Transcript Key Population Trainings of Healthcare Workers in South Africa

Reaching the Unreached
Service Uptake and Retention Among
Marginalised Populations
Workshop
Wednesday 20th July
11:00am – 12:30pm
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Key Population Sensitisation
Training for Health Care Workers in
South Africa
Zoe Duby
Research affiliate
Desmond Tutu HIV Centre
Cape Town, South Africa
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Who, What & Why?
• Specific populations characterised by:
– Disproportionate risk for HIV infection & consequences
– Often stigmatised, excluded from society – largely due to
criminalisation of certain behaviours, societal stigma & discrimination
– Lack access to appropriate health services
– Subject to complex structural, social & individual risk factors
• For public health purposes, these socially marginalised groups are termed
‘Key Populations’ (KP):
– Form part of general population & have many overlapping needs
– Not epidemiologically separated but do have unique impact on both
concentrated & generalised HIV epidemics
• In this presentation we refer specifically to:
–
–
–
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Men who have sex with men (MSM)
People who use drugs (PWUD)
Sex Workers (SW)
A note on terminology
• MSM refers to sexual BEHAVIOUR (men having sex with men)
• Many MSM specifically in South Africa do not identify as gay /
bisexual / homosexual
– ‘Hidden MSM’ (i.e. married ‘straight’ men with female partners)
– ‘Situational MSM’ (i.e. prisoners, miners – who identify as ‘straight’
and are heterosexual but have sex with other men due to
situations)
– Hidden MSM are hard to reach & at risk as they will not / cannot
access services / info specifically targeting MSM
• While South African Constitution does not discriminate directly
against anyone on grounds of sexual orientation, in reality, MSM
continue to be stigmatised & discriminated largely because their
behaviour deviates from social norm, and homoprejudice is
widespread
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Commonalities / Overlapping Risk factors
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South African context
• South African HIV epidemic diverse
• Within generalised national epidemic are several concentrated
sub-epidemics
• MSM, SWs & PWUD experience disproportionately high burden
of HIV but face multiple barriers accessing health care
• Limited focused services & barriers (including discrimination by
health & other service providers) contribute to risk, onwards
transmission & poor health outcomes
• Socio-economic factors, including poverty & marginalisation
contribute to increased vulnerability to HIV & TB
• Exclusion of certain groups at increased vulnerability to HIV
undermines national HIV response
• Interventions addressing specific needs of key populations are
effective in reducing HIV incidence in general population
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What do we know about these Key
Populations in South Africa?
SEX WORKERS
•
•
Estimated 153,000 individuals in South Africa make a living in the sex industry
(SWEAT, 2013)
HIV prevalence among female sex workers in major metropolitan cities estimated
range between 39.4% - 71.8% (Konstant et al., 2015; Scheibe et al., 2016)
MEN WHO HAVE SEX WITH MEN
•
•
No national MSM size estimate exits
HIV prevalence is estimated between 22.3% - 48.2% among MSM in three largest
metropolitan areas (UCSF, 2016)
PEOPLE WHO USE DRUGS
•
•
Population of PWUD not quantified, but modelling study estimated by 2010 there
were 67,000 people who inject drugs (PWID) in South Africa (Petersen et al., 2013)
Only multi-city HIV prevalence survey conducted among PWID found overall
prevalence of 14% (Scheibe et al., 2016)
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Health Care Context
• When KP manage to access health services, those provided in public
sector health system often inappropriate / insensitive:
– Clinic opening hours unsuitable, particularly for SW
– Healthcare providers taking ‘abstinence only’ approach to managing
substance use
– Lack of standard routine risk assessment tools enquiring about sex
work and penile-anal intercourse
– Limited availability of targeted support groups
– Limited availability of harm reduction services including needle and
syringe programmes
– Despite early focus on preventing HIV and STI transmission amongst
SW, few scaled-up targeted interventions have been implemented in
sex work settings, or amongst PWUD
• HIV testing rates are low amongst KP and, timely access of health
services enabling viral suppression for those living with HIV is poor
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South Africa Key Population
Stakeholder Consultation 2011
• Discrimination, prejudice & moralloading by healthcare workers towards
MSM, SW & PWUD is major barrier to
accessing health services & result in
substandard healthcare provision
• KP reluctant to disclose practices due
to fear of:
– Discrimination
– Confidentiality breaches
– Arrest
• HCW lack professional training on
specific health needs of KP, lacking
appropriate skills & knowledge –
inadequately equipped to provide
services
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Identifying a need
• Advocates, service providers & researchers identified need for
increased HCW awareness of issues affecting KP
• Need to build HCW capacity to provide evidence-based, competent
and appropriate services
• Health workers sensitised around issues affecting MSM, SW &
PWUD are also empowered to appropriately engage with other key
populations
• National Strategic Plan on HIV, STIs and TB 2012–2016:
– Health care services need to be responsive
– KP identified as being at greater risk for being infected by or transmitting HIV
when compared to general population
• Operational Guidelines for HIV, STI & TB Programmes for Key
Populations in South Africa:
– Identified HCW sensitisation training as essential intervention to address
these barriers
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Desmond Tutu HIV Foundation’s HCW
Sensitisation training programmes
Introductory trainings to educate &
sensitise HCWs to provide sensitive,
appropriate, relevant, non-discriminatory
and non-judgmental services focusing on:
- MSM
- Sex Workers
- PWUD
MSM trainings
– 2 editions of training manual
(published 2009 & 2011)
– 592 HCW trained across South Africa
between February 2010 and May 2012
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Sex Worker and PWUD trainings
388 HCW trained: March – August 2012
• 10 SW training workshops, reaching 211 HCW at 33 organizations
• 8 PWUD training workshops, reaching 177 HCW at 18 organizations
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Key Population Trainings of Healthcare Workers in South Africa
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‘Integrated Key Populations Sensitivity Training
Programme for Healthcare Workers in South Africa’
‘Healthcare Provision for Men who have
Sex with Men, Sex Workers, and People
who use Drugs: An Introductory Manual
for Healthcare Workers in South Africa’
- Published November 2013
- Developed in partnership with National
Department of Health & South African
National AIDS Council
- Included topics:
-
Social norms and values
Human sexuality & sexual behaviour
Legal & rights context
Socio-structural marginalisation &
prejudice
- Interventions to foster enabling
healthcare environments
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AVAILABLE FOR DOWNLOAD
Integrated Key Population Training Pilot
OBJECTIVES
• Develop sustainable training initiative, including framework for on-going
mentorship, for use by Department of Health for widespread implementation
through regional training centres (RTCs)
• Training materials covered issues relating to HIV, TB and STIs – flexible, client
focused & enable HCWs to employ non-judgmental language and attitudes
when working with MSM, SW & PWUD
• Multi-partner project, led by South African National AIDS Council & South
African Department of Health
ROLL-OUT
• Training of Trainers (TOT) October 2013
• 1 day sensitisation-training programme for HCW
• 405 HCW trained October 2013 - July 2014
• 5 South African provinces: Eastern Cape, Free State, Kwa-Zulu Natal, Limpopo
& Northern Cape
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Evaluation of Pilot Integrated Key Pop Training
• Evaluation of pilot sensitisation training compared 2 provincial capitals:
– Bloemfontein (Free State) – training rolled out
– Mafikeng (North-West) – no training intervention implemented
• Evaluation research conducted October 2013 - July 2014
EVALUATION METHODS
• Mixed-methods evaluation research to assess changes in HCW attitudes
towards KPs & changes in awareness of and capacity to manage KPspecific health due to training
• Qualitative IDIs at 2 time points: “baseline” & “3 months post-training”
with sub-sample of HCW who had received training & HCW who had
not received training
– Interviews explored HCW attitudes towards KP, knowledge levels around
specific health needs & vulnerabilities of KP, as well as awareness of
barriers to KP accessing health services.
• FGDs with members of SW, MSM & PWUD
• HCW who participated in training completed pre & post-training
questionnaires – quantitative data
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Evaluation Findings
BASELINE FINDINGS:
• Discrimination affecting KP in communities & at health facility level
• HCW described own judgemental attitudes towards KP
• HCW lacked relevant knowledge, skills or training to manage particular
health needs & vulnerabilities facing KP
• Evidence-based HIV prevention commodities aimed at KP not available in
these areas
• Provides evidence for need to sensitise HCW in South Africa to needs &
health risks of MSM, PWUD & SW
TRAINING EVALUATION FINDINGS:
• Increased HCW knowledge & awareness relating to health needs of KP
• Reduced judgemental attitudes towards KP
• Resulted in HCW feeling more skilled to provide appropriate & sensitive
services to KP
• On-going need to include in-service & pre-service training
(PAPERS IN PUBLICATION)
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Self-perceived attitude shifts of HCW
After… the training (we realized) that… when they come here (to the health
facility) they must feel welcome. They must be like any other patient, we must
treat them equally. When a person comes here to share their problems they must
not be scared to say that I am a sex worker because they are afraid of how I will
react, what I will say to them and if I will judge them… I must listen to their story
and understand what their problem is… because they are also people, we don't
have to isolate them in society, we must treat them like all the other people.
(HCW, Free State, follow-up IDI)
I can welcome them (KP) properly because I used to think that they are just
naughty before the training. I found out that they are not naughty, at times as a
woman you get feelings for other women and as a man you get feelings for other
men… I can welcome them because now I know what the problem is. They did not
choose… I have learned… not to discriminate them, to end stigma, social stigma.
(HCW, Free State, follow-up IDI
(The training) opened my eyes, (before) I would see them but I didn't understand
them…my attitude has changed. (HCW, Free State, follow-up IDI)
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Challenges of pilot programme
• Limited support from DoH - training only took place when external funding
was in place, most work & impetus by CSOs and donors
• No clearly defined criteria for participation used to select participants
• No clear tool/ guidelines developed to assess competence of trainees
• RTC trainers not equipped / sensitised themselves: limited time to TOT
properly: training time taken up with ground level sensitisation and
information provision – rather than facilitation skills
• Limited to in-service training, pre-service curriculum unchanged
• Once-off training, no commitment to on-going support
• Poor representation from RTCs (especially Limpopo and Northern Cape)
• Very full classes
• Commitment by TOT trainees limited, little support from RTCs provided
• Pulling trainers from all provinces together challenging for travel logistics
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Successes
• Efficiency of coordinated, multi-partner approach to develop
evidence-based, appropriate materials
• HCW sensitisation fostered enabling environments & increased
health service access for MSM, SW and PWUD
• KP community members have reported improvements in HCW
attitudes towards KPs in areas where sensitisation training provided
• Linking of sensitisation training with peer-based outreach &
prevention activities increased KP community trust & use of health
facilities working with KP-focused civil society organizations
• Integration of issues affecting MSM, SW and PWUD enabled HCWs to
engage with trainers around cross-cutting issues
• Established forum where partners can participate in coordinating and
standardising sensitisation training
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Recommendations
• Better coordination needed between training planners
& provincial departments of health (e.g. HAST) to
ensure correct target audience attend trainings
• Training should include skills development around
clinical management as well – this training was only
‘sensitisation’ focusing on knowledge and attitude
• Government training structures (RTCs) are ideally
suited to provide on-going sensitisation training,
however capacity needs to be built and supported
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Conclusions
• KP need to be successfully engaged in health system to improve uptake,
access & utilisation of services, by creating enabling environments where
non-discriminatory services are provided
• High degree of support & commitment from government, AIDS structures,
development partners and civil society organisations can enable successful
sensitisation training programmes
• Criteria for participation in TOT workshops can increase the likelihood of
selecting and training the right people
• Partner coordination & stakeholder commitment can enable skills,
knowledge sharing & standardisation - essential for scale-up &
sustainability
• Building capacity of sensitised HCWs to competently provide appropriate
services for MSM, SW and PWUD (inclusive of mentorship & on-going
support) is next step towards meeting HIV prevention, treatment, care &
support needs of MSM, SW and PWUD
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Partners & Acknowledgements
Development & pilot of integrated training:
AMSHeR, Bonela, COC Netherlands, Desmond Tutu HIV Foundation, ICAP Columbia
University Mailman School of Public Health, the United States Centers for Disease
Control and Prevention (CDC)/ United States Presidents Emergency Plan for AIDS
Relief (PEPFAR), FHI360, Mainline, the National Department of Health, NACOSA, OUT
LGBT Well Being, South African National AIDS Council and Sex Workers Education and
Advocacy Taskforce (SWEAT).
The pilot project built on the tools and experience of:
OUT LGBT Well Being, Desmond Tutu HIV Foundation, ICAP, ANOVA Health Institute,
SWEAT and the National Department of Health
Zoe Duby, PhD
Research Affiliate
Desmond Tutu HIV Centre
University of Cape Town
[email protected]
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