6.1. Overview
The comprehensive package of interventions, outlined in Chapters 3 and 4, includes health interventions common to all key populations as well as additional services for specific population groups. Most of these interventions are the same HIV prevention, diagnosis, treatment and care interventions as for the general population (1). However, there are often complex challenges and barriers, as discussed in Chapter 5, to implementation and delivery of these services to key populations. Programmes need to address these challenges and barriers and provide sustainable HIV services for diagnosis, linkage, retention and adherence for key populations. To maximize impact, services should be made 1) accessible, 2) acceptable, 3) affordable and 4) equitable. Furthermore, key populations need to be made aware of the available services.
This chapter focuses on the service delivery elements important to the comprehensive package of health interventions for key populations. Box 6.1 lists a number of WHO tools that can help guide implementation.
WHO guidance on HIV-related seanchorrvice delivery approaches.
6.2. Key service delivery strategies
Based on evidence and experience, WHO recommends three overarching strategies that can improve service delivery (1): 1) integration, 2) decentralization and 3) task shifting. These strategies, separately or in combination, can improve the accessibility of care. The community and community-led and community-based approaches are integral to these strategies, particularly for key populations. Given the heterogeneity of key populations and of social and epidemiological contexts, their application will need to be based on a situational assessment and undertaken in consultation with key population groups and service providers.
6.2.1. Integration of services
WHO recommends the integration of HIV services with a range of other relevant clinical services, such as those for TB, viral hepatitis, maternal and child health, sexual and reproductive health services and drug dependence treatment (1).
Integration of services facilitates provision of comprehensive and consistent care. It allows individuals to take care of their various health needs at the same time and in the same location.
WHO recommends integration of HIV services into other relevant clinical services, such as TB, viral hepatitis, MCH, sexual and reproductive health services and drug dependence treatment.
Integration of services involves not only providing related services in a single setting but also linkage systems to share information and provisions for referrals across settings and among providers (1). Collaboration between programmes at every level of the health system is important to the success of HIV and other related health and social services.
Aspects of coordination that need consideration include mobilizing and allocating resources; training, mentoring and supervising health workers; procuring and managing drugs and other medical supplies; and monitoring and evaluation. The goal of programme planning should be to create delivery systems that best facilitate access.
Recommendations and guidance
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ALL KEY POPULATION GROUPS
Delivering ART in antenatal care and maternal and other child health settings
In generalized epidemic settings ART should be initiated and maintained in eligible pregnant and postpartum women and in infants at maternal, newborn and child health-care settings, with linkage and referral to ongoing HIV care and ART where appropriate (strong recommendation, very low quality of evidence) ( 1).
Delivering ART in TB treatment settings and TB treatment in HIV care settings
In settings with a high HIV prevalence (≥5%) among TB patients, ART should be initiated for HIV-positive individuals with TB in TB treatment settings, with linkage to ongoing HIV care and ART (strong recommendation, very low quality of evidence) ( 1). In settings with a high burden of HIV and TB, TB treatment should be provided for individuals with HIV in HIV care settings where TB diagnosis has also been made (strong recommendation, very low quality of evidence) ( 1).
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PEOPLE WHO INJECT DRUGS
ART in settings providing opioid substitution therapy
In settings where opioid substitution therapy is provided, ART should be initiated and maintained in people with HIV who are eligible for ART (strong recommendation, very low quality of evidence) ( 1).
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Case study: Integrated services for sex workers in Zimbabwe
CeSHHAR, Zimbabwe
http://www.ceshhar.co.zw
The nongovernmental organization Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe runs the Sisters with a Voice programme, which provides integrated services for sex workers in multiple sites across Zimbabwe on behalf of the National AIDS Council. Collaboration with key government ministries (AIDS, Health, and Social Welfare) and the involvement of sex workers in implementation have contributed greatly to the programme's successes.
Supported by a network of peer educators trained in participatory community mobilization and empowerment, the Sisters with a Voice programme offers HTC, syndromic STI treatment, contraceptives, health education and legal advice. Cervical screening is being rolled out; nurses are being trained in visual inspection and treatment of pre-cancerous lesions using cryotherapy.
Peer educators run community mobilization sessions. The 36 sessions cover issues for sex workers themselves (self-worth, behaviour change, contraception, HIV and cervical cancer), issues relating to clients and partners (communication, assertiveness, serodiscordance, sexual networks and multiple concurrent partnering) and issues relating to the “sisterhood” (advocacy, stigma, rights and support).
Since 2009 the programme has expanded from five sites to a comprehensive network of 36 sites nationally. By 2013 the six fixed facilities and 30 outreach sites together served more than 14 000 women. Moreover, at a site where two population-based surveys were conducted, the proportion of HIV-negative women that reported having a recent HIV test increased from 35% in 2011 to more than 70% in 2013. Over the same period the proportion of women living with HIV who were obtaining ART increased from 28% to 45%.
An example of integrating services is provided by the next case study, where specific health services for transgender people are provided within a general health facility.
Case study: Comprehensive transgender services within a community health clinic
Transgender Family Program, Community Healthcare Network, United States of America http://www.chnnyc.org/
The Transgender Family Program was established in 2004 at the Community Healthcare Network clinics in New York City to improve access to HIV prevention and linkages to primary health care.
To understand how best to integrate comprehensive transgender services into a community health clinic, the Network undertook community mapping, consultations and forums and learning from similar programmes. Importantly, the programme asked patients to form the Client Advisory Board to help guide integration and implementation of services for the transgender community.
Integrated services include transgender care, HTC, medical case management, support for treatment adherence, STI screening and treatment, prevention interventions and mental health and nutritional services. In addition, the programme provides risk reduction counselling, support groups, outreach, bilingual educational workshops and referrals to legal and social services. Recruitment strategies of staff members and trained peer leaders include face-to-face contacts, community-based activities and online methods including advertising and social media tools. Clients are encouraged to engage family members. This has proved to be an important strategy to encourage access and attendance.
Over 750 people have received transgender-specific services. Identified benefits of integrated transgender services include:
improved tolerance of, sensitivity to and long-term acceptance of this population in the larger community
improved accessibility through convenient location of services
flexible hours as a result of larger capacity
increased access to a range of in-house support services.
In addition, in-depth evaluation has found significant decreases in sex work, needle sharing and unregulated hormone injections and increased likelihood of regular condom use.
6.2.2. Decentralization of services
Decentralization aims to deliver all HIV services closer to the individual. In many settings transport costs and long waiting times in central hospitals are significant barriers to access to services and retention in care. Particularly in rural areas, decentralization can reduce the difficulty and cost of travel and shorten waiting times. If carefully planned and implemented, decentralization may provide safer, discreet and more accessible health-care options, particularly for key populations. However, decentralization of services for key populations may not always be appropriate or acceptable. In some settings general HIV services may provide greater anonymity.
WHO recommends decentralization of ART services specifically. Decentralization of a full range of HIV prevention, diagnosis, treatment, care and support services for key populations can also be considered. Decentralizing HIV care and treatment can further strengthen community engagement, can link community-based interventions with health facilities, and may improve access to services, care-seeking behaviour and retention in care (1).
Recommendations and guidance
Case study: Mobile outreach to sex workers in South Africa
Re-Action Consulting, South Africa
http://www.re-action.co.za
In conjunction with the Department of Health, Re-Action! operates a five-year programme to reduce new HIV infections among sex workers and their clients in two rural districts in Mpumalanga province of South Africa. Currently, the programme reaches about 4100 female sex workers.
A nursing team offers multiple free services including health risk screening and testing (including Point of Care CD4 testing), HTC, care and treatment and referral to other health and social services through a mobile clinic. The team visits locations at least twice per week at times convenient to their clientele. With the help of a 28-day calendar, sex workers know where they can obtain services in case of emergencies. If needed, the nurse can provide services, including ART, in the clients' workplaces.
Nurses trained in nurse-initiated and managed ART can diagnose, stage clients and enrol them into the appropriate ART services. The nurses supply patients with medication from the Department of Health, and they visit patients to follow up and teach about adherence to treatment. When a client defaults on treatment, outreach workers provide assistance and follow-up. The programme has a very low default rate of 2.3%, most of it attributed to women moving elsewhere.
6.2.3. Task-shifting the delivery of services
Task shifting can enable the existing workforce to serve more people.
Task shifting involves the rational redistribution of tasks among health-care workers. Where appropriate, tasks are reassigned from highly qualified health workers to health workers with shorter training and fewer complementary qualifications (1). Many countries face a shortage of health-care workers; task shifting can increase the effectiveness and efficiency of available personnel, enabling the existing workforce to serve more people. Community-led organizations can also play important roles in reaching key populations, engaging with them, linking them to services and providing ongoing care and support.
Peer-support workers can provide valuable services and can link the community and health services. Like other health workers, they need regular training, mentoring and supervision (1). They should receive adequate wages and/or other appropriate incentives (14).
Recommendations and guidance
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ALL KEY POPULATION GROUPS
Trained non-physician clinicians, midwives and nurses can initiate first-line ART (strong recommendation, moderate quality of evidence). Trained non-physician clinicians, midwives and nurses can maintain ART (strong recommendation, moderate quality of evidence). Trained and supervised community health workers can dispense ART between regular clinical visits (strong recommendation, moderate quality of evidence) ( 1).
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Case study: Community distribution of naloxone in India
Social Awareness Service Organisation (SASO), Manipur, India
http://sasoimphal.org/
In the state of Manipur, India, since 2000 the Social Awareness Service Organisation (SASO) has provided, among other services, opioid overdose management with free naloxone, through outreach (e.g. at “shooting sites”) and at drop-in centres. Also, through small meetings, one-to-one contacts and counselling, SASO provides information and education about drug overdose and its management to all people who inject drugs and their family members.
The programme was scaled up and strengthened in 2008–09 by involving key stakeholders to facilitate community implementation of naloxone to ensure wider coverage. Ethical concerns about non-medical staff dispensing a medication to people who inject drugs have been overcome through the demonstration of the life-saving nature of overdose management. Between 2004 and 2012 more than 450 overdoses were managed at five centres, and over 90% of those lives were saved. In addition, more than one-third of overdose clients have increased access to drug treatment and other health care, such as HIV/HCV testing and ART.
6.2.4. Community-based approaches
Community-based approaches to service delivery can increase accessibility and acceptability for key populations. Outreach, mobile services, drop-in centres and venue-based approaches are useful for reaching those with limited access to, or underserved by, formal health facilities. These approaches allow for critical linkages and referrals between the community and health facilities, and they support decentralization (see Section 6.2.2). Community-based programmes can also refer to programmes that are led and delivered by members of the key population community. Staff members, including peers, involved in community-based approaches need to be appropriately supported, in terms both of training, supervision and management and of incentives and remuneration.
The community plays a vital role in the HIV response.
Community-led services, in which community members take the lead in delivering outreach and overseeing an HIV prevention programme, have demonstrated significant benefits in terms of HIV outcomes. They also enable community members to address structural barriers to the exercise of their rights and empower them to change social norms, thus reducing vulnerabilities that go beyond HIV.
Community-led services are interventions designed, delivered and monitored by community members. They can play many roles – for example:
providing adequate and reliable access to commodities (condoms, lubricants, and needles and syringes) and clinical services through outreach and referrals;
responding to violence against community members and implementing other structural interventions;
supporting the safe and effective use of naloxone in the community by people who witness an opioid overdose;
promoting behavioural and social change that strengthens not only knowledge but also skills and systems in order to sustain prevention and retention in care and treatment;
offering formal and informal means for the community to provide feedback on the quality of services and to engage with services beyond the HIV programme (
2).
Peer interventions – also termed peer-based or peer-driven interventions – are an important modality for delivering services and exchanging information and skills that promote safer behaviours to individuals or networks of people from key populations. Beyond providing services, peers can act as role models and offer non-judgemental and respectful support that may contribute to reducing stigma, facilitating access to services and improving their acceptability.
Recommendations and guidance
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ALL KEY POPULATION GROUPS
In all HIV epidemic settings, WHO recommends community-based HIV testing and counselling with linkage to prevention, care and treatment services for key populations in addition to provider-initiated testing and counselling (strong recommendation, low quality of evidence) (1). |
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ADOLESCENTS FROM KEY POPULATIONS
Community-based approaches can improve treatment adherence and retention in care of adolescents living with HIV (conditional recommendation, very low quality of evidence) (15). (See Box 6.2.) |
Adolescents from key populations.
Case study: Community-led service delivery centres in Pakistan
Naz Male Health Alliance, Pakistan
Naz Male Health Alliance is a community-based organization in Pakistan serving the community of men who have sex with men and of transgender people. As part of its on-going work to empower the community, the organization operates six service delivery centres in five cities, with 47 000 registered clients. Each service delivery centre is divided into a clinic and a drop-in centre that provides a safe and relaxing atmosphere for the low-income beneficiaries. The centres are located strategically close to “hotspots” for men who have sex with men and where there are concentrations of hijra deras (dwellings of transsexual people). Drop-in centres and outreach activities are complementary: The drop-in centres allow the establishment of long-lasting relationships with the clients, and outreach provides linkage to the drop-in centre.
Service sites are separate for each key population community in order to effectively address their different needs. Each centre has a multidisciplinary staff of about 15 people, including STI specialist doctors, a psychologist, and peer educators. The teams consist primarily of community members; more than 95% of staff staff are men who have sex with men and transgender people.
6.3. Key factors to consider when providing services for all key populations
In summary, assuring access, acceptability and affordability requires attention to multiple, specific elements of programme design and delivery. Action on all these elements, appropriate to the specific context, will yield programmes that best serve key populations.
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Generate demand
Demand for HTC and prevention services can be generated through targeted campaigns in identified key population settings, using community-based outreach, mobile phone technology, social networking and broadcast and online media. |
Case study: Online strategies to increase uptake of HTC services in Bangkok
Thai Red Cross AIDS Research Centre, Bangkok, Thailand
http://en.trcarc.org/
In Bangkok the Men's Health Clinic provides comprehensive and friendly services to men who have sex with men. One of the Clinic's tools to increase uptake of HTC has been the first bilingual (Thai/English) edu-tainment web site for men who have sex with men (http://adamslove.org), launched in 2011.
The web site's goal is to encourage regular HIV testing among men who have sex with men. To link web site visitors to HTC services, a section titled “HIV testing site near you” offers information about how to obtain HTC at sites that are friendly to men who have sex with men in Bangkok and other provinces. Other means of continuous demand creation for HTC services include mass media and targeted media activities such as regular columns in gay magazines, peer-driven interventions and celebrity meet-and-greet HIV testing events.
The number of clients who have obtained HTC services has increased almost fivefold, from 967 in 2008 to 4371 in 2012. The Adam's Love web site attracted more than 500 000 visitors in two years and has its own Facebook page as well, with more than 15 000 fans. One-quarter of clients of the Men's Health Clinic report obtaining HTC services because of the site. |
Address age barriers
Age of consent laws should be examined to determine their effect on access to services. Countries can consider revising age of consent policies and creating exceptions to age limits (i.e. mature minor status). Countries also can consider how best to assess adolescents' capacity to consent. |
Make services convenient
Programmes can consider offering mobile and/or drop-in services and weekend and/or night service times that facilitate access. Outreach, including venue-based and home-visiting services, also can increase access. |
Decentralize services
Shifting services from centralized locations to community-based and/or mobile outreach and peripheral health facilities can increase access. For example, school-based sex education, peer counselling and community-level activities can disseminate behavioural messages, promote follow-up on referrals to services, improve adherence to treatment and increase people's participation in their own health care. |
Case study: In Vietnam decentralization facilitates earlier access to HIV services
Vietnam Authority of HIV/AIDS Control/Ministry of Health and WHO Vietnam
In 2012 the Vietnam Authority of HIV/AIDS Control in the Ministry of Health started pilot-testing a project to expand earlier access to HIV services among key populations, particularly to people who inject drugs, and thus to maximize the therapeutic and preventive benefits of ART by enabling people to start treatment as soon as possible. The pilot project involved decentralizing HTC services from district facilities to commune health stations in Dien Bien and Can Tho provinces. The pilot project introduced such innovations in Vietnam as a fixed dose combination ARV formulation, point-of-care HIV and CD4 testing, and decentralized follow-up.
The project actively engaged community partners, including peer educators, self-support groups and village health-care workers, providing them with community mobilization trainings and holding regular meetings to discuss outreach activities and challenges. Commune health station staff received training on HIV service delivery, including HIV testing using rapid tests, pre- and post-test counselling, adherence support, basic care and dispensing ARV drugs.
This decentralized, community-based model has been shown to promote earlier diagnosis and treatment. People diagnosed at communes have significantly higher median CD4 counts when starting ART (median 294 cells/mm3) than those diagnosed at district facilities (median 88 cells/mm3). Community outreach and trust-building are recognized as critical to facilitating earlier access to HIV services among people who inject drugs. |
Integrate services and assure referrals and linkage to care
Service integration, including integrated HTC and care services and integrated HIV and drug dependence services (e.g. OST, NSP), makes services more convenient and thus facilitates access. To decrease loss to follow-up, standard operating procedures should specify linkages to care and help with transport from HTC to ART sites. Systems that share information between clinics (e.g. TB and HIV clinics), use of outreach workers for follow-up and support from peers can facilitate retention in care. |
Case study: Promoting regular testing and supporting linkage to care in Spain
Projecte dels NOMS-Hispanosida (BCN Checkpoint), Spain
http://www.bcncheckpoint.com/
BCN Checkpoint is a community-based centre in the gay district of Barcelona for the detection of HIV and other STIs among men who have sex with men. Managed by the nongovernmental organization Projecte dels NOMS-Hispanosida, BCN Checkpoint offers free rapid HIV and syphilis testing by peers for early detection, vaccination against hepatitis A and B and promotion of sexual health. To encourage annual repeat HIV testing, BCN Checkpoint uses e-mail, text messages and telephone reminders.
Between 2007 and 2013 the programme performed over 22 000 HIV tests, detecting 756 new infections. For those with HIV-positive results, BCN Checkpoint offers an education and information programme with trained HIV-positive peer counsellors and referrals within one week to the hospital's HIV treatment unit. To ensure linkage to care, all recently diagnosed individuals are followed through a register. Currently, nearly 90% are linked directly to care, while 5% find their own care, and about 4% are in Barcelona only temporarily and obtain care in their home countries. Less than 2% are lost in linkage to care. |
Invest in critical enablers
Countries can support key populations' access to services by investing in critical enablers such as integrated treatment and rights literacy programmes, legal services, programmes to reduce stigma and discrimination, and training for health-care workers and law enforcement personnel. |
Case study: Using social media in Ghana to reach men who have sex with men
SHARPER project, FHI360, Ghana
http://www.fhi360.org/projects/strengthening-hivaids-response-partnership-evidenced-based-results-sharper
The SHARPER project tested use of social media by community liaison officers to identify unreached networks of men who have sex with men. The project launched MSM.net in two locations through informal mapping of the community's networks. Community liaison officers were selected from networks not previously reached by peer educators and were trained on HIV, health information and services. They used social media on smart phones and laptop computers to reach men who have sex with men. “Reached” is defined as receiving a risk assessment, information on HIV prevention and a referral to HIV testing and counselling (or another HIV service).
In 2013 more than 15 000 men who have sex with men were reached through Facebook (45.6%), WhatsApp (13.4%) and other social media platforms. In Accra 82% of the men reached by this approach had not had previous contact with a peer educator. In Kumasi 66% had never been reached before by any intervention. The community liaison officer in Accra identified eight male sex worker brothels and networks previously unknown to the project and other MSM organizations.
Social media proved to be an important means to reach men who have sex with men that peer educators would not usually reach. MSM reached by community liaison officers tended to be older, more educated, single, have a higher monthly income, and (in Accra) to report a larger social network of men who have sex with men than those reached by peer educators. |
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| ACCEPTABILITY |
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Train health-care providers
Sensitize and educate health-care providers (including community workers, peer outreach workers, support staff and management) on issues specific to key populations and on non-discriminatory practices and eliminating stigma, using pre-service and in-service training, job aids, supportive supervision, and training follow-up. Where possible, training should involve representatives of key populations. |
Create a safe and supportive environment
Safe spaces (for both health-care and social services) and confidential and stigma-free environments can encourage access by people from key populations. For example, providing separate and well-lit entrances or locating services in an appropriate setting can decrease barriers to services. |
Provide high-quality services
Services should be acceptable and of high quality. One way to assess quality is monitoring clients' experience, using national and global indicators. |
Assure voluntary and informed consent
Programmes must promote individuals' right to decide on their own treatment and accept their right to refuse services. All services should be voluntary, without any feeling of coercion or conditional requirements for obtaining services or commodities such as HIV testing, condoms or clean needles. Information on services and treatment should be clear, explicit and in the appropriate language. Additionally, information for adolescents needs to be suited to their specific developmental stage. |
Ensure confidentiality
Attention should be devoted to protecting privacy and confidentially, e.g. closing the consultation room door or finding a private place to talk. Clients should be reassured of confidentiality, e.g. seeking permission before disclosing information to other health-care providers. Programmes should address the complexities of maintaining confidentiality in community, outreach and peer approaches particularly. |
Case study: Confidential and anonymous services in Lebanon
Marsa Sexual Health Center, Lebanon
http://www.marsa.me
Marsa Sexual Health Center in Beirut, Lebanon, offers sexual health and reproductive health services to the public in a friendly environment free of stigma and discrimination against age, sex, gender and sexual orientation. Intended clients are youth, unmarried sexually active women and marginalized communities with limited access to other sexual health care facilities, including men who have sex with men and transgender people.
Clients' anonymity and confidentiality when they obtain Marsa services play a key role in attracting the clientele. The center uses a unique file number for each client as a form of identification. The client decides if they would like to provide identifying information for their file.
In addition, the staff of experienced and sensitized professionals is required to maintain confidentiality. Clients feel comfortable to open up to their care providers, disclose intimate details about their lifestyles and seek information from specialists, knowing that their identity will not be disclosed, even among staff members. |
Case study: Online and telephone counselling assures anonymity for young men who have sex with men living with HIV in the Russian Federation
Positive Life programme, menZDRAV Foundation & Phoenix PLUS NGO, Russia
In partnership with a nongovernmental organisation, the menZDRAV Foundation offers services to young men who have sex with men, ages 18–25, living with HIV in six regions of the Russian Federation. Many young men are reluctant to attend support groups for fear that their sexual orientation or HIV status will be publicly identified, and so the Positive Life programme offers individual counselling via phone, social media and Skype.
In each of six cities, peer counsellors staff a telephone hotline with a publicized number. Counselling is also offered via Skype, and young men can send questions to counsellors via email, Facebook, Vkontakte or via a counsellor's profile on gay-oriented web sites.
Counsellors offer callers information on sexuality, safe sex, STIs, adherence to ART, ARV side-effects and disclosure of HIV status to sexual partners. Callers are informed about project services and encouraged to visit the project office for assessments or referrals. Those who are reluctant to visit for fear of being identified can be referred to one of 20 medical specialists across the six regions who have been trained and sensitized to the specific needs of men who have sex with men living with HIV and will provide services without stigma or discrimination.
There are about 80 trained peer counsellors, both project staff members and volunteers. All Positive Life counsellors take part in a centralized training. They receive further training and supervision at the project's regional offices as well as from central project staff who travel to the regions. In 2013 Positive Life counsellors provided almost 1900 phone consultations and 1350 online consultations. |
Engage members of key populations
Members of the key population should be involved in the design of programmes, including their planning, implementation and monitoring and evaluation. Such involvement can increase the community's sense of ownership and, thus, programme success. People from key populations also can be involved as service providers and advocates. |
Case study: Capacity building for transgender community services in the USA
Center of Excellence for Transgender Health, University of California, USA
http://transhealth.ucsf.edu
The mission of the Center of Excellence for Transgender Health is to increase access to comprehensive, effective and affirming health-care services for transgender and gender-variant communities. The ultimate goal is to improve the overall health and well-being of transgender people by developing and implementing programmes in response to community-identified needs. Core faculty and staff with diverse backgrounds and experience offer programmes informed by a national advisory board of 14 trans-identified leaders from throughout the United States of America.
The projects of the Center of Excellence address a wide range of health issues for transgender people. One activity is developing guidelines on a range of primary care topics, including primary and preventive care, hormone therapy, mental health, youth and surgery. Protocols have been published online (http://Transhealth.UCSF.edu/protocols). In addition, the Transitions Project helps build the capacity of community-based organizations to adapt, implement and evaluate evidence-based HIV prevention interventions for transgender communities. |
Case study: Capacity building and training sessions in Tanzania
Médecins du Monde, Tanzania
http://doctorsoftheworld.org/where-we-work/africa/tanzania/
Médecins du Monde, Tanzania, provides comprehensive harm reduction services, including needle and syringe programmes and referral to OST, as well as income generating activities and legal aid. More broadly, Médecins du Monde is involved in building the capacity of nongovernmental and community-based organizations to run harm reduction services, especially drop-in centres with needle and syringe programmes; these include dedicated centres for women, with additional services offered for their children. In 2013 more than 2000 stakeholders were trained in harm reduction approaches and interventions.
The organization also has helped create national and district-level harm reduction committees with representation from governmental and nongovernmental institutions. Sub-committees at both levels focus on resource mobilization. A continuous dialogue with municipal, district and national authorities and sensitization sessions for police, medical staff and journalists have been important elements of the work. |
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Ensure monetary resources
Government commitment and funding are important. Public–private partnerships can spread costs. |
Minimize or eliminate fees
Wherever possible, services should be provided free of charge or at reduced price. Insurance or health subsidies should cover any fees for services. |
Reduce costs
Costs to the health system and for the user can be reduced through the integration and decentralization of services, community outreach and venues, and convenient locations. Costs to the individual can be reduced also by shortening waiting times at the facility through a flexible appointment systems and separating clinic consultation visits from picking up medicines. |
