Q3/2010: Targeted Intervention for HIV/STI Prevention and Treatment
October 15, 2010
July 2010-September 2010
MOBILIZATION AND CAPACITY BUILDING OF FEMALE SEX WORKERS TO IMPLEMENT COMMUNITY LED TARGETED INTERVENTIONS FOR HIV/STI PREVENTION AND TREATMENT
Districts of Jhabua and Nimach in Madhya Pradesh, India
Implemented by: Jeevan Jyoti Health Service Society
Technical Assistance: Real Medicine Foundation India
In April 2010, a Jeevan Jyoti Health Service Society began a targeted intervention (TI) for female sex workers (FSW) in Jhabua and Nimach Districts of Madhya Pradesh. The focus of the intervention is to increase access to HIV/AIDS and STI Prevention, Care, Support and Treatment Services and is funded by UNFPA with technical support from Real Medicine Foundation India.
Objective: Increase the overall access for FSWs to HIV/AIDS, STI, and reproductive health services, while providing counseling and educational services to increase knowledge of prevention and legal rights.
Goal: Promote safe sex practices amongst FSWs and their partners and develop FSW friendly centers to provide essential health services, community empowerment, and prevention-based knowledge.
- To identify and recruit the 12 Peer counselors (FSW) and 2 District Mobilizers for total 2 districts
- To reach a large network of FSW, their clients and their communities through IEC campaigns and targeted community sensitization training.
- To reach 4000 FSWs and their clients on HIV/STI, behavior change counseling and STI /HIV awareness.
- To develop tools, indicators, and monitoring framework to track the progress of the targeted intervention.
- To build the capacity of FSWs to continue peer counseling and outreach work through their own channels
The first quarter the program focused on recruitment and training of staff, and base line survey. In the second quarter full implementation of the TI was possible, with a focus on the implementation of health camps, weekly clinics, condom promotion and distribution, stakeholder meetings and other services for the better health of FSWs. Staff gained experience in working in the field and were able to apply their training and retraining.
The focus of the quarter was on outreach activities and growing the capacity of TI staff. A variety of tools were employed, such as “Safe Sex Kits” for FSWs and penis-models for condom demonstrations. In addition, research and development of a tribal appropriate women’s health flipbook occurred, with production expected next month.
Some of the challenges experienced this month are as follow:
- Monsoon limiting physical access to the field
- Security issues surrounding the Ayodhya verdict
- Social stigma surrounding the target population affecting staff
- Incidents of domestic violence and police interference
- Unavailability of STI kits and HIV rapid test kits at ICTC Centers
The greatest challenge faced in the quarter, by far, was the difficulty in gaining trust of the target community. This challenge was discussed in a program wide training session held in September, and strategies were developed by the program staff to improve the relationships with the FSWs. Despite this challenge, program staff presents optimistic indications for the forthcoming development of trusting relationships amongst the community.
HIV/AIDS in India
According to most recent data, it is estimated that over 5.2 million people (.88%) are living with HIV in India. As more than 99% of India’s population still remains HIV negative, the main strategy for both governmental and non-governmental (NGO) organizations is prevention.
High risk groups for HIV/AIDS present with higher prevalence of HIV/AIDS, and are Intravenous Drug Users (IDU), Men-Who-Have-Sex-With-Men (MSM), Female Sex Workers (FSW), and long-distance truck drivers. Their prevalence levels in India are 8.7%, 5.7%, 5.4% and 2.4%, respectively.
FSW and HIV/AIDS in Madhya Pradesh
Madhya Pradesh (MP) is classified as a highly vulnerable low-prevalence state for HIV/AIDS. With this classification, prevention measures are critical to stop the spread of HIV/AIDS. According to NFHS-3 data on Madhya Pradesh, only 45.3% of ever-married women and 68.3% of ever-married men had heard of HIV. In rural areas, those percentages decreased to 35% and 58.8%, respectively. The data also show that neither women nor men are adequately informed about the use of condoms as a prevention measure, as only 35.7% women and 61.9% men knew that consistent condom use could reduce the chances of contracting HIV/AIDS. In rural areas, those percentages decreased to 25.7% and 51.4%, respectively. There is a clear gap in knowledge between urban and rural residents of MP regarding HIV/AIDS.
In rural areas, factors such as low literacy rates, limited access to knowledge regarding health, and high migration rates increase the risk HIV/AIDS. In addition, MP contains a large number of people considered high-risk, with up to 3,530 IDU, 138,981 MSM, and almost 65,000 FSW.
According to baseline data collected in April 2010, FSWs in Jhabua District are non-brothel based, with the majority working along trucking routes and in alternate locations known to the general public. Jhabua-based FSWs operate through a client network, and have an average of 15-20 clients at a time. Data collected from focus group discussions (FGDs) of FSWs show that 83% had not heard of HIV and 51% had not heard of STIs. Only 15% of these women knew that they could protect themselves from HIV. 97% report having a non-paying partner (boyfriend or husband).
Female sex work in Nimach differs from Jhabua in that it is caste-based prostitution practiced by the Banchhara community. Data collected from FGDs of FSWs show that only 7% had not heard of HIV and 27% had not heard of STIs. 92% knew that they could protect themselves from HIV and 91% of those used condoms in all five out of their last five sexual acts. 62% of interviewed women reported to be married.
This FSW Targeted Intervention (TI) began in April 2010 and is funded by UNFPA. Jeevan Jyoti Health Service Society implements the project and technical support is provided by the Real Medicine Foundation India.
Summary of First Quarter
The program began with the following:
• Hiring and training of staff
• Establishments of Drop In Centers (DIC) for both the districts
• Preparation of staff training module and conducting staff trainings
• Baseline Survey and Assessment
• Commencement of intervention programs
Quarter I began with significant training of staff and baseline data collection. Directly following training, program staff began to outreach and counsel FSWs through fieldwork and utilizing their existing networks.
Second Quarter Results
In the second quarter of the FSW TI, the staff were predominantly in the field counseling and providing FSWs with information regarding the project, problems, availability of treatment, condom use and procurement, advocacy, purpose of the DIC and ICTC centers. Following the advice of NACO and MPSACS, refresher training was held in September 2010.
Regarding typology, the majority of sex work within the network of the TI occurs at home or in secret (67.6%), followed by highway (21.1%), multiple locations (7.5%), and street/public place (3.8%).
HIV testing is considered a main target of the project, however, as of the end of the second quarter, only 104 tests have been performed. Baseline data indicates increased desire for HIV testing in Nimach, but the lack of facilities and the location of the ICTC contributed to the low numbers of testing. Additionally, when FSWs went to the ICTC for testing, kits were unavailable. Jeevan Jyoti addressed this issue by informing and reminding MPSACS that HIV test kits were unavailable in Nimach and coordinating with the Nimach ICTC staff when kits were available for them to pick up. In Jhabua, Jeevan Jyoti runs an ICTC centre with testing kits available, but FSWs are not ready to come to get tested for HIV. Very few FSWs wanted to get tested for HIV and, of those, none felt comfortable coming in, as they feared public disclosure of their FSW status. JJHSS is addressing this issue by increasing counseling in both districts so that FSW feel more confident and comfortable with testing.
Health camps are one of the greatest opportunities for the staff to impress the FSWs and enhance relationships between clients and staff. Two camps were conducted in Quarter II of the program, both in Jhabua district. 64 individuals attended these clinics, in total, and 44 received treatment for STIs.
Condom Promotion and Distribution: 33,690 condoms were distributed in the second quarter, 19,100 in Nimach and 14,590 in Jhabua.
The traditional nature of sex work in the district of Nimach, along with the experience of FSWs with previous HIV/AIDS campaigns, made condom promotion easier there than in Jhabua. FSWs in Nimach district claim to use condom regularly, but were not able to demonstrate the possession of condoms by request during regular baseline data collection. FSWs in the area accept condoms from TI staff easily, publicly express their demand for condom, and come to the DIC to collect condoms. In the district of Jhabua, FSWs are reluctant to come together for common programs and have a tendency to only accept condoms on an individual basis, only after steady contact with peer educators and a feeling of security. High security alerts in Jhabua district contributed to the sharp decline in condom distribution in September.
Drop In Center: FSWs received counseling services at one of the two program DICs. Feedback from program staff indicates an elevation of requests for home-based counseling and testing services. Several staff members have taken this feedback and incorporated small, private, home-based gatherings for women to come and receive peer counseling.
FSW also complained about the cost of traveling to the DIC. While the DICs are both strategically located near large market and transit areas, many FSW who are based in villages are unwilling to travel to the DIC on a regular basis. While they may visit the town where the DICs are located (Meghnagar or Manassa) once or twice a week for market day, the women are usually too busy these days with errands and traveling with their families to discretely come to the DIC.
The Jhabua staff tried to increase DIC attendance by holding bi-weekly sewing, stitching, and embroidery classes at the DIC for any women in the community who wanted to attend, but specifically targeted towards FSW. Opening these classes to any women was a method to decrease the stigma that could possibly be associated. These classes were popular amongst women in the community, but unfortunately, only two out of 15 who regularly attend the class were FSW. The classes successfully decreased stigma associated with the NRC, but did not affect the FSW attendance at the NRC. The funding for this experiment was taken care of separately by another local NGO who donated the class materials and by RMF staff who taught the classes free of cost.
With the failure of these vocational classes to increase FSW attendance at the DIC, JJHSS is going to try more regular, fun activities to draw women to the DIC such as heena parties, beauty workshops, and movie screenings to create a sense of community at the DIC.
Community Linkages: Program staff is working to increase the linkages with existing facilities in the TI districts, to provide the most comprehensive network of support for health access to HRGs, through stakeholder meetings, program referrals, and networking.
Nimach district showed great success in linking with existing organizations such as the link-ART Center and the Network of PLHAs.
Second Quarter Activities:
STI Drug Procurement:
In July JJHSS placed an order for for STI medications for Jhabua and Nimach districts for gynecologist to use during the weekly STI clinics. JJHSS ordered the exact drugs used in the NACO “Color Coded Kits” in order to streamline the activities of the TI with ongoing activities. The drugs only arrived in late July, however, thus delaying the start of the weekly clinics.
In September Jeevan Jyoti Hospital was awarded a Public Private Partnership STI Clinic through MPSACS. Under this agreement, JJH will receive free color coded kits, IEC/BCC materials and testing reagents for STI management. Since free STI medications will not be available in Jhabua, JJHSS is transferring all the STI medications purchased through the UNFPA budget to Nimach where there is a higher demand for testing and less services available.
Flipbook Design: A flipbook demonstrating proper women’s health practices was designed, developed, and translated into Hindi. This project will be completed in the following quarter.
Bags for Peer Counselors: 18 bags were purchased and distributed for the Peer Counselors. These bags were specially designed for use in the field and contain their daily diary, condoms, and a penis model for condom demonstration. The bags were indigenous handicrafts made by local women. These bags will help women in the villages and marketplace identify our staff as “Ladies Health Workers.”
FSW Safe and Beautiful Kits: This Quarter, JJHSS created FSW Safe Sex kits. Modeled after successful programs in Mumbai and the US, these kits are meant to be functional IEC/BCC tools to encourage the practice of safe-sex, increase condom usage, and help create a sense of empowerment and trust amongst the FSW community and TI staff. 500 beauty kits were distributed among the FSWs of both the districts. The kit contains lipstick, condoms, kajal, Fancy Bindi, nail polish, hair band, and a beauty tattoo and the purses were designed and developed by local women.
The FSW responded very well to the “Safe and Beautiful Kits,” with at least 10 women showing up to the Nimach DIC on a regular basis with their bag asking for more condoms to fill it. At first some of the FSW questioned why we would be giving out such bags and wanted to know what JJHSS expected in return. When our staff explained to the FSW that the bags were meant as tokens for their health, then the FSW were glad to accept the kits. FSW agreed that they were more likely to carry a condom with them now that they had a convenient place to store them.
Penis Model for Condom Promotion: 20 penis models were constructed by a local woodworker, and are used by program staff to demonstrate proper condom usage and to assist with the development of condom negotiation strategies.
Advocacy, Networking and Crisis Response: Through the support of the existing HIV/AIDS programs, TI staff in NImach were able to host awareness programs, meetings, and training sessions. See Annex I for details.
FSW stakeholders: clients, community leaders, pimps: TI staff conducted awareness meetings and conferences for stakeholders, such as clients, community leaders, and pimps, suggesting the stakeholders assist and support the TI program and to encourage FSWs to come to the DICs and take the treatment services offered. See Annex I
Regional Capacity Building Workshop: In August a NACO team came to review our TI progress. After the review they suggested that our staff should have more “conceptual knowledge of the NACO TI Guidelines.” From this feedback we called MPSACS to suggest a trainer for bringing the staff up to speed on NACO’s TI Guidelines. A two-day training program was organized in the district of Jhabua for all twelve peer counselors and two district mobilizers. Mrs. Rashmy Vaibhav from MPSACS facilitated the training and went over program purpose, information, challenges, and solutions. Small group activities were employed to assist the staff to develop community-based solutions to challenges, and further knowledge was introduced in areas such as STIs, safe-sex practices, and condom negotiation. See Annex III for details.
Difficulty in Developing Trusting Relationship with FSWs
Even though Peer counselors are trying their best to develop relationships with FSWs through field-outreach and social networking, FSWs are not open to the peer educators and do not readily describe their problems. New FSWs connected with peer educators require a substantial amount of time and effort before the FSW is willing to approach the DIC or receive health services from the health clinics.
Sex work in Nimach district is open and tradition-based, and was expected to have higher numbers of FSWs registration than Jhabua district. However, counselor feedback indicates that it was a challenge for the staff to approach and develop relationships with FSWs. Due to experiences with previous TIs in the region, community members were afraid of the project and doubted the true program objectives. This was discussed in follow-up training sessions held in September, and solutions were proposed.
Interference of Field Based Activities
There were many challenges in quarter II that inhibited program staff from conducting field-based activities and had a significant impact on program results.
- Monsoon season caused many of the roads to be impassable for several weeks.
- Ten days of mandated Section 144 (in which no more than five people may gather in one place) prevented any gatherings of program staff or group activities.
- Security threats surrounding the Ayodhya Verdict called for program staff to remain within close vicinity of his/her home for the latter part of September.
- A multitude of Government holidays, both old and new, gave program staff many days off of work.
- While some challenges, such as monsoon season and government holidays, can be accounted for and planned for in the coming year, others, such as Section 144 and state-wide curfew, can not.
Data Collection Complications
Due to high levels of illiteracy amongst program staff, physical reporting has not been regular or accurate. However, the training of the peer educators and the experience from the field has increased their capacity for proper data collection. In order to collect the most accurate data, program staff has found that it is necessary to collect the data in person, by going through the physical reports and adjusting them along with the PE.
During the second quarter, a police raid of FSWs in Nimach prevented peer educators from going into the field. Prior permission from the government may be necessary for TI staff, in order to ensure the safety of field workers and their clients. This is also a key opportunity to highlight the legal rights for FSWs and to encourage the advocacy of program staff for the community members.
FSWs Unwilling to Disclose Clients
A challenge faced by program staff is accessing the clients of FSWs. Program staff have found it very difficult to develop trusting relationships with FSWs, thereby impeding the ability of the peer educators to access the FSW’s clients. Strategies must be developed to reach out to the clients with prevention activities, safe sex knowledge, and health service providers.
Staffing ComplicationsGiven the stigma surrounding the target population and other unforeseen circumstances, both Jhabua and NImach districts experienced staffing problems.
In Nimach district, five out of the six PEs have been employed since the beginning of the program and are doing good work. The 6th PE position has been difficult to fill however. The women who we hired initially worked for 2 months and then was forced to resign by her husband. Even after counseling the family we were unable to get her to stay. After she left, we have had 3 more PEs in this position and each person has left after 2-3 weeks for a variety of family reasons.
Next week JJHSS will be holding interviews to try to recruit a permanent PE for Nimach. We will ensure that the candidate is aware of all implications of working with this TI before they start and that their family is ready for them to work.
This next quarter JJHSS will focus on consolidating the advances made in the program so far and finishing the year by achieving our targets. Special attention will be paid to monitoring and evaluation to ensure that all the data we present at the end of the year is correct and that we can properly document our successes. Staff will be motivated to ensure that targets are achieved and that the quality of the program is maintained.
Activities will include:
- Condom distribution and female condom social marketing
- Weekly STI clinics for FSW at DICs in Nimach and Jhabua and increased referrals of clients to District Hospitals
- Preferred Care Providers Training
- Advocacy, networking, and stakeholder meetings, especially focused on clients
- Distribution and use of flip books by PEs for better IEC/BCC counseling
- Increased community activities at the DIC supplemented by mini-DIC activities in which meetings will be held and condoms distributed at the homes of FSW volunteers in key areas
- Hiring one district mobilizer for Jhabua and one PE for Nimach
- Cross learning visit for TI staff to experienced CBO led TI
- Documentation of activities, including external review by consultant for one month
Note on this online report: RMF has removed sensitive indicators, such as the exact number of FSW registered and identifying information on certain villages for the safety of our staff and the women we reach out to. RMF is committed to being transparent and sharing information, so if you are interested in obtaining this data, please send a request to RMFIndia@gmail.com.