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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: 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”
• 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
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
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%
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)