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JOB AID FOR HEALTHCARE PROVIDERS WORKING WITH KEY POPULATIONS MINIMUM SERVICE PACKAGE FOR KEY POPULATIONS

KEY POPULATIONS JOB AID

FOR HEALTHCARE WORKERS

JUNE 2018

ISBN: 978-0-7974-9491-6

Ministry of Health & Child Care

Kaguvi Building, 4th Street & Central Avenue, Harare

P.O. Box CY 1122, Causeway Harare

Tel: +263-24-2798 537-60 | Fax: +263-24-2729 154/ 2793 634

E-mail: pr@mohcw.gov.zw

Website: www.mohcw.gov.zw

INDEX

● Introduction to Supporting Key Populations 5 ● Supporting Men Who Have Sex With Men (MSM) and Gay Men 7 ● Supporting Lesbians and Women Who Have Sex with Women (WSW) 9 ● Supporting Bisexuals 11 ● Supporting Transgender and Intersex People 13 ● Supporting Sex Workers 15 ● Supporting Drug Users, Including People Who Inject Drugs 17 ● Supporting Key Populations through Community-based Outreach 19 ● Positive Prevention for KPs Living with HIV 21 ● Importance of Targeted Care, Support & Treatment Services 23 ● Making Your Facility KP Friendly: Referral Pathways 25

Introduction to Supporting Key Populations

Who Are Key Populations?

For the purposes of this training, key populations (KPs) in Zimbabwe are defined as: male and female sex workers (SWs); men who have sex with men, including men in prisons and other closed settings (MSM); people who use and/or inject drugs, (PWUD, PWID); transgender and intersex people (TI).

Why Do KPs Need Targeted Support?

It is a national public health and human rights imperative that all persons, especially those most at risk, have optimal access to health services to ensure they enjoy the right to the highest attainable standard of health. The sexual and reproductive health rights of key populations are protected by Zimbabwe’s Constitution Amendment (No. 20) ACT 2013 (under Chapter 2 Section 29 and Chapter 4 Section 76).

What Minimum Services are Recommended at Your Health Facility?

● Testing & treatment for: HIV; sexually transmitted infections (STIs) & TB; care & support services and/or referrals (including provision of male & female condoms and lube).

● Freely available targeted sexual & reproductive health (SRHR) information, education and communication materials.

● Essential services such as voluntary medical male circumcision (VMCC), contraceptive advice, hepatitis screening, vaccinations for human papilloma virus (HPV) – also for MSM – mental health counselling & support; cancer screening.

● Community outreach to encourage service uptake towards achieving Zimbabwe’s 90–90–90 targets. The material here has been adapted from PEPFAR’S Technical Guidance on Comprehensive HIV Prevention, May 2011.

Supporting Men Who Have Sex With Men (MSM) And Gay Men

HIV Prevention

When taking a sexual history, always ask about:

● condom use and condom compatible lubricant, especially when having anal sex, as well as any other HIV and STI prevention methods.

● known HIV and STI status of the client and of their sexual partners.

● number of sexual partners over the last six months.

● whether they also have female sex partners and recommend VMMC.

● drug and alcohol use.

Discuss HPV vaccination.

HIV & STI Treatment

● Carry out a triple site investigation; follow up with any diagnostics and treat as indicated. ● Advise on antiretroviral treatment (ART), and pre-exposure prophylaxis (PreP) as relevant. Also discuss the value of post-exposure prophylaxis (PEP) for those who are HIV negative.

General Care & Support

● Ask if they are part of a support network; if not refer to the contacts at the back of this job aid. General Counselling

● For suspected mental health issues consider applying the Shona Symptom Questionnaire.

Supporting Lesbians And Women Who Have Sex With Women (WSW)

HIV Prevention

Ask about:

● condom use and condom compatible lubricant with sex toys; use of finger cots and dental dams, as well as other HIV and STI prevention methods.

● known HIV and STI status of the client and of their sexual partners.

● number of sexual partners over the last six months.

● whether they also have male sex partners?

● drug and alcohol use.

HIV & STI Treatment

● Carry out a triple site investigation; follow up with any diagnostics and treat as indicated. ● Advise on antiretroviral treatment (ART) and pre-exposure prophylaxis (PreP) as relevant. Also discuss the value of post-exposure prophylaxis (PEP) for those who are HIV negative.

● Advise on contraceptive use if they also have sex with men.

Care & Support

● Ask if they are part of a support network; if not refer to the contacts at the back of this job aid.

Counselling

● For suspected mental health issues consider applying the Shona Symptom Questionnaire.

Supporting Bisexuals

HIV Prevention

Ask about:

● condom use and condom compatible lubricant including with sex toys, and especially when having anal sex; use of finger cots and dental dams, as well as other HIV and STI prevention methods. ● known HIV and STI status of their sexual partners.

● number of sexual partners over the last six months.

● drug and alcohol use.

Suggest VMMC for bisexual men.

HIV & STI Treatment

● Advise on contraceptive use for bisexual women.

General Care & Support

● Ask if they are part of a support network; if not refer to the contacts at the back of this job aid.

General Counselling

● For suspected mental health issues consider applying the Shona Symptom Questionnaire.

Supporting Transgender And Intersex People

Always ask transgender people their preferred gender (he/ she/ they) regardless of how they present. Also make sure you ask for and use their preferred name, as opposed to the one that may be on their official documents. HIV Prevention

Ask about:

● condom use and condom compatible lubricant, including with sex toys, and especially when having anal sex; use of finger cots and dental dams, as well as other HIV and STI prevention methods. ● known HIV and STI status of the client and of their sexual partners.

● number of sexual partners over the last six months.

● whether they are using hormones for transitioning purposes and if so, whether they plan/ hope to proceed with medical transitioning (surgery). Seek specialist support if hormone therapy is being used or check the following online resource- https://www.hiv-druginteractions.org/drug_queries/neww

● drug and alcohol use.

Suggest VMMC for male-to-female transgender clients.

HIV & STI Treatment

● Advise on contraceptive use for female-to-male transgender people if they also have sex with men. General Care & Support

● Ask if they are part of a support network; if not refer to the contacts at the back of this job aid. General Counselling

● For suspected mental health issues consider applying the Shona Symptom Questionnaire.13

Supporting Sex Workers

Remember that sex workers may be male, female or transgender. Their sex partners may also be of any gender.

HIV Prevention

Ask about:

● number of sexual partners over the last six months.

● drug and alcohol use.

Suggest VMMC for male sex workers.

HIV & STI Treatment

● Carry out a triple site investigation and follow up with any diagnostics and treat as indicated. ● Advise on antiretroviral treatment (ART), and pre-exposure prophylaxis (PreP) as relevant. Also discuss the value of post-exposure prophylaxis (PEP) for those who are HIV negative.

● Advise on contraceptive use.

General Care & Support

● Ask if they are part of a support network, if not refer to the contacts at the back of this job aid. General Counselling

● For suspected mental health issues consider applying the Shona Symptom Questionnaire.

Supporting Drug Users, Including People Who Inject Drugs

HIV Prevention

Ask about:

● whether they inject drugs and what drugs they use.

● condom use and condom compatible lubricant, as well as other HIV and STI prevention methods. ● known HIV and STI status of the client and of their sexual partners.

● number of sexual partners over the last six months.

Suggest voluntary medical circumcision for male drug users.

HIV Treatment

● Advise on contraceptive use.

General Care & Support

● Ask if they are part of a support network, if not refer to the contacts at the back of this job aid. General Counselling

● Advise on the risks of sharing unsterilsed needles for those who inject drugs.

● For suspected mental health issues consider applying the Shona Symptom Questionnaire. ● Advise on the signs and symptoms of hepatitis (all forms).

Supporting Key Populations Through Community-based Outreach

● Disseminate HIV and gender-based violence (GBV) risk reduction information and targeted media.

● Distribute barrier methods including the female condoms, dental dams, condoms and condom-compatible lubricants.

● Train on correct use of barrier methods.

● Provision of referrals and linkages to HIV testing and GBV prevention programmes, drug & alcohol treatment, mental healthcare, HIV care & treatment, non-discriminatory prevention and treatment services that are responsive to the needs of sexual minorities.

● Referrals to key population-affirmative service providers in cases of rape and sexual GBV. ● Work with KP volunteers to reach KP communities and build trust.

● Meet regularly with KP representatives/ clients to get feedback on services.

Positive Prevention For KPs Living With HIV

● Counselling in general, and specifically for serodiscordant couples.

● Inclusion of lesbian, gay, bisexual, transgender & intersex (LGBTI) people living with HIV in all interventions. ● HIV counselling and testing.

● Increased access to HIV testing is critical in reducing the spread of HIV among key populations and their sex partners, and in facilitating access to appropriate healthcare for HIV-positive individuals.

● HIV counselling and testing programmes for key populations should establish strong linkages with other HIV prevention health service providers & clinics that can deliver appropriate healthcare and treatment in a manner that is responsive to the needs of HIV-positive of sexual minorities and that maintains their confidentiality.

● Link HIV testing & counselling (HTC) to outreach.

Importance of Targeted Care, Support & Treatment Services

● Timely access to life-saving healthcare, ART and opportunistic infection prophylaxis has very clear and powerful effects on the health and well-being of people diagnosed with HIV.

● Efforts to provide HIV-positive sexual minorities with access to timely and appropriate HIV care and ART should form part of a comprehensive HIV strategy.

● Comprehensive counselling and trauma debriefing services.

● Targeted information, education and communication (IEC) seeks to: improve HIV knowledge and awareness; promote beliefs, attitudes, and norms that reduce risk; build skills and self-efficacy; and motivate: HIV testing; changes in substance abuse; and sexual practices; and promote other behaviours that reduce HIV and AIDS risk. This includes: evidence-based community, small-group, and individual behavioural interventions; peer education; and the development & distribution of targeted media as part of outreach efforts; HIV testing & counselling; behavioural interventions; and social marketing campaigns.

● Management of STIs.

● Sexually transmitted infections significantly increase the risk of HIV transmission and acquisition.

● Information and education on prevention of STIs should be included as part of a comprehensive package of services

● The improvement of accessibility to and quality of STI prevention & screening; timely provision of STI results and of STI treatment for sexual minorities is of utmost importance.

Making Your Facility KP Friendly: Referral Pathways

Zimbabwe Civil Liberties and Drug Network

Supporting Drug Policy reform, Harm Reduction and Prevention St Barbra House,

Cnr Nelson Mandela and Leopold Takawira,

Harare

(024) 761122

GALZ, An Association PG LGBTIQ

People in Zimbabwe Supporting the health, rights and welfare of KPs 35 Colenbrander

Milton Park

Harare

(024) 741736

Hands of Hope