A Comprehensive Package: HIV Interventions for Most-at-Risk Populations (MARPs)
Introduction
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Cambodian officials from Phnom Penh Health's office cooperate with an NGO to distribute condoms to boat rowers during the Water Festival in Phnom Penh.
Source: TANG CHHIN SOTHY/AFP |
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In many settings, there are individuals who are at disproportionately higher risk of contracting HIV because they engage in socially stigmatized risk behaviors for HIV transmission. These behaviors include sex work, drug use, and male-male sexual behavior.
The U.S. Agency for International Development (USAID), through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), works to provide these groups—which are often difficult to reach—with a comprehensive package of prevention services.
MARPs: The Who, What, Where, and Why
Two main routes of HIV transmission are sex and shared injection drug equipment. Anyone who engages in these practices with someone who is HIV positive is at risk for infection. When it comes to sexual transmission of HIV, biology, behavioral patterns, and social context combine to predispose some populations to higher risk of infection than others.
USAID and the United Nations Joint Program on HIV/AIDS have classified four such populations as MARPs: persons who engage in sex work; clients of persons engaged in sex work; persons who inject drugs; and men who have sex with men (MSM).
HIV spreads rapidly in these populations due to more frequent participation in high-risk behaviors, such as unprotected vaginal and anal sex, multiple sexual partnerships, and sharing injection equipment.
Because individuals engaged in high-risk behaviors often hide them to avoid social stigma, it is difficult to identify MARPs and target HIV prevention messages to them. Also, MARPs are less likely to have access to HIV prevention, care, and treatment services or to use those services due to fears of stigmatization and criminalization.
Other Vulnerable Populations
In many places, other populations have increased vulnerability to HIV due to a combination of behavioral, social, and environmental factors. Mobility and migration, gender and ethnic group economic inequality, alcohol use, and incarceration all contribute to populations facing a higher risk of HIV infection. Sexual mixing among groups at high risk, and bridging from high-risk groups to lower-risk groups are important factors in the spread of HIV in many countries.
Because of these factors, it is often important to also focus HIV prevention messaging on the following populations: military and uniformed services, persons engaging in transactional sex, incarcerated persons, mobile populations, street youth, and persons who engage in alcohol-associated HIV sexual risk behaviors. In general, the selection of target populations for HIV prevention activities should be determined by the epidemiology of HIV in each individual country.
Comprehensive Package of Services
To effectively reduce the risk of HIV in MARPs, USAID supports the delivery of a comprehensive package of services. This comprehensive package strategically combines three different types of prevention interventions: behavioral interventions to change individual risk behaviors and social norms; structural interventions to reduce vulnerability from risky contexts; and biomedical interventions to reduce the probability of transmission.
The comprehensive package includes a variety of services, both clinical and non-clinical, as well as facility-based and non-facility-based. Individual comprehensive packages, including but not limited to the services listed in the textbox below, are developed and modified for specific MARPs, depending on their risk behaviors and health care needs.
Peer outreach is an extremely important element in HIV prevention services for MARPs. It often provides an entry point to other services, as peer educators serve as liaisons between HIV services and hidden populations at high risk of infection. Their liaising activities include providing referrals and creating demand for HIV prevention, care, and treatment services.
Kroeger, K and Patel, S, 2008
Behavior change communication (BCC)
Providing HIV/AIDS Services for Men Who Have Sex with Men in Ghana
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Peer educators participated in a session on stigma during training on behavior change materials. Learning is hands-on as the peer educators try out the cue cards in the toolkit.
Source: AED |
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Due to stigma, discrimination, persecution, and lack of knowledge, many MSM in Ghana do not seek HIV prevention, treatment, and care services. Most MSM in Ghana, including advocates and leaders in the community, do not publicly identify their sexual orientation. This makes them difficult to reach with HIV services. With support from PEPFAR and USAID, groundbreaking HIV programming for MSM has been developed in the country. Through technical assistance and funding from the Academy for Educational Development, organizations in Ghana worked to provide MSM with a level of services previously not seen in the country.
To effectively reach MSM with prevention messages, a package of behavior change communication tools and interventions was developed, including a training curriculum for peer educators; communications materials; job aids for peer educators and health care workers; and a cell phone-based information, referral, and counseling service called the Text Me! Flash Me! Helpline.
Peer Education and Outreach Events
Peer educators ran outreach sessions for MSM and promoted risk reduction behaviors, offered referrals to clinics, and sold condoms and lubricants. Also, trained health care workers provided counseling at the clinics. Outreach events integrated HIV prevention messaging into a social setting. Events included large community parties and small gatherings at private homes and at bars and clubs that attract MSM clientele. These events raised awareness in social settings of the value of communication in MSM relationships and the importance of condom use, partner reduction, and other prevention behaviors.
Text Me! Flash Me! Helpline
The Text Me! Flash Me! Helpline used an already existing practice in Ghana. In this practice, someone contacts others by “flashing” them (calling their number and hanging up before the recipient picks up). The Helpline was originally staffed by a few implementing partners and HIV counselors from government clinics. Each staffer went through a training curriculum and received ongoing support when they needed it. During a set period of time each day, callers could “flash” the counselor, and the counselor would call each person back to answer questions, provide support, or share information about where to find services. Users could also send text inquires to the Helpline and receive an automated text in return, which covered a variety of topics relevant to MSM health. While confidentiality was a large concern, the clinic was still able to keep users’ numbers on file and send them text message reminders about condom use and the need for HIV testing, as well as messages of encouragement to call the Helpline when needed. The Helpline’s counselors could provide directions to clinics whose specially trained staff provided callers with encouragement, which is sometimes needed to get them inside the clinic.
The Helpline was extremely successful. In the launch month, September 2008, the five initial counselors spoke with 439 MSM callers for an average of 20 minutes each. After the launch, there was an increase in demand for HIV counseling and testing, as well as sexually transmitted infection (STI) diagnosis and treatment services. The number of MSM who subsequently received STI services at USAID-funded drop-in clinics increased tremendously.
The U.S. Agency for International Development works in partnership with the U.S. President's Emergency Plan for AIDS Relief.
January 2011
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