Dr Jayadarie Ranatunga, Consultant Venereologists, Teaching Hospital, Ragama

1. Dr Jayadarie Ranatunga
Consultant venereologist
North Colombo Teaching Hospital
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2. Outline of the presentation
Definition of key populations , country context and
their importance
The importance of MSM to the Sri Lanakan epidemic
 Comprehensive care for MSM
Access to STI services
Commonly identified barriers
Novel methods to overcome barriers
Some key points in overcoming barriers
Success story of the peer escort model
Challenges in peer escort and out reach models 2

3. Definition of key populations with
regard to HIV
Epidemiologically, the group faces increased risk,
vulnerability and/or burden with respect to HIV due
to a combination of biological, socioeconomic and
structural factors
 Access to relevant services is significantly lower
for the group than for the rest of the population
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4. Key populations
The group faces frequent human rights violations,
social and economic marginalization and/or
criminalization which increases vulnerability and risk
with reduced access to essential services.
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5. Who are key populations in the context of
HIV ( At risk and vulnerable)
Female sex workers (FSWs)
Male sex workers (MSWs)
Injecting drug users (IDUs)
Men having sex with men (MSM)
People infected with HIV
People affected by HIV
 HIV orphans, uninfected partners of sero- discordant couples.
Beach boys
Prisoners
 Sexual minority groups
 Socially marginalized (eg Lesbians, Transgender, )

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6. Key populations are important
In many low- and middle-income countries, key
populations face HIV prevalence rates that are 15-25%
higher than the surrounding general populations.
The HIV prevalance among MSM in Sri Lanka is 0.88
 UNAIDS (2012). Report on the global AIDS epidemic. Available:
http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiol-ogy/2012/gr20
 IBBS -2014
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7. General target
• About 60%of MARPs need to adopt safer behaviours
if HIV epidemics are to be reversed
• To achieve that level of behaviour change, service
coverage has to reach at least 80%
(MDG 6)
Report of the commission on AIDS in Asia 2008
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8. MSM are an important key
population in most of the
countries
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9. The importance of MSM to the Sri Lankan
epidemic
Sri Lanka is classified as a country with a low level
epidemic of HIV with an estimated HIV prevalence of
less than 0.1% among adults (15-49 years).
In low level epidemics, the key strategy for scaling up
HIV prevention, treatment and care is targeting key
populations.
The NSACP has identified this group in the national
strategic plan.
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10. What is included in
comprehensive care for MSM
Aims of providing comprehensive services for MSM
Minimize the transmission of HIV
Reduce HIV related
1.Mortality
2. Morbidity
3.Stigma and discrimination.
Which contribute to the attainment of the three
Zeros: Zero new HIV infections, Zero
discrimination, and Zero AIDS-related deaths.
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11. Human rights and inclusiveHuman rights and inclusive
environmentsenvironments
Good Practice
Individual Sexual BehaviouralIndividual Sexual Behavioural
Non-discrimination in health-Non-discrimination in health-
care settingcare setting
HIV Testing and CounsellingHIV Testing and Counselling
Behavioural interventions and IECBehavioural interventions and IEC
Substance use,Substance use,
prevention of blood-borne infections,prevention of blood-borne infections,
male circumcisionmale circumcision
HIV care and treatmentHIV care and treatment Prevention and care of other STIsPrevention and care of other STIs
Prevention
HTC
Care
Provision of comprehensive care
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12. The Comprehensive Package
of MSM and TG Services
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Strategic InformationStrategic Information
AdvocacyAdvocacy
Legal FrameworksLegal Frameworks
PolicyPolicy
Relationships with gatekeepersRelationships with gatekeepers
Stigma and discrimination
programmes
Stigma and discrimination
programmes
Organizational developmentOrganizational development
Capacity BuildingCapacity Building
Community mobilizationCommunity mobilization
Structural InterventionsStructural Interventions
THE COMPREHENSIVE
PACKAGE
 HIV Prevention
 Access to HIV treatment,
care and support
 An enabling environment
for prevention and care
services
 Strategic Information
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13. HIV diagnosis, Prevention, Teatment, Care
and support
Services should be offered on voluntary basis
Linkage to care and treatment services should be
provided for those infected with HIV and in need of
care
 Linkage and referral mechanisms to community
support programmes should be established to
ensure retention and follow up into care and
treatment services.
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14. Some identified barriers in
treatment and care
All MSM are started on treatment after diagnosis
irrespective of the CD4 count so many of them are
asymptomatic at the start of ART
Most of them are unmarried and no person to support
Reluctant to join HIV support groups
Reluctant to divulge sero status due to their MSM
behaviour
The fear of identification as a Retroviral positive by the
peers
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15. Managing common infections,
co-infections and co-morbidities
Diagnosis and management of STIs.
Syndromic/ Etiological
Prevention and treatment of Hepatitis C and B
Interventions for harmful alcohol and substance use
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16. Social behavioural interventions for HIV
prevention
 Provide community-based outreach and peer
education incorporated into service delivery to
improve engagement and connectivity to health
and other social services
 Community empowerment interventions should
be developed to empower on their rights and access
to health
 Messages promoting consistent and correct use
of condoms for them and their sexual partners
or clients are needed.
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17. Providing services to MSM in Sri
Lanka ( access to STI services)
Voluntary
Peer escort model ( under the global fund)
Out reach by STD services
Referrals
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18. Common methods of reaching MSM
through STI services
1. As STI patients at the clinic
2. Through contact tracing process
3. As clients for STI/HIV screening
4. Escorted persons from NGOs working in the field
5. Networking techniques/Snowballing
6. Through outreaching programmes
7. As a part of sentinel sero-surveillance
8. Participation of programmes organized by MARP
groups/NGO
9. Partnership with MARP groups and NGOs working with
them
10. In ad hoc surveys and research

19. Why should we analyze the
barriers
The targets by 2020
Ensure that 90% of all people living with HIV will
know their HIV status,
90% of all people with diagnosed HIV infection will
receive sustained antiretroviral therapy
90% of all people receiving antiretroviral therapy will
have viral suppression.
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20. The commonly identified barriers to
provide comprehensive care
Legal barriers
Stigma and Discrimination
Self stigma
Factors related to service provision
Factors related to prioritizing activities
Funding
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21. The Enabling Environment
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
An enabling
environment for
prevention and care
services
Harmonize HIV policies with laws
that impede HIV prevention and care
including age of consent laws
Reduce harassment, violence, stigma
Ensure continuity and consistency of
programmes and services
Support MSM & transgender CBOs
and NGOs
Improve quality and flow of strategic
information
Remove structural barriers to the use
of services
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22. Laws and policies that impact on
MSM and transgender people
Sodomy and other sexual behaviour laws
Differential age of consent laws
Relationship recognition
Adoption and family law
Immigration
Public decency and nuisance laws
Pornography laws
Drug laws
Mental health law
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23. Effects of stigma and discrimination
Fear or actual experience with S&D
1. Avoid the practice of prevention (Continue risk
behaviour)
2. Reduce access to HTC services (avoid testing)
3. Non-disclosure of HIV status to others
4. Reduce access for HIV treatment care and counselling
services
5. Discourage people from using other social services
6. Suffering from Psychological distress
As a result, that hamper prevention and care efforts and fuel
the HIV/AIDS epidemic
©karawita

24. The situation of stigma in Sri
Lanka
The level of stigma and discrimination in Sri Lanka
experienced by the MSM community is not similar to
other SEA countries.
Sri Lanka's education as a service has reached out for
many for a considerable period of time
The influence of Buddhism encourages people to
respect diversity.
The cultural factors have a significant negative
impact on stigma
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25. The barrier which is most difficult to
overcome
MSM population, especially the bisexual
males remain largely hidden and mobilizing
them to access testing requires a different
approach.
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26. Barriers …….
 Majority of the MSMs who are educated and
economically sound, access medical care and
information as much as a non gay person would
access without experiencing any difficulty.
But the transgenders and socially and economically
marginalized males resort to sex work and get away
from services
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27. Behavioural interventions and novel
communication strategies/outreach
Conditional recommendations
• Implementing individual and
community-level behavioural
interventions
• Targeted internet-based
targeted information
• Using social marketing
strategies
• Implementing sex venue-
based outreach strategies
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28. Overcoming barriers ……..
To improve the health literacy among key
populations
More trainings on human rights and legal services
Development of synergies such as linkages to
employment, education, and social protection
services.
Investing more on service delivery.
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29. Provision of targeted technical assistance to support
the meaningful engagement of key populations as
well as broader communities
Planning of interventions which specifically addresses
the communities, rights and gender issues
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30. Evidence shows that community- and peer-led
education and services can be more conducive for key
populations.
Scale-up of community oriented and peer-led service
delivery is an essential component.
Community systems strengthening is a major
component in overcoming barriers
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31. Community systems
strengthening
Key populations often depend more upon community
systems than members of the general population.
The development of social networks and
organizations for support, advocacy, is crucial for key
populations who often fear and mistrust government
affiliated health systems, receive poor treatment
within those systems, and fear disclosure.
Strengthening these social networks and
organizations can have a positive impact on the
ability of key populations to engage in health care.
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32. Community systems
strengthening
It is observed that there is a global increase in net
works of key populations
Further development of these networks can serve to
build national and local level capacity to advocate for
and provide services to key populations.
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33. A success story of the peer escort
model
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34. The attendance of MSM to STD clinic/
NCTH
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35. Diagnosis of STI/HIV among
MSM in STD clinic/NCTH
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36. Number of STI/HIV among
MSM in STD clinic/ NCTH
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37. Some challenges in peer escort
model
Low level of personal/institutional management
No control/ influence over their peers
The reach is only limited to some social strata
As it is a funded project, the sustainability of the
model is a question
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38. Some challenges in the out
reach model
They are mostly a hidden population unlike the FSW
and drug users
They are a very diverse population in all aspects so
different models should be used for different groups
(eg- for MSM, TG, BISEXUAL)
It is practically difficult to out reach without the
support of community groups
The working hours of government services and the
lack of trained staff in out reaching is an obstacle to
efficient out reach
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39. Conclusions
There are many barriers in providing comprehensive care
to MSM
The legal barriers and human rights should be discussed
and relevant changes should be made
The social net works of MSM should be analysed in detail
for behaviour change through IEC
The government services must strive more to provide
services without stigma and discrimination
Mass media support is necessary for educating society on
the present status of the epidemic and the importance of
early identification
Country specific interventions should be identified 39

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