Integrated clinical and health education reach populations most at risk for HIV in Central Asia.

Central Asia has one of the fastest growing HIV epidemics in the world, concentrated primarily among people who inject drugs (PWID), and sex workers. This is a result of risky behaviors that are common within these populations—sharing of needles and syringes and unprotected sex—and a lack of services and ready access to critical prevention and treatment supplies and medicines.

To curb the epidemic, it is crucial to increase knowledge about transmission and prevention, to build skills around how to prevent transmission, provide the means for prevention for those at highest risk, and ensure referral and uninterrupted access to essential HIV treatment. This approach remains true whether working with PWID or sex workers.

JSI, through the USAID-funded CAPACITY Project and the TUMAR Project funded by the Central Asia AIDS Project (CAAP) implemented in four countries—Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan—successfully created a model that demonstrated how to reach nearly all members of two key population groups—PWIDs and sex workers. JSI reached the most at-risk in given regions with prevention and referral to HIV treatment interventions—including education, provision of supplies, and access to medical services—with the goal of increasing knowledge and skills, decreasing HIV-related risk behavior, and increasing the number of people in HIV care.

How change happened
JSI developed a comprehensive package of services based on international standards with four key elements:
• Reduction of stigma and discrimination.
• HIV education and information.
• Distribution of individual means of protection against HIV infection, e.g., condoms and safe injection equipment.
• Access to relevant HIV medical services.

Implementation
JSI trained outreach workers for education and distribution, and set up drop-in centers. Both contributed substantially to our efforts to reach people most at risk. Outreach efforts reached about two thirds of the total population contacted while drop-in centers reached one third.

At the drop-in centers, clients received a set of holistic and integrated services provided by psychologists, lawyers, substance use counselors, and STI specialists. Through outreach efforts and drop-in centers, clients received medical referrals to government run antiretroviral therapy (ART) centers. We improved usage of the referral services by having volunteers escort referred clients to the service sites and help them enroll. Former PWIDs volunteered to help those who wanted to enter detox or other rehabilitation services, which increased positive treatment outcomes.

Advocacy
JSI fully recognizes the importance of educating policymakers and other community stakeholders to reduce stigma and discrimination and to create a favorable environment for working with key populations.

We routinely held meetings with local partners including city administrators, law enforcement agencies, and local education and health departments to discuss program progress and results. We conducted trainings on HIV prevention and reduction of stigma and discrimination for law enforcement, religious leaders, and journalists. We also developed a video addressing HIV-related stigma and discrimination that was shown in drop-in centers, medical clinics, and on television.

Capacity building
Building the capacity of local NGOs, clinics, and consultants to provide HIV-prevention services to key populations was important to ensuring services were available. Service providers received ongoing consultations and onsite coaching.

Results
During the 18-month implementation, JSI reached nearly all—97 percent—of the targeted key populations in program catchment areas at least once. We reached more than half of that population five or more times, which resulted in even better results in that group.

JSI was able to demonstrate that compared to those from control sites, people with access to the program had significantly lower levels of needle and syringe sharing and much higher levels of consistent condom use. They were significantly more likely to get tested for HIV and seek STI diagnosis, and receive their results and have more accurate knowledge about HIV transmission and prevention.

For example, among PWID in the project group, 95 percent reported in a follow-up survey they did not share syringes in the last month, while 61 percent in a control group said they did not share. Among that same group, 54 percent reported always using condoms during sex in the last 12 months, while in the control group, only 28 percent did.

By joining the resources and technical expertise of the CAPACITY and TUMAR projects, JSI demonstrated how to effectively provide comprehensive HIV prevention services and referrals to critical clinical care to sex workers and PWID. Quickly achieving high-service coverage for key populations is possible, and it is necessary to slow the HIV epidemic in Central Asia. To do this, national governments must make resources available to local NGOs to scale up these activities in HIV-hotspots in each of these countries.

Learn more:

Abstract for Oral Presentation at IAC 2010, Vienna:
Comprehensive HIV prevention services for sex workers reduces HIV risk in Central Asia

Abstract for Poster Presentation at IAC 2010, Vienna:
High coverage of injecting drug users (IDUs) with comprehensive HIV prevention services reduces HIV risk in Central Asia

Blog on Reaching IDUs & sex workers with comprehensive HIV workers in Central Asia

PowerPoint presentation at GHC, 2010, Washington, DC
High coverage of most-at-risk populations reduces HIV risk

Abstract published in the proceedings of IAC 2008, Mexico City
Achieving high coverage of vulnerable populations with an essential HIV/STI prevention package