Reaching out, Stepping up: Working with Vulnerable Populations in a Difficult Context

Melbourne - July 23rd, 2014

Dr. Cherif SolimanFHI 360 - Egypt

HIV/AIDS Situation in Egypt • General Population : about 87 million (CAPMAS Egypt)

• UNAIDS estimates: – 6,500 PLHIV (4,300 – 10,000) – Estimates for MARPs (2011):

• 100,000 IDUs• 48,000 MSM• 24,000 FSWs

– HIV Prevalence : less than 0.1%

“Low prevalence does not mean low risk”

Challenges: Captaining

Curling team = Skip & Sweepers

Challenges: Collaboration

NGOs, Civil Societies

Government

Outreach, Limited services ARVs, Viral load , Hospitalization

Different key players are not always included

Challenges: Sustainability

• No income generating activities to ensure sustainability

“My Pyramid, My Project”

IIIIII

Challenges: Coordination

Duplication and Competition

• Weak Monitor and Evaluation system at both governmental and CSOs levels

• Research and Ethics principles are not always followed up

Challenges: Data & Documentation

HIV Bio-BSS among MARPs (FHI 360/2006-2010)

Groups 2006 2010

Street boys Cairo 0.0% 0.5%

Street girls Cairo 0.0% 0.5%

FSW Cairo 0.8% 0.0%

MSM Cairo* - 5.7% (2.6 -10.1%)

MSM Alex* 6.2% (1.7-14.4) 5.9% (3.0 -10.2%)

MSM Luxor* - 0.0%

Male IDUs Cairo* 0.6% (0.1-1.8) 6.8% (3.9 -10.8%)

Male IDUs Alex* - 6.5% (3.3 -10.3%)

* RDS population estimates

FSWs in Cairo (Bio BSS 2010)

25.0%

11.0%

Commercial Non-commercial

n=200 n=73

Reported Condom Use during Last Sex

n=200

Under 20 years of age 10.5%

Ever had sex before 16 years 22.5%

Currently married 45.5%

Injecting drugs in past 12 months 6.0%

21.9%

54.9%

25.0%19.2%

Commercial Non-commercial

Cairo

Alexandria

MSM in Cairo and Alexandria (Bio BSS 2010)

Reported Condom Use during Last Sex

Cairo n=260

Alexandrian=262

Ever had sex with a female 39.8% 59.2%

Currently married 3.4% 4.7%

Injecting drugs in past 12 months 2.3% 4.9%

Forced sex with a male partner in past 6 months 12.7% 14.6%

n = 87 n = 83

3.2% 2.6%

30.4%

17.3%

12.2%

0%

Regular non-commercial

Non-regular non-commercial

Commercial

Cairo

Alexandria

Male IDUs in Cairo and Alexandria (Bio BSS 2010)

Cairon=275

Alexandrian=285

Currently married 48.7% 29.3%

Shared needles with one or more partners in past month 22.9% 40.5%

Ever had sex with a male 14.3% 7.7%

n= 182n=175 n=29 n=32n=93n=61

Reported Condom Use during Last Sex

Transmission through Mosquito BitesFSWs: 20.8%Male IDUs: 35.3%MSM: 35.9 %

Ever Tested for HIV FSWs: 3.4%Male IDUs: 9.5%MSM: 22.1%

HIV/AIDS Misconceptions among MARPs in Cairo

Peer Education

VCT

Clinic

Provision• Syringes• Condoms• IEC Counseling

• Addiction• HIV

• Rehab. • ARVs • Social• Legal• Medical• Religious

• STI• General• Home care• HIV

Support Groups

Approaches for Services Provided to MARPs

FHI 360 Comprehensive Care Center (CCC)

ReferralOutreach

Approaches for Services Provided to MARPs

Direct Referral

Direct Street ReferralNo CCC

Outreach

Building a Good Will (Benefit for All)

Potential Complications

Transmission Dynamicsat the Population Level

Adapted Harm Reduction Approach that consider local context

Overlap of Risk Behaviors

Combination of safe sex and safe injection

Security Concerns

New needle & syringe instead of needle

exchange

High Stigma towards MSM and FSWs

IDUs are the entry Point to outreach Other stigmatized

populations

• Gradual implementation• Different outreach techniques • Provision of services for all MARPs & related communities• Anonymous, confidential and free of charge

Difficulty in Dealing with MARPs• For All

– Stigma and discrimination

– Lack of trust– Security issues

• Females – Not motivated to participate– Low status limit ability to

negotiate safer sex, obtain information and receive health care

• Male IDUs– Lack of concentration

(High on drugs)– More concern toward

Hepatitis Infection

• FSWs– Weak networks – Very low self-esteem – Pimps are the principal

recruiters

Location of the CCCs

Connection Path between Rich and Poor Districts

Standardized, high quality and stigma-free services for MARPs and related communities

23 Members (Dec 2013 till June 2014) 13 CSOs/Projects4 UN agencies2 Funding agencies: Drosos Foundation – Ford FoundationNAPFHI 360BeneficiaryResource Person

NAHR Objectives

• Establish NAHR as coordinating body for all harm reduction projects in Egypt

• Strengthen the capacity and improve access to quality services for MARPs and PLHA

• Reduce stigma and discrimination among MARPs and PLHA through advocacy

Outreached (n = 3859) Visited the CCCs (n=3215)

Received Full VCT (n= 2902) Number of Condoms Distributed (n= 17927)

NAHR Beneficiaries reported by 6 CSOs(Jan 2013 – May 2014)

NAHR Beneficiaries (n=3215)

(Jan 2013 – May 2014)

2.7% were detected HIV+ve 11 Support Groups (143 sessions – 90 beneficiaries)

FSWs2%

MSM 39%

IDUs51%

Others8%

Religious Leaders are the Best Supporters

1.Equal Rights, Care and Support for all human beings

2.Build a Good Will (Benefit for all)

3.Reduce vulnerability (do not push MARPs for confrontation)

4.Empower MARPs to deal with their needs

5.Build social capital among members

6.Partnerships and collaboration (Synergy); CSOs, Gov. etc.

7.Provide continuous capacity building for high quality of services8. Identify creative ideas to attract females

Elements for Success

Elements for Success

9. Create an enabling environment (supportive groups including religious leaders)

10. Adapt Harm Reduction approaches that:- Consider local context- Deal with different risky behaviors - Provide services to partners and family members as well

11. Develop a strong M&E system; transparency in sharing information

12. Ensure participation, commitments and ownership of all members (including MARPs and peers)

Thank You