KP-led HIV Prevention Programming That Achieves UNAIDS 95:95:95 Outcome Strategies: Ugandan KP Demography

Key Population-led and mentored formulation of HIV Prevention interventions in Uganda is both targeted and evidence-based driven as Well. But, what exactly are these interventions?

There are basic outcome strategies KP-led organizations in Uganda can adopt if they were to be effective change agents cascading into UNAIDS 95:95;95. 

Working hand on hand and allowing KP-led organizations in Uganda participate in verbalizing, designing, visibilizing and mainstreaming what works is commendable. It is the only sure way to also ensure PEPFAR HIV Preventions funds are well spent. Allowing them to access funding has leveled the HIV Prevention ground. This is commendable indeed.

For most of the organizations, it will be an opportunity for autonomy and self-directed agency. For the money to be spent on efforts to eradicate HIV, there is need to include self assessment. Researchers in Uganda who have sent over 20 years working with KP designed a 6W1H model (What, Who, Where, Why, When, Which & How).

This allows organizations to conduct readiness examination into how effectively they could operationalize or implement HIV Prevention services. 

The aim of this report is to link research into KP Programmatic interventions to quality health and evidence-based goals. With this model, KP-led organizations will devise and own ways to make HIV Prevention roll out to meet UNAIDS 2030 Goals.

An effective plan must maximize opportunities to meet UNAIDS 2030 Goals. This is possible when organizations go through participatory reflexive/deflective roles with the aim of creating optimizing activities for PEPFAR/KPIF funds to be spent on the outcome strategies:

Treatment 

• As far as TB/Malaria/Hepatitis/HIV what latest information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Prevention

• There is Primary, Secondary and tertiary Prevention. CBOs are more concerned with Primary Prevention. As far as TB/Malaria/Hepatitis/HIV is concerned, what latest prevention information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a Prevention strategy to serve my catchment area so well? Who exactly are we linking to Prevention Services as well as other social services? Who do we meet as far as Prevention social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Palliative care

• Palliative care interventions are the kind where an organization set aside time, resources and money to engage in activities that relieve symptoms and stress among beneficiaries living with long-term debilitating illnesses. What latest information, Education, Communication (IEC) on Palliative Care does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources on Palliative Care necessary for TB/Malaria/Hepatitis/HIV eradication? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Abstinence-until-marriage programmes

• As far as abstinence goes, what latest information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources eradicating in linking abstinence to TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

OVC/Youth-Headed Households below 18 years

• This area requires working with Ministry of Gender, Development & Social Development, Religious Organizations and other support CSOs. What latest information, Education, Communication (IEC) does my organization have on social development issues and concerns? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking social issues to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Delay of sexual debut

• This is a behavioural aspect very much connected to vulnerability and susceptibility chain (VASC) risks to HIV/Hepatitis/TB/Malaria. What latest information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking delaying sexual debut to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Monogamy

• This is a behavioural aspect also known as Zero-grazing. It is encouraged because it is thought having one sexual partner  lowers risk to acquiring or transmitting infections. What latest information, Education, Communication (IEC) does my organization have on monogamy? What does my Social Activities Map (SAM) show as far as a monogamy strategy goes to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking monogamy to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Fidelity

• This is a behavioural aspect in which commitments and agreements are made. It is known to highlight partner support practices (PSP) such as attending life preserving sessions with a partner. When partners attend education sessions together it builds bonding and  focus to achieve goals. What latest information, Education, Communication (IEC) does my organization have on fidelity? What does my Social Activities Map (SAM) show as far as a fidelity strategy goes to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking fidelity to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Counselling geared at increasing events where sex with partner is with any kind of HIV prevention method (that is with a condom, PrEP or an undetectable viral load)

• This is a milestone prevention skills development opportunity that involves committing to  life promoting or prevention activities. It is known as Prehensile Prevention Prophylactics Affirmation (PPPA). It is encouraged because use of prevention lowers risk to acquiring or transmitting infections. What latest information, Education, Communication (IEC) does my organization have on Prevention methods ? What does my Social Activities Map (SAM) show as far as Prevention methods strategy goes in order to serve my catchment area so well? Who exactly are we linking to Prevention methods counseling and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking Prevention methods to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Partner reduction activities in any host country with a generalized (high prevalence) epidemic

• This involves avoiding toxic and precarious practices as well as deliberately reducing sexual partners. It is also best practice to familiarize yourself with country-based guidelines on how to address high prevalence. Such guidance is available from MoH and Development Partners. What latest information, Education, Communication (IEC) does my organization have on prevalence? What does my organization do to access guideline in order to serve my catchment area so well? Who exactly are we linking with? Where do we get our resources? Why do we spend time, money and resources linking resources to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

There are over 107 KP organizations scattered in all over Uganda. 44 (and counting) of these also defined as sexual minorities and are registered with the Uganda KP Consortium. 

A rapid appraisal of HIV Prevention Strategies of 23 of these between 2017-2020 shows the following:

1. 14/23 of these have positioned themselves strategically for HIV Prevention but their capacity lies in the following areas: Humans Rights/Litigation Advocacy; Condom and Lubricant sourcing and distribution
2. 2/23 had conducted internal 3-5 internal meetings or short trainings for staff and during the events tasked the staff to give out Condoms and Lubricant consumables. 
3. 35/44 are Kampala-based KP-led organizations, which means they are overlapping in the catchment zone. Two (2) were Kampala-based but had outreach stations 100 miles out of Kampala City. Outreaches are a good way to put HIV Prevention facilitation to good use. There is need for deciding on zoning here.

PEPFAR And Global Fund, A History:

The U.S. is the single largest donor to the Global Fund. Congressional appropriations to the Global Fund totaled $16.6 billion from FY 2001 through FY 2018. The Global Fund provides another mechanism for U.S. support by funding programs developed by recipient countries, reaching a broader range of countries, and supporting TB, malaria, and health systems strengthening (HSS) programs in addition to (and beyond their linkage with) HIV. To date, over 150 countries have received Global Fund grants; 53% of Global Fund support has been committed to HIV and HIV/TB programs, 29% to malaria, 16% to TB, and 2% to other health issues. The original authorization of PEPFAR, and subsequent reauthorizations, included a limit on annual U.S. contributions to the Global Fund that prevented them from causing cumulative U.S. contributions to exceed 33% of the Global Fund’s total contributions; this requirement is in effect through FY 2023.

Aligning  And Stepping Up The HIV Prevention By KP:

It is clear that KP-led organizations need to be supported in realistic HIV Prevention programming and the outcome strategies below need to be mainstreamed if UNAIDS 95:95:95 goals are to be met.

1. Treatment
2. Prevention
3. Palliative Care
4. Abstinence-until-marriage programmes
5. OVC/Youth-Headed Households below 18 years
6. Delay of Sexual debut
7. Monogamy
8. Fidelity 
9. Counselling geared at increasing events where sex with partner is with any kind of HIV prevention method (that is with a condom, PrEP or an undetectable viral load)
10. Partner reduction activities in any host country with a generalized (high prevalence) epidemic

The Link Between Violence Against Women and Children And Quality of RMNCAH Outcomes In 8 African Countries

Background: Effective and quality RMNCAH outcomes are linked to reduced risk to violence. This study explored negative stereotypes of hegemonic masculinity and the social structures linked to it. An exploration of 8 Sub-Saharan African countries found 3 country-specific definitive social structures impacting the stereotypes, i.e., Enabling; Restrictive; and Hindering structures.

Methods: A meta-analysis of data from 2015-2019 of relationship between violence against women and children, is reflected in: Trauma Informed Care (TIC); comprehensive RMNCAH strategies such as IMNI, A/PNC, KMC, perinatal death review, and/or integrated maternal and perinatal death surveillance and response (MPDSR) processes; enforcement of legal gender equality; religious and traditional support for respect and dignity of women; uptake of gender-specific prevention services; Domestic Violence (DV) reports and HIV Prevention. 170 articles and reports were identified but 80 met inclusion criteria.

Results: Stereotypes of hegemonic masculinity exist in all 8 countries studied. Politics, religion and tradition influence risk reduction, e.g., enforcement of legal gender equality, political commitment and accountable judiciary ensure women can report abuses. Male dominance beliefs; traditions e.g. precarious toxic masculinity, indifference to expectant mother health by males, stigmatization of frequent clinic visits; and gender of breadwinner are linked to violence-related risks. Compared to all 8 countries, Rwanda, Ethiopia and Kenya have a hindering structure promoting significant risk reduction with institutions fostering increased rule of law, political commitment to RMNCAH outcomes, enforcement and risk-reduction consciousness. Uganda and Tanzania have a restrictive structure characterised with legal loopholes, irregular enforcement and ambivalent political commitment to address acts of violence against women and children. In Senegal, South Africa and Nigeria political, religious and traditional factors blatantly backing traditional negative stereotypes of hegemonic masculinity foster violence enabling structures entrenching repressive acts and hate crimes against women and children. In all countries however, Delivery room reception; level of Health Information Management skills; HIV criminalization; affinity and sensitivity to quality health by all people; stigma around attending clinics by males; negotiating for safer sex by women which is circumscribed as a threat to male dominance, subvert or support optimal RMNCAH goals.

Conclusions: Justice dispensation, economic autonomy, religion and traditional backing contribute effectively to risk-reduction. Contexts hindering violence prevail where state-led commitment thrives and these have far reaching benefits e.g., more people benefit from RMNCAH outcomes. Effective and quality RMNCAH programming in the countries studied will be effective if it is designed to address hegemonic masculinity practices too. Mortality implementation audits need to be disaggregated to reflect causes of and contributing factors to deaths.

The Link Between Violence Against Women and Quality of HIV Programming in 8 African Countries

Background: Effective and quality HIV programming is linked to reduced risk to violence. This study explored negative stereotypes of hegemonic masculinity and the social structures linked to it. An exploration of 8 Sub-Saharan African countries found 3 country-specific definitive social structures impacting the stereotypes, i.e., Enabling; Restrictive; and Hindering structures.

Methods: A meta-analysis of data from 2013-2017 of relationship between violence and comprehensive combination HIV prevention strategies, political commitment, rule of law, enforcement of legal gender equality, religious and traditional support for respect and dignity of women, uptake of gender-specific prevention services, Domestic Violence (DV) reports and HIV trends. 175 articles were identified and 80 met inclusion criteria.

Results: Stereotypes of hegemonic masculinity exist in all 8 countries studied. Politics, religion and tradition influence risk reduction, e.g., enforcement of legal gender equality, political commitment and accountable judiciary ensure women can report abuses. Male dominance beliefs; traditions e.g. precarious toxic masculinity, forced marriage, genital cutting; and gender of breadwinner are linked to violence-related risks. Compared to all 8 countries, Rwanda, Ethiopia and Kenya have a hindering structure promoting significant risk reduction with institutions fostering increased rule of law, political commitment, enforcement and risk-reduction consciousness. However, HIV criminalization and stigma subvert risk-reduction goals. Uganda and Tanzania have a restrictive structure characterised with legal loopholes, irregular enforcement and ambivalent political commitment to address acts of violence against women. In Senegal, South Africa and Nigeria political, religious and traditional factors blatantly backing traditional negative stereotypes of hegemonic masculinity foster violence enabling structures entrenching repressive acts and hate crimes against women. Clinical trials and male medical circumcision (MMC) in the 8 countries are poorly received. Negotiating for safer sex by women is circumscribed as a threat to male dominance.

Conclusions: Justice dispensation, economic autonomy, religion and traditional backing contribute effectively to risk-reduction. Contexts hindering violence prevail where state-led commitment thrives and these have far reaching benefits e.g., more people engage in clinical trials, TB prevention, Hepatitis screening and immunization. Political and legal commitment are key in violence risk reduction. Effective and quality HIV programming in the countries studied is possible if it is designed to address hegemonic masculinity practices too.