drug use was not an eligibility requirement. Method included a 30 minute questionnaire that gathered information on demographics, IDU, sexual behavior, general health, HIV awareness from individual participants. There were also qualitative interviews using open ended questions with some individuals (n=15).

RESULTS

mean age of respondents was 42 (between 21-70).
The majority of respondents were Malay Muslims = 91%.
Those having less than secondary school education = 54%.
Those married = 51%.
Those who earned below poverty level = 44%.
Those who spent more than 6 months at sea per year = 84%.
Among these fisherman 38% had injected drugs, 30% were recent injectors, 66% of IDUs had not shared, heroin was most common drug used = 78%.
25% continues to use port doctors despite having access to new needles
4 reported visiting sex workers in previous month: 3 were HIV+ and only one used condoms.
IDU correlated with 1. Occupational role as crew. 2. Being unmarried 3. Time spent at sea. 4.
Consumption of alcohol was high.
Drugs and Fisherman: fisherman and drugs cannot be separated.

SUMMARY

HIV prevention remains a challenge with this population because they are often away from HIV prevention activities, drug use is culturally embedded within fisherman's lives; ii is as yet unclear the role of alcohol and IDU; HIV and drug treatment will similarly pose a challenge due to logistical constraints.

LIMITATIONS

Relatively small convenient sample; limited to one geographical area.

BROADER IMPLICATIONS

fisherman appear to contribute greatly to the economy of SEA;
fisherman are at increased injection and sexual risk in Thailand, Vietnam, Cambodia and Indonesia;
no clear and effective model for reducing HIV transmission and providing treatment in this logistically challenging population.

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