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Linking HIV/AIDS treatment, care and support in Sexual and Reproductive Health care settings: Examples in Action
Contents
SECTION 1: Introducing the Models of Care Project
What does the project aim to achieve? What are the different project components? What is the aim of this booklet? What have the projects achieved?
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SECTION 1
Zusammenarbeit (GTZ), the project ran from June 2004 until the end of 2005. It aims to produce knowledgeable and sustainable HIV/ AIDS models in different SRH settings that can be adapted and implemented by IPPF MAs worldwide. The project aimed to strengthen and link the delivery of HIV/AIDS care and treatment to already existing family planning and SRH services, together with developing the HIV/AIDS skills and competencies of MA staff.
INTRODUCTION
INTRODUCTION
negotiations are taking place for PROFAMILIA to provide training to government officials. In Kenya, the staff capacity of the MA, the Family Planning Association of Kenya (FPAK), has been greatly improved as a result of the pilot. Clinics have provided HIV/AIDS services to an increasing number of people and, after a site assessment, FPAK is already delivering ART. Ongoing meetings are being held with government HIV/AIDS structures, local organizations and the GTZ country office to build support for the programme. In Rwanda, the MA, Association Rwandaise pour le Bien-tre Familial (ARBEF), did a site assessment and is preparing to link HIV prevention and care more comprehensively. In the meantime, it continues to refer clients to access ART from government. The assessment recommended that ARBEF should draw on its lengthy experience in family health and strong community links. ARBEF is continuing to strengthen its staff capacity. In Colombia, the MA, Asociacion Pro-Bienestar de la Familia Colombiana (PROFAMILIA), has moved from its very productive first phase and is carrying out a number of activities, such as a series of far-reaching sensitization workshops with 35 PROFAMILIA clinics. PROFAMILIA developed a variety of creative materials to reach vulnerable populations, including men who have sex with men (MSM) and their partners. In the training and capacity-building component of the project, IPPF held an innovative two-week HIV/AIDS: Vulnerability, Rights and Young People course in South Africa in November 2004. The course focused on the policy and programme links between HIV/AIDS, vulnerability, human rights and young people. At the end of the course, participants from MAs developed action plans, based on lessons from the course. Funding was made available for selected small-scale projects to: Promote the participation of young people living with HIV/AIDS in Kenya and Nigeria. Mitigate stigma and discrimination against people living with and affected by HIV in Uganda. Reduce barriers and improve SRH and HIV/AIDS links in Sudan. ncrease HIV voluntary counselling and I testing (VCT), and improve pre- and posttest counselling in Colombia.
Dominican Republic
DOMINICAN REPUBLIC
SECTION 2
for managing and treating HIV/AIDS through two clinics in the Dominican Republic. mprove the awareness and attitudes of I PROFAMILIA staff on care around HIV infection and treatment, including stigma reduction. xpand advocacy efforts that target E influential people and decision-makers in the health sector in order to promote the right to timely, quality care and access to ARV medicines for PLHAs.
Case studies
DOMINICAN REPUBLIC What needs did the project respond to?
The IPPF-affiliate PROFAMILIA Dominican Republic (Asociacin Dominicana Pro-Bienestar de la Familia) has been engaged in a GTZ-funded pilot project to provide comprehensive HIV/AIDS care and treatment, including ART. About 29% of the population of the Dominican Republic live below the poverty line, according to World Bank statistics. In 2001, the Government of the Dominican Republic included a strong population perspective in its Poverty Reduction Strategy Paper, and several successful programmes on adolescent reproductive health have operated over the last few years. Today, poverty and domestic and gender-based violence remain enormous challenges. The Dominican Republic is among the countries with the highest prevalence of HIV in the Caribbean 120,000 people are living with HIV/ AIDS, nine times the total number of reported cases. In particular, the prevalence of HIV is rising in the 1524 age group (Presidential Commission for HIV/AIDS). HIV/AIDS is the leading cause of death among women of reproductive age. Prevalence is highest (5% of adults) among low-income groups that include many Haitian immigrants living in rural communities and working on sugar cane plantations. Prevalence among female sex workers is about 8%, reaching 12% in some cities. PROFAMILIA has a lot of experience in working with youth aged 13 to 20, providing them with education and services in SRH through a network of more than 600 trained youth peer educators. PROFAMILIA does awareness-raising in local and national media on reproductive rights, teen pregnancy, and the importance of sex education in schools. Since the early 1990s, PROFAMILIAs SRH project began including HIV/AIDS, health rights, and HIV and sexually transmitted infection (STI) prevention in its clinical and community outreach work. When its youth programme included HIV prevention in its health promotion activities, PROFAMILIA clinics saw an immediate increase in new people needing VCT. By the late 1990s, there was a need for PROFAMILIA to train its staff to be able to respond to the clinical management and treatment needs of people living with HIV/AIDS. The pilot project in the Dominican Republic aimed to: ncrease access for people living with I HIV/AIDS (PLHAs) to comprehensive services
return every six months for a general check-up and laboratory tests. All clients living with HIV are invited to attend monthly support group meetings, where nurses lead discussion on topics such as self-esteem and nutrition.
According to educator, Ana Gloria Garcia, after almost nine years of HIV prevention efforts that still left patients dying:
PROFAMILIA has compensated in one and a half years for the impotence of the past decade. We are saving lives.
Developments in Santiago
Following the success of the model in Santo Domingo, PROFAMILIA decided to expand treatment to the Santiago Clinic in mid-2005. Here health service options include hospitalization and extend beyond SRH services. Yet, PROFAMILIA was keen to ensure that new HIV/AIDS treatment services would integrate into the clinics other services, rather than creating a separate area of service. People who do not qualify for ARV treatment receiving general counselling on HIV/AIDS, and
Empowerment of clients
People living with HIV become empowered and independent in taking responsibility for improving their health. Additionally, they realize that HIV/AIDS is a chronic disease that they can manage. Clients arrive with little hope and in time learn to live with HIV/AIDS.
DOMINICAN REPUBLIC
Adherence
The pilot project has achieved good levels of adherence, with 95% of clients staying on ART for six months or longer. The team attributes this to the multi-disciplinary team approach, especially the in-depth counselling and education sessions. A client on ARVs in Santo Domingo captures the sense of hope that treatment and adherence can bring: After I started on ARVs, my life has dramatically changed these medicines are marvellous because they make miracles possible Thanks to God and to you who facilitate these medicines I know that with these medicines, I can live a long life when they are taken as prescribed.
first ARVs were requested for the Santiago Clinic in November 2005.
A client on ARVs in Santo Domingo captures the sense of hope that treatment and adherence can bring:
After I started on ARVs, my life has dramatically changed these medicines are marvellous because they make miracles possible Thanks to God and to you who facilitate these medicines I know that with these medicines, I can live a long life when they are taken as prescribed.
National treatment model: alliance with Dominican Government Models of Care Project
Two PROFAMILIA clinics have been incorporated into the Dominican National AIDS Care Network of 18 health care centres as model programmes to be replicated nationally. This network membership will ensure access to and cover the costs of ARV medicines and certain laboratory tests. Network benefits have yet to be fully evaluated as they only began in Santo Domingo in September 2005, and the
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HIV Positive client, Santiago Clinic It is critical to address gender inequity in HIV/AIDS services. Once a womans HIV status is determined, her primary concern is how her partner may react. Her HIV status has the potential to lead to gender-based violence in various forms.
that offer medical services for people with HIV have rejected PROFAMILIA clients with OIs needing hospitalization. PROFAMILIA in Santiago initially covered hospitalization for HIV clients, but found that the cost was too high. Clients in both clinics highlight the inhumane treatment that people living with HIV/AIDS often receive at public hospitals.
DOMINICAN REPUBLIC
Publicizing of services
Publicity about HIV/AIDS services at PROFAMILIA clinics has been discreet because of their capacity limitations. If demand for PROFAMILIAs HIV/AIDS services dramatically increased, the clinics may not be able to meet the demand.
Gender-based violence
Women living with HIV often ask how to tell their husband or partner about her HIV status. The Santo Domingo clinics counsellor is interested in studying the different patterns in partner response, based on whether the partner is male or female. This will test the theory that male partners tend to react violently and abandon their female partners with HIV, while female partners tend to remain with and care for their male partners with HIV.
Building alliances
Multisectoral approaches should be promoted with the involvement of, for example, government, NGOs and academics. Programme sustainability depends on broadbased commitment and resource mobilization. Local government plays an important role in mobilizing funds and medicines, as well as creating an enabling policy environment. Universities and international agencies offer crucial technical assistance that is often lacking.
I feel like any other person in the waiting room. We sit in the same seats and share the same room as everyone else, and thus, I do not feel pinpointed. No one knows in the waiting room that I am HIV positive.
HIV Positive client, Santiago Clinic
Once people feel physically better, they see less reason to have the physical exam at the clinic. Some even begin to question the need to continue with the treatment programme.
The Santo Domingo nurse, Flor Benitez
Access to ARV medicines has been inconsistent and costly in Santo Domingo. Initially, the Clinton Foundation provided ARVs and now these come from the Dominican Government. However, there have been gaps in availability. Consistent access to ARVs is critical to ensure adherence, avoid viral resistance and achieve high quality service.
DOMINICAN REPUBLIC
Expense issues
Analysis is costly, as only three machines exist in the country to measure CD4 counts and viral loads. All are in Santo Domingo. PROFAMILIA is currently negotiating the donation of a CD4 machine for Santiago, as well as the payment of CD4 tests for five years.
Kenya
KENYA
Historically, the FPAK has complemented the efforts of the Government and other agencies to improve a national family planning and reproductive health programme. FPAK has also focused on specific issues such as youth services, the status of women, the involvement of men, and developing its own services. FPAK has played a key role in integrating HIV prevention into national SRH services. The pilot project built on HIV/AIDS prevention and care work already present in FPAK services, including: eer education and behaviour change P communication. oluntary counselling and testing (VCT). V revention of mother-to-child transmission P (PMTCT). upport groups to promote positive living S and psychosocial care. The pilot aimed to increase access to and use of HIV/AIDS care and support services for people living with HIV/AIDS (PLHAs) in Kenya. Specific aims were to: trengthen the capacity of FPAK to provide S HIV/AIDS care and support services. radually increase the level of access to HIV/ G AIDS care and support services for PLHAs in four FPAK clinics.
Project approach
The projects approach was based on four main elements: uilding the capacity of FPAK. B ctual delivery of services. A emand for the services, and participation of D people living with and affected by HIV/AIDS. esearch, monitoring and evaluation. R
eadership and management experience L and capacity. ervices and clinical care. S onitoring and evaluation. M uman resource capacity. H aboratory capacity. L rug management and procurement. D
service and health care providers, and HIV/AIDS support groups. Examples of methods are: ne-on-one dialogue. O ealth education talks in the clinic setting. H rochures and posters. B takeholder meetings. S
KENYA
Reproductive health, HIV and poverty are so interconnected and must be addressed in an integrated way.
Dr Joachim Osur, FPAK
Staff training
A core service delivery team (one from each of the four sites and three from FPAK head office) was trained in a six-day HIV/AIDS care course in South Africa. With other Kenyan HIV/AIDS care training professionals, the core team then designed and facilitated a step-down training for other FPAK staff in two six-day sessions. This was also an opportunity for participatory development of service delivery tools, such as guidelines and procedures for client selection and follow-up. Further training initiatives focused on: raining in HIV/AIDS programme T management. raining in other specialist skills, such as T adherence counselling. xperiential training and mentoring. E raining community-based resource people, T including distributors of contraceptives, peer educators, and PLHAs as mobilizers and supporters of other PLHAs.
KENYA
Among Kenyan youth today, it is seen as cool to know your HIV status. Those who dont go for VCT sometimes feel out of step.
Rufus Murerua, youth centre coordinator
Among Kenyan youth today, it is seen as cool to know your HIV status. Those who dont go for VCT sometimes feel out of step. (Rufus Murerua, youth centre coordinator)
ongoing education and treatment support groups. These needs are vital for people on ART, those considering ART, and clients not yet needing ART. The experience in FPAK is that only 10% or less of the PLHAs under care actually need ARVs. HIV has opened debate about things that were never discussed before. People are now willing to sit down and say: okay, lets talk. (Rufus Murerua, youth centre coordinator)
HIV has opened debate about things that were never discussed before. People are now willing to sit down and say: okay, lets talk.
Rufus Murerua, youth centre coordinator
HIV affects almost every area of sexual and reproductive health work, so you cant avoid dealing with it. (Dr Winifred Mwangi, Nakuru Clinic)
Home Based Care group providing food and advice on nutrition in Nakuru
KENYA
Competition
There has been a degree of competition and a lukewarm reception to FPAK from other HIV/AIDS service providers. For example, some existing ART services do not accept FPAK staff attachments for training, while others question the role of a family planning and SRH service agency in HIV/AIDS care.
Rwanda
One of the income generating activities organized by the HIV positive support group in Rwanda
and ART. ARBEF would do follow-ups to ensure adherence and monitoring of clients. The specific aims of the pilot were to: trengthen the capacity of ARBEF to provide S HIV/AIDS care and support services for PLHAs, including treating OIs and providing ARVs. ncrease access to HIV/AIDS care and support I services for PLHAs in two ARBEF clinics.
RWANDA
Partnerships
As part of incorporating VCT services and care in its clinical care package, ARBEF selected four of its existing partner associations of PLHAs to be part of the pilot project. The pilot also formed partnerships with Central Hospital University Kigali and Butare University Hospital. Both provincial hospitals are responsible for providing supervision to all health facilities in each province. In addition, the Treatment and Research AIDS Centre (TRAC) was to serve as a referral for laboratory service and ARV management.
Site assessment
A site assessment exercise was conducted in the Butare and Kigali clinics in March 2005 to assess their viability for initiating, managing and sustaining ART programmes. This included assessing ARBEFs clinics in the following areas: eadership and management experience and L capacity. onitoring and evaluation. M uman resource capacity. H aboratory capacity. L rug management and procurement. D The site assessment indicated that both clinics were generally in the planning phases for
RWANDA
the provision of ART services. Major barriers existed in the areas of infrastructure, staffing, capacity building and logistics. However, the vast experience of ARBEF in family planning programme implementation, and the links with the community through community based distributors, associations of PLWA and the NGO forum on HIV/AIDS, were important assets on which to build this project. The Model of Care project brought some improvements in the facilities including better reception rooms for SRH and VCT, extra counselling rooms and new laboratory equipment. In addition, two doctors were recruited to respond to the increased demand for services.
Training
Training and capacity-building activities included: n IPPF training workshop in South Africa A focusing on Clinical Management of HIV/AIDS, attended by four ARBEF staff (two doctors and two nurses from Butare and Kigali). workshop on managing ART, attended A by two Kigali staff.
Until I came to ARBEF I did not know my HIV status. When I got tested, I was told that my CD4 count was so low that I must take medicines urgently. I was then referred to TRAC (Treatment and Research on AIDS Center) where I got the required medicines and now I have a new hope in life.
HIV positive woman, now working for ARBEF
raining on ART, and managing STIs and OIs T for 12 staff members, including nurses and counsellors. raining on providing integrated services (SRH T and HIV/AIDS) for 18 staff. raining for 60 volunteers from PLHA T partner associations on home based care.
in these cases are virtually absent. In addition, the referrals to TRAC lack a proper feedback mechanism. The referral forms are not returned to ARBEF, which relies on clients who come back to the clinic or on the reports from the community volunteers.
RWANDA
Project sustainability
For the sustainability of the project, there is a need to have sufficient supplies of equipment and drugs. The projects progress seems to rely on the fact that it fitted within the already existing ARBEF structures. However, a successor project will have to be considered to ensure continuity at the end of the pilot project period. Ultimately, the success of the project will depend on increased staff capacity to manage ART. There is also a need to train more staff in community-based care and management, in addition to clinical training in managing OIs. The pilot has shown the importance of appropriate, hands-on skills. For example: hile non-medical coordinating staff is able W to ensure the success of the community approach, they are unlikely to be fully able to supervise project staff with medical and clinical expertise. coordinator based at the Kigali Clinic may A be limited in supervising the Butare Clinic.
If ARBEF had not referred me for ARV treatment, I would be history by now. Who would have looked after my children?
HIV positive man, rural area
RWANDA
the site assessment pointed to staff capacity gaps as a barrier to introducing the ART-related programme. ARBEF has experienced insufficient space to provide services to meet the demand for a range of services from an increasing number of clients for example, the lab and counselling rooms are small, and can compromise confidentiality. High rental costs of additional office space have also been a challenge draining potential sources of funding away from priorities like staff development.
Colombia
COLOMBIA
COLOMBIA
What needs did the project respond to?
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Promoting Sexual Rights and HIV/AIDS Prevention among Men who have Sex with Men (MSM) in Colombia was an innovative pilot project funded by the GTZ and run by the IPPF MA, PROFAMILIA Colombia (Asociacin Pro-Bienestar de la Familia Colombiana). In many parts of South America, sex between men and drug use are the most common routes for HIV transmission. While the adult rate of HIV infection in Colombia is at a relatively low 0.4%, the MSM population has an incidence rate of 18% (HIV Prevalence Study, Instituto Nacional de Salud, 2000). PROFAMILIA Colombia, an IPPF MA, began HIV/AIDS prevention activities in the 1980s, including educational activities and condom distribution at a wide range of venues. In 1991, PROFAMILIA began providing HIV tests with VCT. Most of the first group of people living with HIV was gay men and sex workers. The epidemic later affected groups not initially considered vulnerable heterosexual men and women. The ratio of women compared to men with HIV increased from 1:20 (1980s) to 1:10 (1990s) to 1:3 currently (Instituto Nacional de Salud, 2003). PROFAMILIA studies show that women (young and old), for cultural reasons, do not demand that their male partners use condoms, especially when in stable relationships. Colombian youth under 19 have difficulty in discussing sexuality, negotiating condom use, and often choose not to use condoms as a sign of love (PROFAMILIA, 2002). In 2002-2003, PROFAMILIAs HIV/AIDS strategy shifted to adolescents through a video series highlighting responsible sexuality around issues like STI/HIV prevention, condom negotiation and preventing pregnancy. PROFAMILIA diversified its HIV/AIDS strategy in 2004 with a programme to integrate HIV/AIDS in all its services. This was the start of a Sexual Health and Gender Programme to coordinate projects and activities related to HIV/AIDS, STIs, gender and sexual diversity, including a focus on MSM. The GTZ/IPPF-funded pilot projects aim, as part of defending SRH rights, was to reduce stigma and discrimination, improve access to health services for MSM, and to reduce mortality due to HIV/AIDS. Specific aims were to: ncrease the availability of quality HIV/AIDS/STI I information at 35 PROFAMILIA health centres, including the needs of MSM populations. mprove the strategies for the provision I of quality HIV/AIDS/STI services in 5 PROFAMILIA centres, including the specific needs of MSM. rom lessons learnt, adapt and develop F services for the special SRH needs of MSM populations.
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bisexual venues. rochures and postcards with service B coupons for men in homosocial spaces. adio spots on condom negotiation and R VCT materials for women.
The experiences of women using PROFAMILIA services point to the risks faced by women who are possible partners of MSM: Question: Why do you say, apparently you know when your husband is faithful? Response: Well lets say in my case, he is far away, over there he is surrounded by many men I say that most men have their adventures I dont know, anyway how God created you, you for the man and the man for the woman, anyway you are somebody who accepts things. Unfortunately especially (for) women, that is the law and that is the tradition and that is how we are, and the tradition will go on and on.
COLOMBIA
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Developing partnerships
PROFAMILIA developed a close relationship with the lesbian, gay, bisexual and transgender (LGBT) population. This linked LGBT groups to PROFAMILIAs services and helped with strategic planning and project implementation. In particular, the participation of Colombia Diversa in focus groups facilitated an understanding of the particular needs of the MSM population and encouraged a broader panorama of themes around sexual diversity, sexuality and rights. The project also achieved a close working relationship between male prisons and battalions, and PROFAMILIA services. This partnership strengthened the understanding of this population and risk factors for HIV transmission.
Profamilia
Para una vida sexual plena
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COLOMBIA
pressure, power relationships and rights. These topics require careful analysis of the practices and rights of MSM, and consultations with organizations that work with LGBT and people living with HIV. The MSM population is not located in a specific place. It is very diverse and includes groups such as gay men, bisexual men and men in homosocial contexts. Recognizing this diversity makes it possible to establish different strategies to reach MSM.
For the workshops with Profamilia staff, we used Latin American films. We selected films illustrating five situations which are part of the MSM experience, including the experience of a married man who is having relations with young men, the situation faced by men in a homosocial space like the prison and different experiences of young people who have been sexually exploited which opens a discussion about who are the potential clients.
Jos Fernando Serrano, Proyecto Colombia Diversa
Sensitive communication
The communication strategy should be based on rights, gender and the experience of sexuality in everyday language. For example, any woman could be the partner of a MSM, but few think that it could happen to them. For this reason, a message directed to women has to explore issues of gender, condom negotiation and promoting HIV testing, rather than suggesting that their partner could be involved with another man. The development of a project of this nature should be supported by LGBT organizations, as their previous knowledge will enrich the communication strategy. PROFAMILIAs ability to adapt slogans and messages, and to develop conventional and non-conventional materials, enabled the project to appeal to and reach diverse populations. For example, a web page was developed with the stories of three characters, depicting issues like their sexual practices and identity, and their perceptions of risk.
There is clear resistance in some areas, where models of masculinity are more rigid and heterosexist. Therefore, it is vital to consider regional trainings when thinking of addressing topics related to sexuality, sexual diversity and gender. PROFAMILIA also has to respond to the particular needs of different target groups, for example, transgender people. HIV/AIDS education for MSM and for women who are partners of MSM should be complemented by appropriate services and trained staff to address their counselling, education and service needs.
Responding to difference
The perception of sexual practices among men is not the same in all parts of the country.
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COLOMBIA
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YOUTH COURSE
SECTION 3
methodology of the course. As a result, the course content tried to enable participants to: mprove their understanding of the global I context, trends and impact of the HIV/AIDS pandemic. nderstand vulnerability and how to start U comprehensive programmes to address it, while ensuring the full participation of vulnerable groups. trengthen their commitment to addressing S the SRH and development needs of the most vulnerable individuals and groups. evelop skills to create gender-sensitive and D rights-based programmes to lessen stigma and discrimination against people living with HIV/AIDS. xplore approaches and challenges to E mainstreaming HIV/AIDS into SRH and rights. nderstand and improve access to services U on the HIV/AIDS care continuum. hare experiences of and visit innovative S projects that address vulnerability. Four key questions guided the evaluation of the course: hat changes were there in participants: W nowledge about HIV/AIDS vulnerability? K kills for responding to HIV/AIDS S vulnerability? upport for responding to HIV/AIDS S vulnerability? ow did the design and implementation H of the course impact on participants achievement of the courses learning objectives? s a result of the course, what changes were A there in the programmes and policies of MAs in responding to HIV/AIDS vulnerability? hat further capacity-building do MAs W need to be able to respond to HIV/AIDS vulnerability? The consultants developed a questionnaire for participants with closed questions measuring changes in key course competencies. Open questions asked participants how various course elements could be improved, and how they had applied the course learning in their work. The questionnaires were followed up with some telephone interviews with participants working as HIV/AIDS programme managers in MAs to determine how course learning was operationalized in MA programmes and policies, and what additional capacity-building they needed to work with vulnerable young people.
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he geographic mix of participants created T some tensions, but these tensions helped participants to examine their own values. Some participants said that the sharing of experiences gave them new perspectives on their values and their work. fter the course, participants succeeded A in passing on their learning to their MA colleagues. In smaller MAs, this meant debriefings to colleagues on what participants learned. In a larger MA, this could mean first training front-line service providers and later on the middle-management staff. articipants want more follow-up to the P course, particularly through electronic media. They felt that a more interactive, electronic follow-up medium would make even more of an impact. he course helped participants identify T capacity needs on vulnerability. IPPF needs to provide participants with the competencies to do their work differently, such as techniques for strengthening participation, and more specific methods to reduce stigma and discrimination. he vulnerability pilot projects supported T after the course helped MAs generate new learning and strengthen their reputations in HIV/AIDS work: After developing a partnership with people living with HIV/AIDS, we gained the trust of the community, and people are more interested in participating and collaborating with us. (participant) We had been concentrating more on prevention... now we are workikng more on care and support, and stigma and discrimination, and HIV vulnerability. I think this is a major success. (participant)
YOUTH COURSE
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