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Supporting community action on HIV, health and rights to end AIDS

setting the SCENE Assessing and planning with harm reduction partners

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What is the International HIV/AIDS Alliance? Established in 1993, the International HIV/AIDS Alliance (the Alliance) is a global alliance of nationally based organisations working to support community action on AIDS in developing countries. To date, we have provided support to organisations from more than 40 developing countries for more than 3,000 projects, reaching some of the poorest and most vulnerable communities with HIV prevention, care and support, and improved access to HIV treatment. The Alliance’s national members help local community groups and other NGOs to take action on HIV, and are supported by technical expertise, policy work, knowledge-sharing and fundraising carried out across the Alliance. In addition, the Alliance has extensive regional programmes, representative offices in the USA and Brussels, and works on a range of international activities such as support for South–South cooperation, operations research, training and good practice programme development, as well as policy analysis and advocacy.

© International HIV/AIDS Alliance, 2013 Cover images, clockwise, from top: An outreach worker (pictured) shares information with people who inject drigs, Kenya © Nell Freeman for the Alliance Drug use and HIV are prevalent among deep-sea fishermen in Malaysia. One of the outreach sites, Kuantan. © Slava Kushakov/International HIV/ AIDS Alliance in Ukraine Needle exchange at a palm plantation in Malaysia. © Slava Kushakov/ International HIV/AIDS Alliance in Ukraine Unless otherwise stated, the appearance of individuals in this publication gives no indication of either sexuality or HIV status. Information contained in this publication may be freely reproduced, published or otherwise used for nonprofit purposes without permission from the International HIV/AIDS Alliance. However, the International HIV/AIDS Alliance requests that it be cited as the source of the information. Registered charity number 1038860 Published: March 2013 www.aidsalliance.org 2

Reaching drug users with outreach services


Acknowledgements This publication was produced by the International HIV/AIDS Alliance with the support of the Ministry of Foreign Affairs of the government of the Netherlands as part of the Community Action on Harm Reduction (CAHR) project. It has been coordinated by the Regional Technical Support Hub for Eastern Europe and Central Asia. This report is based on a series of capacity assessment visits to China, India, Indonesia, Kenya and Malaysia. The assessment was conducted thanks to the efforts of staff from the following organisations: the India HIV/AIDS Alliance, the Kenya AIDS NGOs Consortium (KANCO), Rumah Cemara, the Malaysian AIDS Council (MAC), the International HIV/AIDS Alliance in China, and the International HIV/AIDS Alliance in Ukraine. The following consultants were involved in the assessments and the development of the publication: Olga Varetska, Vyacheslav Kushakov, Liudmyla Shulga, Pavlo Smyrnov, Olga Golichenko, Maryna Braga, Tetyana Deshko, Olga Morozova, Paola Pavlenko, Tetyana Nima, Oleg Kukhar, Maria Samko, Pascal Tanguay and Anna Dovbakh. Susie McLean (International HIV/AIDS Alliance) reviewed and edited the publication. The final editing was done by Kathryn O’Neill. Designed by Progression (www.progressiondesign.co.uk)

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Contents List of abbreviations and acronyms

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1. Introduction

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Objectives and structure of this report

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Community Action on Harm Reduction (CAHR) project

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The assessment and planning technique

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The structure of the assessment and planning toolkit

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The main areas of the assessment and planning process

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2.

The findings of the country on-site assessments

CHINA

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HIV epidemic and services

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Policy and environment

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Organisational development

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Monitoring and evaluation

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INDIA

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HIV epidemic and services

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Policy and environment

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Organisational development

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Monitoring and evaluation

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KENYA

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HIV epidemic and services

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Policy and environment

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Organisational development

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Monitoring and evaluation

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INDONESIA

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HIV epidemic and services

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Policy and environment

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Organisational development

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Monitoring and evaluation

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MALAYSIA

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HIV epidemic and services

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Policy and environment

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Organisational development

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Monitoring and evaluation

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3.

Strengths, weaknesses and applicability of the assessment and planning tool

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Strengths

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Limitations and areas for improvement

4. Conclusion

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Abbreviations APT Assessment and planning technique ART Antiretroviral therapy ARV Antiretroviral ASEAN Association of Southeast Asian Nations AusAID Australian Agency for International Development BCC Behaviour change communication CAHR Community Action on Harm Reduction CDC Center for Disease Control and Prevention DFID UK Department for International Development EC European Commission GDP Gross domestic product HBV Hepatitis B HCV Hepatitis C HIV Human immunodeficiency virus IBBS Integrated bio-behavioural surveillance IEC Information, education and communication IHRA International Harm Reduction Association INPUD International Network of People who Use Drugs IT Information technology KANCO Kenya AIDS NGOs Consortium MAC Malaysian AIDS Council MARP Most-at-risk populations M&E Monitoring and evaluation MMT Methadone maintenance treatment NAC National AIDS Commission NACADA National Agency for the Campaign Against Drugs NACC National AIDS Control Council NACO National AIDS Control Organization NACP National AIDS Control Programme NADA National Anti-Drugs Agency NASCOP National AIDS and STI Control Programme NGO Non-governmental organisation NSEP Needle/syringe exchange point OST Opioid substitution therapy PEPFAR The United States President’s Emergency Plan for AIDS Relief PMTCT Prevention of mother-to-child transmission PSB SASO Social Awareness Service Organization SPYM Society for the Promotion of Youth & Masses SRHR Sexual reproductive health and rights STI Sexually transmitted infection TB Tuberculosis UNDP United Nations Development Programme UNODC United Nations Office on Drugs and Crime USAID United States Agency for International Development VCT Voluntary counselling and testing WHO World Health Organization

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1. Introduction Objectives and structure of this report This report summarises the results of site assessments on HIV and drug use in China, India, Indonesia, Kenya and Malaysia. The assessments were conducted by the International HIV/AIDS Alliance and their teams of experts in four technical areas: HIV prevention services for people who inject drugs; HIV and drug-related policy and environment; organisational development issues; and monitoring and evaluation of interventions. The assessments were conducted to guide planning for the Community Action on Harm Reduction (CAHR) project, funded by the Ministry of Foreign Affairs of the government of the Netherlands and implemented by the International HIV/AIDS Alliance. The assessments focused on the Alliance’s lead partners in implementation of the CAHR project: the International HIV/AIDS Alliance in China (Alliance China)1, the India HIV/AIDS Alliance (Alliance India), the Kenya AIDS NGOs Consortium (KANCO), the Malaysian AIDS Council (MAC), and Rumah Cemara in Indonesia. The assessments also focused on the sub-recipients (implementing partners) of these five organisations, along with an in-country situation assessment. The report is structured as follows. The introduction describes the CAHR project and the assessment and planning technique (APT) used to carry out the assessments. Section 2 presents the results of the country assessments. For each country, the results are structured in accordance to the technical areas assessed, in the following order: HIV epidemic and services, policies and policy environment, organisational development, and monitoring and evaluation. Within each technical area there are sub-sections on key findings, recommendations, and results/plans generated on the basis of the assessment results. Section 3 describes strengths and weaknesses of the assessment and planning technique identified during the assessment, as well as the potential for its future use outside of the CAHR project. Section 4 presents the conclusions.

Community Action on Harm Reduction (CAHR) project Community Action on Harm Reduction (CAHR) is an ambitious project spanning five countries (China, India, Indonesia, Kenya and Malaysia) that will expand coverage to more than 230,000 people who inject drugs, their partners and children, with a wide range of services (HIV prevention, treatment and care, sexual and reproductive health and other services) by 2014. In addition, CAHR aims to protect and promote the rights of these groups by fostering an enabling environment for HIV and harm reduction programming in the five countries. The goal of this project is to enable people injecting drugs, their partners and children to be healthier, less marginalised, and more engaged in social and community life. This will be achieved through four pillars: increasing access to services, building capacity, promoting human rights, and brokering knowledge. The programme is structured around four objectives: Objective 1: To improve access to HIV prevention, treatment and care, sexual and reproductive health, and other services for people who inject drugs in China, India, Indonesia, Kenya and Malaysia.

1. International HIV/AIDS Alliance China is the CAHR partner at the time of going to print. In 2013 the Alliance will welcome AIDS Care China as a new Linking Organisation, and the work under the CAHR programme will continue with AIDS Care China as the country partner

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Objective 2: To increase the capacity of civil society and government stakeholders to deliver harm reduction and other health services to people who inject drugs and their partners in China, India, Indonesia, Kenya and Malaysia. Objective 3: To promote and protect the human rights of people who inject drugs and their partners in China, India, Indonesia, Kenya and Malaysia, and advance their rights within global institutions. Objective 4: To increase learning about effective and efficient harm reduction programmes in China, India, Indonesia, Kenya, Malaysia, Ukraine, and globally.

The assessment and planning technique The assessment and planning technique (APT) is a process which involves the application of a set of simple assessment and planning tools in order to develop a detailed plan for a new area of programming. The APT is a management rather than a research instrument and is designed to assist managers in starting up new programmes. It is designed to be applied in situations where: n

there is sufficient information collected through previous research and practice to inform the basic directions and scale of the future intervention

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top-level parameters of the intervention have already been developed

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funding for the intervention has already been secured

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the lead implementation agency has already been identified.

The APT is based on existing rapid assessment techniques, including the World Health Organization (WHO)’s Rapid assessment and response (RAR)2, The Global Fund to Fight AIDS, Tuberculosis and Malaria’s Principal recipient (PR) assessment tools3, as well as Developing HIV/AIDS work with drug users: a guide to participatory assessment and response4 and other participatory techniques developed by the International HIV/AIDS Alliance and its partners. APT shares the key features of the Who’s rapid assessment and response methodology, including speed, cost-effectiveness, use of existing data, multiple indicators and data sources, investigative orientation, induction, relevance to interventions and practical issues, community involvement, and adequacy rather than scientific perfection. More specifically, the APT prioritises the following aspects of the assessment and planning exercise and shares the key features of the Alliance’s guide: 1. Community participation. 2. Expediency of the process. This is ensured through:

a. a pre-APT agreement regarding the top - level parameters of intervention

b. elimination of the time gap between assessment and planning

c. inclusion of organisational development analysis and planning to enable implementation of the intervention.

3. Stakeholder and intervention alignment. The assessment and planning exercise takes into account the relevant programmes and agendas of other organisations working on HIV and drug use issues in each of the CAHR project countries, and explores opportunities to collaborate. 4. Country ownership over the intervention.

2. W  orld Health Organization (2003), Rapid Assessment and Response Technical Guide, Geneva, Switzerland: WHO. Available at: www.who.int/docstore/hiv/Core/Index.html 3. T  he Global Fund to Fight AIDS, Tuberculosis and Malaria (2011), LFA Manual, July 2011. Available at: http:// www.theglobalfund.org/en/lfa/documents/ 4. International HIV/AIDS Alliance (2003), Developing HIV/AIDS work with drug users: a guide to participatory assessment and response, Brighton, UK: International HIV/AIDS Alliance. Available at: www.aidsalliance.org/ publicationsdetails.aspx?id=88

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The structure of the assessment and planning toolkit The assessment and planning toolkit consists of the main guide and a set of auxiliary documents including budgeting and planning templates, and a list of recommended services based on the Alliance’s Good practice HIV programming standards5 and service analysis tool. The main guide is a collection of key questions/statements describing the desired state we are aiming to achieve as a result of implementing the CAHR programme. The assessment process is designed to identify the gaps between the desired state described in each statement and the current state of the policy environment, the organisation and its programmes. The planning process defines what needs to be done in order to bridge the identified gaps and achieve the desired state. The actions may involve additional data collection and analysis, developing other programme activities, and policy or capacity-building work to enable the implementing organisation to implement programme activities effectively. The planning process also identifies the resources needed to perform the actions, including funding, time, human resources, technical support, etc.

Data collection and analysis In order to establish the current state concerning each of the questions/ statements, the assessment and planning team had to analyse existing information and collect new data. Various methods were used, including content analysis of available literature, interviews, focus group discussions, and direct observation. The audiences included some of the key international and local stakeholders such as: people who inject drugs; representatives from relevant governmental agencies, multilateral and bilateral agencies and donors; and key implementers of major HIV/AIDS programmes (such as those funded by the Global Fund). But most of the discussions had an internal nature and involved the assessment team and staff or consultants of the country’s CAHR project implementation partner, which is represented by Alliance linking organisations or a country office in each country. It is assumed that the country implementation partner possesses sufficient understanding of the approach and related issues based on their programmatic experience as well as relations with the stakeholders, including the affected communities. The APT aims to eliminate any significant time gap between data collection and other assessment elements on the one hand and the intervention planning process on the other. To this end, the APT avoids “heavy” and time-consuming documentation techniques such as recording and transcribing the in-depth interviews and focus group discussions. As far as possible, data collection incorporates analysis, which in turn informs any extra data collection that may be required. The actual planning process follows immediately after the analysis stage of the assessment. There is a scoring system applied to the main guide. The scoring is intended to simplify summary findings and recommendations as the scores indicate whether a particular aspect of service development and delivery, policy development, monitoring and evaluation (M&E) or organisational development requires particular attention during the planning process and further implementation of the programme. The scores allow for quick identification of all areas of programming and organisational capacity development that will require the most significant input.

5. International HIV/AIDS Alliance (2010), Good practice HIV programming standards. Available at: www.aidsalliance. org/publicationsdetails.aspx?id=451

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The main areas of the assessment and planning process The main areas explored include risks and vulnerabilities associated with injecting drug use, the current and desired state of HIV and harm reduction services for people who inject drugs, monitoring and evaluation of interventions, HIV and drug-related policy and environment, and organisational development issues. The following themes are included in the part of the process related to programmatic aspects of CAHR implementation (HIV epidemic and services): n

People who inject drugs, and their associated vulnerabilities and needs

This area is designed to set the key parameters of the planning process and define the programme’s approach to service development and delivery. It ensures that key areas of need and vulnerability are driving the process of defining the services provided through the programme. It also looks at the programme in relation to other programmes and service providers, and defines the extent to which the programme will reinforce the existing social safety nets accessible to people who inject drugs. n

Availability, accessibility and quality of services

This area looks at the services currently available to people who use drugs, including the range of services, their accessibility, scale and quality. It also examines the service providers and their capacities as well as identifying any gaps in the existing service packages and the potential to modify them or include additional categories of clients. It also defines the implementing partner’s plans with regard to coordination with other harm reduction programmes in the country or expanding its current harm reduction portfolio. Finally, this area looks at the potential of linking services and service providers together through referral and other relevant mechanisms. It sets out a framework for analysing the quality of services provided. n

Policy and environment

This area describes how drug-related policy and the broader policy environment influence provision of harm reduction services. It looks at procedures, policies and laws that enable and promote access to comprehensive HIV prevention services for people who inject drugs, or create barriers to people accessing those services. Analysing social and political environment helps to identify the key barriers to launching some of the essential interventions for people who use drugs. This area briefly describes the role of the government and nongovernmental organisations (NGOs) in implementing the national HIV prevention programme, and how it targets people who use drugs.

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2. The findings of the country on-site assessments CHINA HIV epidemic and services China country profile Number of people living with HIV: 740,000 [540,000–1,000,000] HIV prevalence, adults aged 15–49: 0.1% [0.1% –0.1%] Adults aged 15 and over living with HIV: 730,000 [530,000–1,000,000] Women aged 15 and over living with HIV: 230,000 [160,000–300,000] Deaths due to AIDS: 26,000 [24,000–49,000]6  ost popular drug: heroin (87.6%), swallowed or inhaled ketamines and M amphetamine-type stimulants7

Key findings China’s efforts to tackle HIV and AIDS among people who inject drugs are concentrated on the provision of methadone. Government programmes are supported via AIDS Bureaus and Centers for Disease Control and Prevention (CDCs) established in 2001, and include education, prevention, treatment, surveillance, and pilot projects for high-risk populations. According to the national programme on HIV and AIDS, drug-using populations also have access to syringes. The range of services available for people who inject drugs is increasing and the government is trying to make them more accessible, though serious barriers still exist. According to the Regulations on the prevention and treatment of AIDS, and China’s Action plan for reducing and preventing the spread of HIV/AIDS (2006–2010), the Chinese government enhanced its policy framework and started providing free antiretroviral (ARV) treatment, treatment for cases of motherto-child transmission, free schooling for orphaned children, and economic assistance and care to affected households. At the same time, access to general health care in China is based on the cost-sharing principle, which means that people can access services such as provision of methadone maintenance treatment (MMT), examination to get ARV treatment, and drug-free rehabilitation – but only at a certain cost. Such an approach makes it difficult for people who inject drugs to get access to medical services beyond their basic needs. There is a broad range of services provided for people who inject drugs but these are not always tailored to clients’ needs. Most HIV prevention services are provided at MMT sites and needle and syringe exchange sites. Services include: condoms, Hepatitis B (HBV) vaccination, information, education and communication (IEC) materials, lubricants, MMT, needle and syringe exchange, overdose prevention and response, peer counselling, prevention of mother-tochild transmission (PMTCT), psychological support, rehabilitation, treatment for

6. U  NAIDS (2009), ‘China country situation 2009’. Available at: www.unaids.org/en/regionscountries/countries/china/ 7. Q  ian H.Z., Schumacher J.E., Chen H.T., Ruan Y.H. (2006), Injection drug use and HIV/AIDS in China: review of current situation, prevention and policy implications, Harm Reduction Journal, Feb 1(3), p 4. Available at: www. harmreductionjournal.com/content/3/1/4/abstract

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sexually transmitted infections (STIs), testing and treatment for tuberculosis (TB), and voluntary counselling and testing (VCT). Services are mainly designed to meet the needs of male drug users and do not account for the type of drugs used. Regular HIV testing in China is not always anonymous. The test is often performed at a laboratory in the local health centre. Results are given after several days. These procedures discourage drug users from having an HIV test. Despite the fact that sexual transmission of HIV is becoming more widespread in the country, vulnerable populations have very little access to sexual and reproductive health services, which are usually limited to distributing condoms and providing access to abortions. Little attention is paid to providing information about hepatitis B and hepatitis among people who use drugs; testing and treatment for hepatitis C in China is only available via some private insurance companies. At the time of the assessment, China received assistance from a variety of foundations, civil society groups, corporations, and international organisations, including The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), the United States Agency for International Development (USAID), and the United States President’s Emergency Plan for AIDS Relief (PEPFAR)8. However, there is little optimism around future financial support for HIV and AIDS programming in China, especially in the case of the Global Fund because of risk of programme interruption. NGOs that provide HIV services are obviously underrepresented in China; most community-based organisations (CBOs) are actually owned by the government. During the assessment, the following organisations working on HIV and AIDS issues were visited in Cheng Du city, Si Chuan: Cheng Hua Qu and Jin Niu Qu CDCs (proposed project site partners for CAHR), Cheng Du city Center for Disease Control and Prevention (CDC), the Global Fund programme management office, Association for STI and HIV prevention,the International HIV/AIDS Alliance (UK) Kunming Office, Minority Supplier Development (MSD) Sichuan programme management office, Sichuan provincial CDC, Sichuan STI and HIV Prevention and Control Association, and state clinics providing MMT.

Recommendations The assessment of HIV prevention and treatment services for people who inject drugs in Si Chuan and Yunnan provinces led to a broad list of recommendations for the International HIV/AIDS Alliance (UK) Kunming Office, which we summarise here. n

n

n

n

n

There is an urgent need to scale up harm reduction services. Syringe exchange and methadone maintenance treatment (MMT) programmes need to be expanded to rural areas and towns that currently lack such services. Participation of civil society and representatives of key populations in service delivery needs to be increased. In order to better tailor services to the needs of people who inject drugs, there should be a participatory assessment in both provinces to improve data on sub-groups, enabling and AIDS prevention programmes to be better designed. A number of services are currently lacking and need to be established within the CAHR project. The most urgent are: an overdose prevention and response programme, including Naloxone distribution to decrease the number of lethal cases of overdose; and rapid HIV/STI testing facilities in order to improve the access of vulnerable populations to testing services. The quality of printed materials produced should be improved, and their quantity increased. This includes toolkits, peer working guides, training manuals, and brochures for people who inject drugs.

8. U  SAID (2010), China HIV/AIDS health profile. Available at: www.usaid.gov/our_work/global_health/aids/Countries/ asia/china_profile.pdf

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Results/Plans Recommendations developed during the course of the assessment were incorporated as specific action points in the workplans and budgets to be implemented in three project sites (Cheng Hua District CDC of Cheng Du city, Jin Niu District CDC of Cheng Du city, and the third site to be identified in 2012). An essential package of services based on the harm reduction package recommended by the World Health Organization (WHO)9 was identified and will be provided in all project sites. It includes: clean needles; referral to MMT and MMT-related information, including support for the MMT programme; referral to other related services, including for VCT, TB and STIs; IEC materials on overdose, STI, TB, and hepatitis; condom promotion; counselling and support (VCT, STI, TB, hepatitis); and basic medical care. Hard-to-reach vulnerable populations will be reached through adopting evidence-based interventions accounting for the different needs of certain groups of people who use drugs, such as: group-level intervention for amphetamine-type stimulant users; anonymous rapid testing for HIV, hepatitis and syphilis; and overdose prevention and response using Naloxone in existing peer-support harm reduction projects. It is also planned that within the CAHR project, good practice in harm reduction will be documented, published and disseminated among the project sites to strengthen the quality of services provided by the organisations. The development of IEC materials will be substantially enhanced; and gendersensitive services will be further developed by Alliance China.

“I plan to be the first person in Emei who manages to quit methadone.” In a quiet backstreet near the river in Emei city (Sichuan, China), a shabby teahouse is crowded as usual. Sichuan province is famous for its relaxed tea-drinking culture, and at first glance there is not much to set this teahouse apart from thousands of others. It is only a closer look that reveals that a woman at one of the more popular tables has a roll of newspaper in front of her containing a bunch of syringes. Cheng Ling* comes here most days after finishing work at the local methadone maintenance treatment (MMT) clinic to provide clean needles for heroin users, and to talk about the risks and realities of drug use. She has been a peer worker with the NGO, Five Hearts, since 2007. “Helping others makes me feel better,” she says. Cheng has a six-year-old daughter. Life is not easy for her daughter, who faces discrimination from teachers and parents of classmates who know about her mother’s background. “I might have changed, but other people haven’t,” says Cheng. But the project has provided her with stability, purpose, and a safety net. “I’d like to do more and help more; at the moment, my ability is still limited but I want to learn.” * some names have been changed Lily Hyde, International HIV/AIDS Alliance

Methadone dispenser at the MMT centre in China. © International HIV/AIDS Alliance.

Policy and environment Key findings People who inject drugs in China face detention for possession of needles, forced labour rehabilitation, publicly exposed registration lists, lack of access to clean needles, and discrimination in the workplace. Due to the government’s increased awareness about public health risks related to drug use elimination, only limited progress has been made in recent years in humanising drug policies. The Anti-drug law of the People’s Republic of China 9. W  HO, UNODC, UNAIDS (2009), Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. Available at: www.who.int/hiv/pub/PID/targetsetting/en/index.html

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(2008) started to introduce public health approaches. The Public Security Bureau (PSB) is cooperating with provincial-level Centers for Disease Control and civil society organisations to implement methadone maintenance therapy and needle exchange pilots. However, all these positive changes have not led to a decrease in the number of new HIV cases, and criminalisation continues to dominate public health approaches to drug use. It is still illegal to purchase clean needles in pharmacies. Civil society organisations depend heavily on the government due to the legal requirement for community-based organisations to be registered in order to receive funding and implement service delivery programmes independently. As a result, the current service delivery model for harm reduction is very limited, and some community-based organisations are restricted to operating in certain geographical areas.

Recommendations One of the main recommendations is to eliminate the legal and technical barriers that prevent civil society organisations providing comprehensive harm reduction services to people who inject drugs. There is a need for Alliance China to participate more proactively in provincial and local HIV and AIDS coordinating committees. It is recommended that Alliance China, together with local civil society organisations, should build partnerships with the Public Security Bureau, international organisations and welfare services. People who inject drugs need to develop stronger leadership and advocacy skills. Alliance China should strengthen its advocacy capacity and develop strategic partnerships to influence the Chinese policy landscape, including at national level. Cooperation between community-based organisations and Centers for Disease Control should focus on strengthening the government’s harm reduction policy implementation. Specific changes need to be advocated for, including: making harm reduction services available to people who inject drugs, sustaining the gains achieved by MMT programmes through interventions aimed at greater social integration and eliminating discrimination in the workplace; and removal of people who inject drugs from PSB lists. It is also important to advocate for the introduction of HIV prevention interventions for people who use new types of drugs.

Results/Plans Alliance China, together with partners, will be working to reduce stigma and discrimination against people who use drugs and their families in the workplace and in health care settings. CAHR advocacy activities will contribute to the development of communitybased organisations, including a local network of people who use drugs (Sichuan province) and a national network. This will help to increase civil society participation in public debate on drug control as well as HIV and AIDS policies. The programme will strengthen the advocacy and leadership capacity of people who use drugs and community-based organisations in Sichuan province through training in leadership and media work, as well as advocacy events. Lessons learnt and sharing of best practices from CAHR will provide information to local and national partners that will help them formulate national-level advocacy tasks related to harm reduction programmes. 13

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People receiving treatment at the MMT Centre in China. © Slava Kushakov/International HIV/AIDS Alliance in Ukraine.

Organisational development Key findings The CAHR implementing partner in China, the International HIV/AIDS Alliance (UK) Kunming Office, was registered with the Civil Affairs Bureau in Kunmingas an international non-profit organisation in October 2010. Alliance China has its main office in Kunming/Yunnan province and a small office (with two staff) in Nanning (Guangxi province). Alliance China has been implementing HIV harm reduction interventions among people who inject drugs, men who have sex with men, sex workers, and care and support projects for people living with HIV or AIDS in three provinces: Yunnan (Kunming city), Sichuan (Emei and Fushun counties), and Guangxi (Nanning city), financed by USAID, the UK Department for International Development (DFID), the Global Fund, and the Levis Strauss Foundation. As of 2010, Alliance China provided technical support and resources to key communities through grants to eight local partners (sub-recipients), disbursing around $291,000 (the average grant being $40,000). The total Alliance China 2009 budget was $757,000. The overall budget utilisation rate is 95%. In 2009-2010 USAID was the major donor accounting for the almost 100% of the Alliance China’s annual budget. Alliance China has a good track record in working with donors. Alliance China has well-established organisational management systems and policies. The staff manual contains sections on ‘Human resources’, ‘Decisionmaking’, ‘Information technology’, and ‘Travel and finance’ policies. Some parts need to be updated. There is also a separate document, the Financial policies and procedures manual, which guides Alliance China office activities and ensures that staff are accountable. In terms of partnerships, selection of sub-recipients, capacity assessment, grants, monitoring and reporting are regulated by the Onward granting manual.

Recommendations The main recommendations for Alliance China are to update the existing staff manual, and to allocate specific human resources to programme, advocacy and M&E activities. The most recent versions of the Financial policies and procedures manual (including headquarters in Kunming), the Branch financial manual and Onward granting manual should be included within the Staff manual. A new chapter on M&E procedures and standardised forms for data collection and analysis should be added. The organisational structure should be reviewed, based on the programmatic approach and long-term strategy regarding mostat-risk populations (MARPs); it should consider having dedicated staff for programmes on people who inject drugs, men who have sex with men, and care and support for people living with HIV or AIDS; and there should be a dedicated M&E strategy and clearly elaborated policy and advocacy positions. 14

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Results/Plans The CAHR workplan addresses two of the recommendations for organisational development by including a revised organisational structure under Objective 2 (to increase the capacity of civil society and government to deliver harm reduction and health services to people who inject drugs, their partners and children), and by allocating funding for a designated M&E person. Some of the other recommendations will be routinely implemented during the project term.

Monitoring and evaluation Key findings The M&E system at Alliance China was mainly represented by a reporting system that functions across all sub-recipient organisations, known as the Monitoring and Reporting System (MRS), which was developed by the Alliance secretariat. M&E guidelines for sub-recipients are mainly limited to describing the reporting process. Although quarterly data are being collected by Alliance China in a coordinated manner, there is limited aggregation and analysis of the data collected. There was no designated person responsible for M&E at the time of the assessment, mainly due to lack of resources for a dedicated staff member. Data quality assurance of reports submitted by sub-recipients is not being carried out in a systematic manner. Monitoring visits carried out by programme officers mainly focus on reviewing programme-related activities, and less attention is given to data quality assurance. Standard indicators are being used for sub-recipients’ reporting, most of which are drawn from international indicators (e.g. the second generation PEPFAR indicators). However, there is a lack of clarity and mutual agreement on coverage definitions. For example, it is not quite clear what combination of services should be provided to people who inject drugs in order for them to be counted as having been reached with HIV prevention services. Formats for data collection (e.g. logbooks, daily registers of service delivery, etc) used by sub-recipients are not standardised; different organisations use different forms. There is no universal coding system being used; people who inject drugs are mostly registered by name, which increases the potential for double-counting.

Recommendations Efficient use of data is key to an effective M&E system. It is therefore recommended that Alliance China starts aggregating data across projects and ensures that data are used for decision-making and not just for reporting. It is strongly recommended that Alliance China appoints at least one full-time dedicated M&E member of staff to be responsible for strengthening M&E activities. It is also recommended that Alliance China should develop written M&E guidance and procedures and distribute them to all sub-recipients. This should include: n

clear definitions and descriptions of all indicators being used

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how late, incomplete or inaccurate reporting will be addressed

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n

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the formal procedure for assessing M&E capacities of sub-recipients for reporting, and identifying areas for building the capacity of sub-recipients to carry out M&E standard documents to be used across all partners implementing similar services (e.g. field-level data collection forms)

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n

n

n

standard mechanisms (procedures) to periodically verify the quality of reported data at the service delivery points (e.g. random review of registers, log-sheets, etc) a systematic way of providing feedback to sub-recipients partner that would include actions to be taken to strengthen data quality (e.g. provision of further technical support, additional visits, etc) how data is to be analysed and used at all levels.

It is recommended that Alliance China establishes a unique identifier coding system for clients of all projects, based on personal data, to eliminate the potential for double-counting and obtain accurate data on coverage levels. It should also carry out a review of the existing Excel database that is being used by the Five Hearts NGO (provided by the CDC) and, if appropriate, roll this database out across all needle/syringe exchange point (NSEP) projects. This database, together with a unique coding system, would ensure a higher degree of accuracy in data reported by the implementing partners.

A meeting with officials in China to discuss the opening of the new harm reduction site. Š Slava Kushakov/International HIV/AIDS Alliance in Ukraine.

Results/Plans As a result of the capacity assessment exercise carried out with Alliance China in 2011, the role of M&E has been enhanced within the framework of the CAHR project, as well as for Alliance China in general. The activity and budget plans for 2011–2014 earmark funding for a number of M&E-related tasks that did not previously exist. First, a full-time position of M&E officer was budgeted for the whole term of the project. It is envisaged that this officer will coordinate the M&E of the CAHR project as well as M&E of other donor-funded programmes implemented by Alliance China. The following core M&E activities were also planned for and budgeted:

16

n

annual training for implementing partners on M&E

n

a sufficient number of monitoring visits to ensure data quality

n

production of client cards and a corresponding consultation meeting.

Reaching drug users with outreach services


INDIA HIV epidemic and services India country profile Number of people living with HIV: 2,400,000 [2,100,000–2,800,000] HIV prevalence, adults aged 15 to 49: 0.3% [0.3%–0.4%] Adults aged 15 and over living with HIV:2,300,000 [2,000,000–2,600,000] Women aged 15 and over living with HIV: 880,000 [730,000–1,000,000] Deaths due to AIDS: 170,000 [150,000–200,000] Most popular drug: cannabis, opiates 10, 11, 12, 13

Key findings The National AIDS Control Programme-III (NACP) in India is headed by the Secretary and the Director General of the National AIDS Control Organisation (NACO), and the Department of AIDS Control, under the Ministry of Health and Family Welfare. The Secretary and the Director General provide overall coordination of the national response and its partners11. There are also local NGOs working in the region supported mainly by international donors or the government. Examples of such organisations are the India International HIV/AIDS Alliance and the Social Awareness Service Organisation (SASO). Other organisations working in Delhi and Manipur include: the National AIDS Control Organization, Ministry of Health and Family Welfare, UNAIDS, the Bill & Melinda Gates Foundation, the Emmanuel Hospital Association (the Global Fund Round 9 Principal Recipient), the International Network of People who Use Drugs (INPUD), the International Harm Reduction Association (IHRA), and the United Nations Office on Drugs and Crime (UNODC). There are some harm reduction programmes in India; however, they remain fragmented and are often not available in certain geographical areas. The number of substitution therapy sites is limited, which creates a major challenge for people who use drugs when accessing them. Treatment of hepatitis C is not affordable for people who use drugs. The range of HIV prevention services in India includes: VCT, ARV treatment, testing for and treatment of STIs, substitution treatment, detoxification programmes, rehabilitation, needle and syringe exchange, TB treatment, IEC, testing, treatment and vaccination for HBV, HCV testing, PMTCT, core advocacy groups, etc. However, the scale of such services cannot be considered sufficient. Some services are available in some parts of the country, but they are not connected and are barely accessible by people who inject drugs without the supervision of an outreach worker. The government claims to have a referral system in place across the country; however, this system has significant gaps and creates considerable barriers for clients (for example, antiretroviral therapy (ART) counselling is provided only to people who decided to stop using drugs). In addition, the referral system is almost non-existent in smaller, rural areas. Services provided for people who inject drugs are generic for all types of drugusing populations; understanding of gender issues is limited to having separate locations for service delivery for women and men. 10. N  ACO (2004), Extent of injecting drug use and HIV/AIDS in India. Available at: www.unodc.org/pdf/india/ publications/idu_and_HIVAIDS_in_India-Monograph/08_extentofiduhiv-aidsinindia.pdf 11. UNAIDS (2009), India country situation 2009. Available at: www.unaids.org/ctrysa/ASIIND_en.pdf 12. U  NODC (2004), India country report 2004. Available at: www.unodc.org/pdf/india/publications/south_Asia_ Regional_Profile_Sept_2005/10_india.pdf 13. U  NODC (2004), India country report 2004. Available at: www.unodc.org/pdf/india/publications/south_Asia_ Regional_Profile_Sept_2005/10_india.pdf

17

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The number of syringes given out to a client daily is limited (usually two or three). Syringes are also available over the counter, but they are relatively expensive: one syringe costs about 7 rupees, the same price as enough bread to feed three people. IEC materials provided by outreach workers and peer educators that should address all treatment-related issues in relation to TB, STIs and hepatitis usually lack information on those diseases. This is partly due to the low level of literacy among the population. Overdose prevention and response services are not available in most locations, so people who inject drugs avoid calling an ambulance in case of an overdose. As a response to this, some organisations like SASO have established emergency teams who provide an immediate injection of Naloxone, if needed. Since Naloxone is a prescription drug in India, it needs to be considered in programme design. To summarise, despite the fact that India has significant experience in HIV prevention, programmes mostly focus on testing, treatment and PMTCT. Although harm reduction concepts are not new in India, harm reduction interventions are not widespread and not widely accepted. Abstinence-based approaches to drug use predominate.

The assessment team visiting SPYM (Society for the promotion of youth and masses) project in Dehli, India. Š Slava Kushakov/International HIV/AIDS Alliance in Ukraine

Recommendations Based on the findings of the assessment recommendations for Alliance India, suggested that the following components are included in the HIV and AIDS response programme in India: n

n

18

Expand outreach interventions to cover rural and remote areas, providing injecting equipment and information on HIV and AIDS and STIs to people who inject drugs in those areas. Introduce a controlled secondary syringe exchange programme to develop a better understanding of drug-using populations and increase the number of clients.

Reaching drug users with outreach services


n

n

n n

n

n

n n

Build up the system of pharmacy-based syringe distribution/exchange programmes. Provide training for VCT counsellors to improve access of people who inject drugs to testing and treatment for HIV and STIs. Develop services on sexual and reproductive health for women and men. Develop IEC materials of higher quality, which are tested prior to publishing and meet clients’ needs. Support inclusion of low threshold overdose prevention and response strategies into the national guidelines on harm reduction.

Expand the territory of service delivery. Increase the attractiveness of harm reduction services by introducing a mixed package of services to people who inject drugs.

Liudmyla Shulga, International HIV/ AIDS Alliance in Ukraine

Establish gender-sensitive programmes for people who inject drugs. Include operational research as a key component of HIV prevention programme development and testing to collect evidence on common practices.

The following recommendations were included in the CAHR programme strategy to be implemented by Alliance India in partnership with local service providers such as Sharan in Delhi, the Society for the Promotion of Youth & Masses (SPYM) in Jammu and Kashmir, Sharan in Uttar Pradesh, Sankalp in Maharashtra, Calcutta Samaritans in Bihar, Calcutta Samaritans in Jharkhand, LEPRA in Orissa, and Social Awareness Service Organization (SASO) in Manipur:

n

n

Tailor harm reduction services to the needs of sub-groups of people who inject drugs, including continued development of gender-sensitive services and introduction of adjusted service combinations for users of pharmaceutical substances.

Policy and environment Key findings The discriminatory policy undertaken by law enforcement agencies in India remains the major obstacle for implementation of harm reduction programmes in many states. The Ministry of Social Justice and Empowerment, as well as the Narcotics Control Bureau, claim to undertake a “welfare� approach to drug problems while at the same time applying punitive measures to reduce drug demand and supply. People who inject drugs face discrimination and harassment from law enforcement agencies as well as insurgent groups in the North Eastern part of the country. The findings of the assessment also indicate that the government is reluctant to undertake a reliable estimate of drug use prevalence in India. This is a major limitation in our assessment of the needs of people who inject drugs.

Recommendations There is a need to strengthen implementation of existing policies, build stronger relations between multiple stakeholders, and integrate a human rights approach to harm reduction services in India. Stronger partnerships should be built with networks working at national, state and local levels, such as the Indian Drug Users Forum. 19

SASO, a local NGO in Manipur, demonstrated the remarkable efforts being made to provide harm reduction services to drug-using populations. Staff demonstrate a high level of commitment to what they are doing and to the people they are serving. Despite poor economic conditions in the state, SASO manages to support the work of two community centres (one for men and the other for women) and one post-rehabilitation centre. The syringe exchange programme is implemented in the poorest districts, where roads are often littered with used syringes. Despite the challenges, the staff work very hard and educate volunteers among their clients, as well as working with relatives of people who use drugs. Visiting SASO was an inspirational experience, demonstrating how a group of people can make a significant change in a community even with limited financial support.

Establish a system on sexual and reproductive health (SRH) education and SRH service delivery for men and women with respect to drug use that goes beyond condom distribution and support for abortions.

Results/Plans

n

Service delivery in Manipur, India

Reaching drug users with outreach services


People with experience of drug use should embrace a more active role in HIV and drug-related policy processes. Advocacy efforts should enhance the quality and availability of harm reduction services. Examples of improvements needed include: legalisation of Naloxone and its administration without prescription; increased availability and accessibility of rapid HIV testing; and ensuring that the needs of people who use drugs are appropriately addressed within the next National HIV and AIDS programme. Service providers should include provision of legal support as part of the harm reduction package.

Results/Plans The main advocacy objective is to expand the number and geographic coverage of MMT sites, including through civil society organisations becoming providers of these services. The evidence base on HIV and hepatitis C co-infection will be developed in cooperation with the government through an enhanced national surveillance system. CAHR advocacy activities will contribute to creating an enabling environment for people who use drugs to access services and rights. Advocacy will be undertaken to ensure that legal services are included in harm reduction packages as well as building better links with different advocacy networks and pressure groups. At the national level, Alliance India will engage with NACO to expand coverage, ensuring that the needs of various groups are adequately addressed.

Outdated posters aimed at people who use drugs (on the left) alongside new ones on the right, India. Š Slava Kushakov/International HIV/AIDS Alliance in Ukraine.

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Organisational development Key findings The India HIV/AIDS Alliance is a non-profit organisation registered under the Companies Act 1956. It is also registered under the Foreign Contribution (Regulation) Act (FCRA) for receiving foreign funds. Alliance India implements a Global Fund Round 6 Grant (care and support programme) with consistent A1 ratings from the donor, which indicates achievement of all programmatic targets. It also implements a Global Fund Round 9 Programme for men who have sex with men and transgenders. Besides this, the organisation implements an Elton John Foundation-funded programme for female injecting drug users, sexual reproductive health and rights, and programmes to support people living with HIV and AIDS funded by the European Commission (EC) and the United Nations Development Programme (UNDP). The organisation has a comprehensive and recently updated Staff manual, which includes chapters on ‘Human resources’, ‘Financial policies and procedures’, ‘Decision-making’ and ‘Procurement’. It describes decision-making authorities and responsibilities at different levels. Management of sub-recipients, including their selection, disbursement of funds, termination and suspension of grants, and monitoring and reporting of activities is regulated by the Onward granting manual, which is mostly based on the requirements of specific donors. Alliance India has a separate Grants management unit, which monitors and manages the grants at sub-recipient level. The organisation systematically provides technical support to its sub-recipients. A capacity-building plan is prepared on the basis of a capacity assessment carried out at the beginning of the granting process. Progress on capacitybuilding is regularly monitored during visits. Alliance India also has good experience in management of contracts, and its procurement systems are well placed to address various contractual requirements. It has effective and robust financial management systems that enable the organisation to operate with a large number of sub-recipients and sub-contractors and use its funding effectively. This is also supported by reliable budgeting and accounting systems.

Monitoring and evaluation Key findings In general, Alliance India’s M&E systems are sound and constitute a solid basis for CAHR programme monitoring. The organisation has extensive experience in data collection and producing reports for various donors, including the Global Fund, UNDP, and the EC. As mentioned earlier, it has consistently received an A1 rating as the Global Fund’s Principal Recipient. All M&E-related processes and procedures in Alliance India are well documented; there is an M&E handbook for each project, which contains detailed guidelines and tools for implementing M&E activities. All relevant M&E plans, process maps, recording and reporting forms are tailored to each project. Quarterly review and technical support visits to sub-recipients (and occasionally to sub-sub-recipients) focus on data quality assurance, as well as programme practices. The visits take place over two to three days; they involve random data checks, development of corresponding recommendations, and review of the implementation of recommendations from previous visits.

21

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Different software tools are used for data tracking within different projects. A comprehensive and sophisticated online database is used for the Global Fund’s Round 6 project (care and support for children affected by AIDS); some projects use Excel, others do calculations manually using paper-based forms. Alliance India attempts to minimise double-counting when calculating coverage of services provided. Several client coding systems exist in supported projects, and each system is linked to a particular project. There are several drawbacks within the current system of client coding: (1) the client code has the NGO identifier in it, thus there is a potential for double-counting when aggregating data across NGOs; (2) a client is usually “assigned” to an outreach worker, so if this client is also registered by another outreach worker, there is potential for doublecounting; (3) client cards are not in use; it is necessary to retrieve the client’s code from the “master” registry each time the service is provided, increasing the potential of error as coverage numbers increase; (4) the coding system might differ depending on the service even within the same provider, which sometimes leads to assigning several codes to a client even within one project.

Recommendations Alliance India’s M&E team has full capacity to develop or adapt an M&E system for the CAHR programme without external support; however, it should still consider learning from the experience of other countries (e.g. Ukraine) in M&E of interventions targeted at people who inject drugs, especially in relation to using a client database (possibly SyrEx) and unique identifier code. Given the scale of interventions planned under the CAHR programme, manual calculation of coverage will be extremely difficult, and a software tool should be used to enable proper data processing, as well as a reliable coding system – preferably one that is unique throughout services/NGOs and based on clients’ personal data.

Results/Plans Two important practical steps were taken in order to ensure that the recommendations outlined above will be implemented. First, Alliance India’s M&E Manager visited Ukraine in November 2011 to share experiences, and specifically to learn about the SyrEx database used for client tracking in Ukraine and assess its applicability for India. Next, a technical support visit to India and further discussions were carried out in March 2012 in order to customise the database to meet Alliance India’s needs, conduct training sessions for Alliance India staff and its major sub-recipients, and ensure a smooth roll-out of the tool for efficient data collection and analysis.

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KENYA HIV epidemic and services Kenya country profile Number of people living with HIV: 1,500,000 [1,300,000–1,600,000] HIV prevalence, adults aged 15–49: 6.3% [5.8%–6.5%] Adults aged 15 and over living with HIV: 1,300,000 [1,200,000–1,400,000] Women aged 15 and over living with HIV: 760,000 [650,000–860,000] Children aged 0–14 living with HIV: 180,000 [98,000–260,000] Deaths due to AIDS: 80,000 [61,000–99,000] Orphans due to AIDS aged 0–17: 1,200,000 [980,000–1,400,000] 14, 15, 16 Most popular drug: injecting and non-injecting heroin, used by 1.9% of the population17

Key findings The HIV and AIDS response in Kenya is regulated by the Kenya National HIV and AIDS Strategic Plan. This is organised around four primary strategies: health sector HIV service delivery; sectoral mainstreaming of HIV; community-based HIV programmes; and governance and strategic information.18 Kenya has extensive experience in HIV prevention among the general population. The same methods are applied to specific vulnerable populations and, therefore, key needs of those populations are overlooked. There are strong indications that new resources to fund HIV work with mostat-risk populations (MARPs) will soon be available from a number of sources, including the Global Fund, as Round 10 money is disbursed, and also from the US government, following changes in policy to support a more evidence-based approach to HIV and drug use. However, currently, services for people who inject drugs are rarely provided by HIV service organisations; the anticipated Global Fund support focuses on general prevention programmes and those meeting the needs of people on ART. The following organisations were working on HIV and AIDS issues at the time of the assessment: the International Centre for Reproductive Health (ICRH), the Kenya AIDS NGOs Consortium (KANCO), the National AIDS Centre, the Kenya Red Cross Society, the Reachout Centre Trust, the Nairobi Outreach Service Trust (NOSET), the Muslim Education and Welfare Association (MEWA), the Omari Project, and the Teens Watch Centre. There is a lack of services for drug-using populations in Kenya. For example, there are no information materials focusing on safer drug use (whether injecting or non-injecting practices); the drug-using population are not mobilised and not engaged in planning and implementation of programmes.

14. UNAIDS (2009), HIV and AIDS estimates. Available at: www.unaids.org/en/Regionscountries/Countries/Kenya/ 15. UNGASS  (2010), Country progress report – Kenya. Available at: www.unaids.org/en/dataanalysis/monitoringcou ntryprogress/2010progressreportssubmittedbycountries/kenya_2010_country_progress_report_en.pdf 16. U  NGASS (2006), Country progress report – Kenya. Available at: data.unaids.org/pub/Report/2006/2006_ country_progress_report_kenya_en.pdf 17. N  ieburg P., Carty L.( 2011), HIV prevention among injection drug users in Kenya and Tanzania: new opportunities for progress. A report of the Center for Strategic& International Studies (CSIS) Global Health Policy Center. Available at http://csis.org/files/publication/110428_Nieburg_HIV_Web.pdf 18. U  SAID (2010), Kenya country profile. Available at: usaidlandtenure.net/usaidltprproducts/country-profiles/kenya/ kenya-country-profile

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After years of work tackling HIV and AIDS in Kenya, there are many HIV-related services available: ART, VCT, community health centres, condoms, drop-in centres, family counselling and family planning, HBV vaccination, HCV testing and treatment, hospital-based rehabilitation, IEC on general HIV prevention, PMTCT, referral for VCT and rehabilitation services, reproductive and sexual health programmes, testing and treatment for STIs, and screening and treatment for TB. However, all those services are not readily available for people using drugs due to the strong stigmatisation related to drug use, along with requirements to pay for services. For example, according to a reference group of people who inject drugs, out of 308,000 patients on ART in 2009, only 38 were people who inject drugs. Payment for services imposes additional barriers. For example, STI treatment in a government clinic costs $2.5; drug treatment and rehabilitation in one of six centres costs $335, which is beyond what many people can afford. Methadone maintenance treatment (MMT) and overdose prevention and response programmes are generally not available, although methadone is available privately at a high cost in a small number of sites. NGOs do not provide community-based syringe exchange programmes. Syringes can only be bought in the pharmacy at a price of $0.10; however, they are sold on at up to $0.40 each to people who inject drugs. There are also no specific services for women using drugs. It is reported that the proportion of women among the drug-using community is as low as 5–10%. However, considering that Kenya lacks reliable data on drug-using populations, this number might be significantly under-reported.

The man taking Rohypnol. Š Slava Kushakov/International HIV/AIDS Alliance in Ukraine.

Recommendations Kenya has solid experience in implementing programmes on HIV and AIDS prevention and has enough potential and resources to establish services for drug-using populations. As a priority, KANCO:

24

Reaching drug users with outreach services


n

n

n

n

n

n

n

Initiate rapid scaling-up of a comprehensive HIV prevention programme targeting people who inject drugs across the country, focusing initially on syringe exchange and gradually adding other components to decrease the incidence of HIV and STIs. Conduct operational research to study key characteristics of drug-using populations and sub-groups. Develop an effective programme aimed at satisfying the needs of those groups, based on the research results. Pay particular attention to sub-groups of people who inject drugs, such as young drug users, drug users who are switching from smoking to injecting, and female drug users. Adopt a strong referral system, which could substantially strengthen access of vulnerable communities to services already provided in the country. Improve access to information materials and equipment for harm reduction to meet the needs of people who use injecting and non-injecting drugs. Advocate for the human rights of people who inject drugs, including universal access to health and social services.

Results/Plans The following activities were planned within the CAHR project on the basis of the assessment results: n

Technical support will be provided in the following areas to build the capacity of existing civil society organisations and stakeholders:

1. The development of interventions addressing the risks of transition from heroin smoking to injecting.

2. The development of a behaviour change communication (BCC) strategy to strengthen the impact of current BCC activities.

3.

4. The development of good practice guidance and tools/protocols to facilitate monitoring and evaluation.

5. Further analysis of the nature, challenges and opportunities for programming presented by the local drug scene.

6. Analysis of laws and policies and their implementation in order to inform the development of policy to regulate the delivery of harm reduction services.

n

The development of structured and monitored referral mechanisms.

The number of services provided by community-based organisations to drug users will be expanded through grants to sub-recipients working with people who use drugs, such as the Omari Project (Malindi), the Reachout Centre Trust (Mombasa), MEWA (Kilifi), the Teens Watch Centre (Ukunda), and NOSET (Nairobi).

Policy and environment Key findings The Narcotic Drugs and Psychotropic Substances Act (1994) criminalises drug use. It is illegal to possess syringes without a purpose; this can lead to criminal prosecution and imprisonment for four years. Thus far, the response to drug use in Kenya has focused on drug control with little regard to its consequences for HIV. Law enforcement agencies, the criminal justice system and the National Authority for Campaign against Alcohol and Drug Abuse (NACADA) have been working towards a “drug-free Kenya”. 25

Reaching drug users with outreach services

An episode of drug use in Kenya The man who was injecting was a very experienced drug user who had been injecting for more than 20 years. He used an insulin syringe already filled with the solution. He showed us how he mixed heroin with water using a plastic cup from the syringe. He put the powder in the cup and added a little bit of water. The syringe was half full and only 0.5 ml of water had been used for the injection. The water used was drinking water from the bottle. To rationalise the use of water, it is usually put in the plastic bottle cup. I was told that the drug should be dissolved in warm water, otherwise “you will get shakes”. No filter was used this time. To tie up the arm, he used a string which he had on his neck; it looked like the one for a conference badge. He was trying to find the vein but could not do so. He finally managed to inject and we left the place. While we were walking back to the docks, two military policemen with machine guns approached us. The social worker talked to them and it seemed that they understood the purpose of our visit and were aware of the outreach project. One of the drug users was holding injecting water and spirit wipes in his hand and the policemen noticed this but did not say anything. The drug users and the social worker acted normally and it was hard to say that they were at all disturbed or worried by the police approaching us. Pavlo Smyrnov, International HIV/ AIDS Alliance in Ukraine


These practices have led to stigmatisation and marginalisation of people who inject drugs. Current demand reduction interventions include drug prevention awareness and education campaigns, restriction and control of supplies, and rehabilitation for dependent drug users to attain abstinence. There are currently no government-funded HIV prevention programmes for people using drugs. Furthermore, a high level of corruption and involvement of government officials in the drug trade adds more complexity to the policy landscape. At the same time, the policy space for harm reduction approaches to HIV and drug use is increasing as the National AIDS Control Council (NACC), the National AIDS and STI Control Programme (NASCOP) and the Ministry of Health are acknowledging the lack of focus on the most-at-risk groups, including people who use drugs. The government is starting to recognise that current drug control-related policies and practices undermine its ongoing efforts to reduce the spread of HIV.

Kibera slum in Nairobi, Kenya. Š Slava Kushakov/International HIV/AIDS Alliance in Ukraine

Recommendations HIV legislation, policies and programmes should be amended to allow for harm reduction strategies to be legally implemented and integrated with existing health services and law enforcement strategies. Introduction of harm reduction policies should be a core part of a comprehensive, efficient HIV response. The legal environment should respect the rights of people who inject drugs. Clients of harm reduction programmes or patients of substitution treatment should be treated the same as those receiving abstinence-oriented treatment programmes. Legal support should become part of the basic harm reduction package of services; the advocacy capacity of people who use drugs needs to be strengthened. There is also a need to conduct internal advocacy within implementing organisations to build stronger confidence in harm reduction approaches.

Results/Plans It is expected that CAHR advocacy activities will aim to promote an enabling environment for the scale-up of effective HIV and harm reduction services. The 26

Reaching drug users with outreach services


advocacy agenda will focus on positioning harm reduction as an important part of the broader national HIV response. A core advocacy strategy is to promote methadone maintenance treatment (MMT) as a key HIV prevention and ART adherence measure. Advocacy will include developing operating policies and procedures, establishing mechanisms for collaboration between service providers, law enforcement agencies and civil society organisations. A particular priority is to improve cooperation between health service providers, law enforcement agencies and the prison system, bringing greater coherence to law enforcement and public health approaches to HIV and drug use. Case-work advocacy and strategic litigation implemented within the CAHR project will enable KANCO and its partners to provide legal representation and advocacy for individuals to enable them to access their entitlements to health care and social protection. Advocacy capacity for harm reduction and drug policy reform will be built among civil society stakeholders. Project activities will contribute to the development of a Kenyan network of people who use drugs. Furthermore, it is expected that KANCO and its partners will build collaborative relationships with key agencies involved in the development of policy and interventions related to HIV and drug use.

Organisational development Key findings KANCO is a national membership network of NGOs, community-based organisations and faith-based organisations involved in HIV and AIDS and TB activities in Kenya. KANCO was established in 1990; it is open to all registered NGOs, community-based organisations, faith-based organisations, people living with AIDS support organisations, educational establishments, and public and private sector organisations in Kenya. Since 2002, KANCO has worked with 87 sub-recipients. It has documented The grant strategy (2009), specifying the onward granting cycle, how it assesses the capacity of sub-recipients, how it regulates selection of sub-recipients, and outlining procedures for contracting and granting, including reporting requirements. Management of relationships with sub-recipients is incorporated into grant agreements, as are the reporting requirements for sub-recipients. Financial monitoring of sub-recipients is carried out via analysis of their monthly financial reports. Monitoring of programme implementation is carried out by the Partnership and Business Development Manager through the verification of programme reports. The grant strategy does not specify the organisation’s methodology in respect of programme and financial monitoring, and should be updated to include such policies. Whenever it provides financial support, KANCO also identifies the subrecipient’s technical assistance needs. KANCO has Procurement guidelines, which outline basic procurement rules/principles, procurement methods and choice of procurement procedures, including the threshold for tendering procedures, selection criteria, and the procurement process. It also has a Conflict of interest policy (2010), which outlines what constitutes a conflict of interest and procedures for disclosing and dealing with conflicts of interest. KANCO does not have a separate approach in the approval system in respect of healthrelated and non-health procurement. It has a Financial and accounting policy and 27

Reaching drug users with outreach services


Procedures manual; however, there is no formalised anti-fraud policy. KANCO plans to elaborate a Risk management policy, which would address this issue.

Recommendations KANCO should: extend its capacity for grant management (including strengthening human resources); consolidate assessment tools for subrecipients into a single document; develop its onward granting software system to manage sub-recipients; develop its capacity-building strategy to provide adequate technical support for sub-recipients; update its procurement guidelines to define the composition of and decision-making process for the tender committee; and update its financial and accounting policy and risk management policy to address issues of fraud, stock-take process, and categorisation of expenses, authorisation principles, roles and responsibilities.

Results/Plans All recommendations were either incorporated into the CAHR strategy and workplan or will be carried out routinely in the course of implementing the CAHR programme.

A discussion of voluntary counselling and testing with a member of Reachout Centre Trust in Mombasa, Kenya. Š Slava Kushakov/International HIV/AIDS Alliance in Ukraine

Monitoring and evaluation Key findings The M&E system observed in KANCO at the time of the assessment was functioning well in terms of data collection, aggregation, and reporting, but it is very much donor-driven; KANCO was carrying out limited data analysis across all the projects being implemented. There is one designated staff member responsible for M&E, but this same person is also responsible for overall management of certain projects. This does not allow sufficient time for adequate data analysis and use and development of standard operating procedures in the area of M&E. Verifying the quality of data used in reports is carried out by both individual programme managers and the M&E Manager. However, there is no standard visit report form to be completed, which would summarise any gaps identified, provide recommendations, and check that recommendations from previous visits 28

Reaching drug users with outreach services


are being acted on. In general, such visits focus on programme-related activities; data quality assurance is not prioritised. The major weakness identified in KANCO’s M&E practices was the lack of a mechanism that would allow the organisation to generate accurate coverage figures for services targeted at most-at-risk populations. At the level of service provision, there is no coding system for risk groups, thus complicating registration of service provision. There is strong potential for double-counting. The indicators are mostly manually calculated and entered into data reporting systems or templates as there is no central database, which would capture information on individuals reached and services provided to them across projects funded by different donors. One potential sub-recipient for the CAHR project does use a code-based electronic database to record service delivery and certain data quality assurance procedures; however, the client code is linked to the outreach worker ID, which may cause problems when aggregating data across different periods and /or outreach workers.

Recommendations There were several key recommendations, which, if implemented, will provide a solid basis for good-quality M&E activities within the CAHR programme in Kenya, and reliable reporting: 1. KANCO should develop an M&E Handbook/Standard operating procedures manual, including sections on: data collection, verification, analysis, tools used, reporting requirements, standard definitions of core indicators, instructions on data entry and use, responsibilities for data collection, procedure in relation to incomplete or inaccurate reporting by sub-recipients, provision of technical support, pre-assessment, and field visits (including relevant forms), with corresponding templates of reports and programme evaluation. 2. It is strongly recommended that KANCO employs a corresponding technical assistance to help roll out a unique client identifier code, which would be based on personal data of people reached with services, but at the same time would not breach confidentiality. A client card system will need to be rolled out to all clients. 3. KANCO should use a database that would allow data aggregation across different periods of time and would be flexible enough to analyse data and produce various user-defined reports centrally. The SyrEx database currently used in Ukraine and planned for use in Malaysia is one option; another would be to carry out a detailed analysis of the database used by the potential subrecipient in Mombasa to ascertain if it would be appropriate for use by the CAHR programme. 4. KANCO should provide sufficient human resources, within the consortium and for sub-recipients, in order to ensure proper monitoring of activities, data quality assurance, and analysis of programme data so that it can inform future decision-making on programme activities.

Results/Plans M&E-related technical support was already planned for year two of the CAHR programme’s implementation, which would aim to address all existing gaps in the M&E system, including the development of a unique identifier code and establishment of a client database. Other activities, such as workshops with sub-recipients on data recording and reporting, became part of the workplan for future programme implementation.

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INDONESIA HIV epidemic and services Indonesia country profile Number of people living with HIV: 310,000 [200,000–460,000] HIV prevalence, adults aged 15–49: 0.2% [0.1%–0.3%] Adults aged 15 and over living with HIV: 300,000 [200,000–460,000] Women aged 15 and over living with HIV: 88,000 [58,000–130,000] Deaths due to AIDS: 8,300 [3,800–15,000]19 Most popular drug used: heroin, amphetamine-type stimulants20, 21, 22

Key findings In its response to HIV and AIDS, Indonesia established a National AIDS Commission (NAC) in 1994 to focus on preventing the spread of HIV and coordinating the efforts of government, NGOs, the private sector, and community organisations. The government prioritised certain areas of the response, including prevention of HIV among vulnerable populations, ARV treatment and voluntary counselling and testing (VCT).23 The Governmental harm reduction programme initiated in 2003 to reduce the incidence of HIV transmission was based primarily on syringe exchange, condom distribution, and VCT. NGOs’ efforts in Indonesia are extensively donor-driven, with strong donors such as the Global Fund, the Australian Agency for International Development (AusAID), and the United States Agency for International Development (USAID). Although partnership between the major donors is regulated by a memorandum of understanding, there are tensions between organisations, which have created difficulties for programme planning and coordination. The following organisations were working in CAHR-supported areas at the time of the assessment: the Counsellors Network, the Drug User Network, the Harm Reduction Network, Rumah Cemara, and others. The following services were offered in Indonesia at the time of the assessment: ARV treatment, TB treatment, community health centres, HBV vaccination, HCV testing and treatment, VCT, hospital-based rehabilitation, IEC, MMT, needle and syringe exchange, PMTCT, referrals, and testing and treatment for STIs. Services are mainly provided in local health clinics and outreach spots that operate till 2pm. The number of items distributed is limited to three syringes, three condoms and three alcohol swabs. District health clinics provide a range of services. For instance, VCT is widely available in 547 clinics with all sites giving an option of laboratory or rapid testing (performed by three tests of different manufacturers) at a cost of $3.87.

19. U  NAIDS (2009), HIV and AIDS estimates. Available at:www.unaids.org/en/Regionscountries/Countries/ Indonesia/ 20. N  ational AIDS Commission Indonesia (2010), UNGASS Country progress report: Indonesia, 2010. Available at: aidsdatahub.org/en/indonesia-reference-library/item/12188-ungass-country-progress-report-indonesianational-aids-commission-indonesia-2010 21. T  he Department of Health Indonesia, the National AIDS Commission, KomisiPenanggulanganAIDS, et al. (2007), Integrated biological- behavioral surveillance among most-at-risk groups in Indonesia, 2007: surveillance highlights – injecting drug users. 22. U  NAIDS (2010), Republic of Indonesia country report on the follow-up to the declaration of commitment on HIV/ AIDS (UNGASS) reporting period 2008–2009. Available at: www.unaids.org/en/dataanalysis/monitoringcountrypr ogress/2010progressreportssubmittedbycountries/indonesia_2010_country_progress_report_en.pdf 23. Ibid

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Testing and free treatment for STIs (excluding hepatitis C) is also available, although a nominal fee of $0.33 is charged. Free treatment for STIs and TB is supported by the Global Fund grant. ARV treatment is provided free but the registration fee to start treatment costs $1.70. Fees for service registration or delivery are, in many cases, a significant barrier for vulnerable populations to get access to those services. According to the United Nations General Assembly Special Session (UNGASS) 2010 report on Indonesia, HIV prevention programmes traditionally target male drug users, while women represent less than 5% of those reached. Sexual and reproductive health services are very limited in many parts of the country and focus mainly on condom distribution. There are numerous challenges in delivering these services, given cultural sensitivities. Furthermore, most staff in harm reduction projects are self-trained, and programmes are often planned based on their personal experience. This has led to some gaps such as reaching out to drug users taking drugs other than opiates, or work with women using drugs.

Peer educators, Banceuy Narcotics Prison, Indonesia. Rumah Cemara work with this group providing psychosocial support. Š International HIV/AIDS Alliance.

Recommendations Several specific approaches that relate to service delivery were suggested to Rumah Cemara during the assessment. They include the following: n

n

n

n

n

31

Introducing a system of ongoing education and technical support for the staff of Rumah Cemara and implementing partners. Training programme staff to conduct operational research for further programme development. Introducing a gender-sensitive approach to service delivery and improving access to sexual and reproductive health services. Working towards taking control of the production and distribution of IEC materials. With high rates of opiate consumption in the country, it is necessary to establish overdose prevention and response programmes that include Naloxone distribution.

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Another list of recommendations relate to longer-term tasks: n

n

n

Increase coverage of vulnerable populations by delivering HIV/STI prevention services, including scaling up the programme to all parts of all provinces. Develop integrated client-friendly and cost-effective system of service delivery. There should be stronger collaboration between government, local and national NGOs, and international agencies in combining their efforts to prevent HIV.

Results/Plans In order to cover the gaps identified during the assessment, Rumah Cemara included the following activities/elements in the CAHR project: n

n

n

n

The basic package of services for CAHR clients will include syringes, alcohol wipes, condoms, information materials, and peer counselling. Provision of psycho-social support for MMT clients will include case management, self-help groups, family counselling, employment assistance, professional counselling (spiritual, legal), and nutrition. Psycho-social support will be introduced in Bandung (in partnership with Komets), Cirebon (in partnership with Cirebon Plus Support) and Sukabumi (in partnership with Sukabumi Positive Community). Support to people who inject drugs who are preparing for release from prison will be provided through group sessions. This intervention will be undertaken in Bandung and in Cirebon by the organisations mentioned. More efforts will be used to reach out to younger people who inject drugs via peer outreach in the nightclubs of Bandung.

Policy and environment Key findings Legislation passed in 2009 decriminalised drug use in Indonesia. This represents an important legal change compared with the previous 1997 legal provision. At the same time, Indonesia retains the death penalty for drug offences. In 2004, the National AIDS Commission and provincial officials signed the first official agreement to support and implement harm reduction services, and in 2009 police regulation outlined a special approach to women. However, in practice, the 2009 law and other regulations are not applied, and law enforcement officers and courts continue to prosecute drug users. Indonesian laws do not provide guidelines for sentencing based on the amount of narcotics in possession, so judges have broad leeway to hand down heavy sentences. According to NGO workers, needles and syringes can be used as evidence of drug use, and it is not clear whether needles and syringes are prohibited by law. Weak implementation of existing policies is one of the major obstacles for implementation of an effective HIV response among people who inject drugs in Indonesia.

Recommendations CAHR project advocacy activities should focus on awareness-raising and building stronger partnerships with local law enforcement authorities, paralegal staff and government officials. In addition, there needs to be greater participation of people who use drugs in decision-making processes; referrals from the court system to NGO-operated treatment and rehabilitation programmes need to be increased; and harm reduction services need to be implemented in a more

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Reaching drug users with outreach services

A visit to a prison in Indonesia The prison Lapas Klas IIA in Banceuy Bandung is an unusual one – with very good living conditions for inmates, free movement within the prison areas, sports grounds, outdoor garden with a pond and a fountain, and an opportunity to keep domestic animals such as cats. The staff seem friendly and supportive towards NGOs who work with them on harm reduction issues, providing comprehensive care to inmates who have a history of drug use. And they have been a longstanding recipient of funds from the Dutch Ministry of Foreign Affairs. Prisons do not normally provide VCT, ART and not all prisons have a methadone maintenance treatment (MMT) programme. This prison has a low rate of TB cases, and 50% of the people on MMT were HIV positive. But that could change due to the discontinuation of support from the donor. So in that situation, the prison would be even more in demand for NGOs supporting a referral system for people who use drugs to take up services outside of the prison after their release. Introduction of syringe exchange programme in prisons may face barriers. Prison staff do not mention inmates using drugs in prison, but it is highly likely that drug use occurs. Paola Pavlenko, International HIV/ AIDS Alliance in Ukraine


comprehensive way. Taking into consideration public concerns on how the government is addressing drug issues, it may be possible to leverage public opinion as part of advocacy activities. Advocacy is needed to: end the criminalisation of drug use; expand access to pharmacy-based syringe distribution/exchange programmes; mobilise resources to cover the gap in counselling, diagnostics and treatment for hepatitis; and to waive payments for services such as PMTCT, VCT and MMT for people who inject drugs, to increase uptake of those services.

Results/Plans A number of specific steps will be taken by Rumah Cemara to address these recommendations: n

n

n

n

Local-level advocacy to protect the human rights of people who use drugs and promote referrals from criminal to rehabilitation services. Regular meetings with local police, judges, and prosecution teams in Bandung, Cirebon, Bogor and Sukabumi. Training on advocacy and human rights for Rumah Cemara and implementing partners. Documenting and disseminating best practices in advocacy and human rights in Indonesia.

Rumah Cemara has been winning tournaments and breaking down HIV stigma by playing football Š Rumah Cemara.

Organisational development Key findings Rumah Cemara is a community-based, not-for-profit service organisation of and for people who used or are using drugs in West Java/Indonesia, with its main office in the city of Bandung. Rumah Cemara’s membership constitutes the largest network of people living with HIV and people using drugs in West Java; it includes 4,317 people living with HIV and drug users, and 1,276 people affected by HIV or AIDS within 61 peer support groups. The organisation was registered in December 2008. It has been implementing harm reduction programmes and outreach for people who inject drugs with needle and syringe exchange, distribution of condoms and of information materials, helping peer-support groups, and providing

33

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care and support activities for people who inject drugs who are HIV positive. The organisational culture within Rumah Cemara is that “everyone is equal”, with one person often carrying out a mix of roles and no formal line management responsibilities. Decision-making is done through discussion among all Rumah Cemara staff members before going to management and the board for approval. The organisation has developed a draft Staff manual with sections on ‘Human resources’, ‘Reporting’, ‘Communication and complaints/Grievance procedures’. Recruitment is mainly done among recovering drug users who went through the Rumah Cemara Treatment Centre, based on the principles of the therapeutic community. There are no written procedures for selection and management of sub-recipients. In practice, Rumah Cemara places an advertisement on its website to invite proposals from potential sub-recipients. The submitted proposals are shortlisted by the Resource Mobilisation Manager with support from the Treatment Manager, Grant Manager and Finance Officer. The visit to assess capacity is usually carried out by the Resource Mobilisation Manager, with one other staff member. Rumah Cemara has no written procedures on procurement.

Recommendations During the assessment it became clear that certain areas of the organisation’s functioning need to be improved and strengthened. It is recommended that Rumah Cemara management develop, in consultation with the board and staff, clear terms of reference for board members. It is important to strengthen and clarify individual reporting lines within the organisation. An ‘Onward granting’ section in the manual should formalise capacity assessment and monitoring of sub-recipients as well as relationships between Rumah Cemara and its sub-recipients. It is also suggested that steps are taken to strengthen the organisation’s financial planning and reporting oversight. An Operational Manager should be recruited, who would be responsible for organisational policies and procedures, and take charge of the administration and financial units.

Results/Plans The CAHR workplan addresses recommendations for organisational development and includes three activities under Objective 2: a) development of a staff manual (onward granting, HR, filing, procurement); b) training for finance staff on budgeting, forecasting, and management of accounts; and c) development of an organogram with units, positions, reporting lines and names.

34

Reaching drug users with outreach services


A field visit to the outreach site in Bandung. Š International HIV/AIDS Alliance in Ukraine

Monitoring and evaluation Key findings M&E is viewed as an important area of work at Rumah Cemara. For example, apre-assessment form used to assess the capacity of its implementing partners contains a section on M&E; and M&E-related technical assistance is provided during monitoring visits. However, there are no programmatic M&E procedures that would describe data recording and reporting processes and functions, either for Rumah Cemara or its implementing partners. Nor is there any established procedure for data quality assurance; monitoring visits mostly focus on service delivery issues. A number of staff are involved in M&E: outreach workers/case managers, coordinators of specific areas of work and the Data Manager have a role in data recording, aggregation, producing donor-specific reports, data entry, etc. An electronic database exists as a data saving tool rather than for data aggregation and analysis. It is not used to generate reports for donors; instead, the Coordinator produces reports based on electronic versions of paper-based registration forms completed by outreach workers. Rumah Cemara tries to avoid double-counting of clients reached with its services. For example, sub-recipients use client coding systems. However, the coding system is not unique (different coding systems are being used depending on who provides the services); furthermore, client cards are not being used, requiring the outreach worker/peer to establish the code during each episode of service delivery, which maximises the potential for error. All these factors make it difficult for Rumah Cemara to identify the actual number of people who inject drugs they are reaching with harm reduction services.

Recommendations Rumah Cemara should develop standard operating procedures for M&E, or an M&E Manual, which would describe procedures for data collection, aggregation, analysis and reporting, the paper-based and electronic forms that are being used, as well as clear responsibilities of each member of staff and at every level of the process, as well as the database and its functions. The roles and responsibilities of different staff members and of sub-recipients should be clearly defined in this document. There is also a need to standardise the system of data collection: the organisation should use one format for client registration forms, a unique code for each client, and a standard format for client cards. 35

Reaching drug users with outreach services


It is also recommended that Rumah Cemara reviews the function of the existing electronic database, or introduces a different one (e.g. SyrEx, currently used in Ukraine and recently introduced in Malaysia), in order for it to function effectively as an instrument for client-level data analysis and report generation, not simply for data storage. There should be more emphasis on data quality assurance at all stages of the M&E process. Data quality checks should become part of routine monitoring visits to sub-recipients. Corresponding forms needs to be developed, which would indicate which specific documents should be checked and for what, so that the procedure does not depend on the knowledge of the person who implements it. Programme staff and M&E staff should both pay greater attention to data quality during monitoring visits.

Results/Plans The M&E-related activities are represented within the CAHR workplan and technical support plan, and include training for staff of sub-recipients, monitoring visits, and technical support to improve M&E practices. The technical support visit took place in January 2012 and focused on a number of areas identified in the recommendations, including development of M&E policies and procedures and electronic database-related support.

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MALAYSIA HIV epidemic and services Malaysia country profile Number of people living with HIV: 100,000 [83,000–120,000] HIV prevalence, adults aged 15–49: 0.5% [0.4%–0.6%] Adults aged 15 and over living with HIV: 100,000 [83,000–120,000] Women aged 15 and over living with HIV: 11,000 [8,600–15,000] Deaths due to AIDS: 5,800 [4,500–7,200] 24 Most popular drug: heroin with amphetamine-type stimulants on the rise 25

Key findings Malaysia has a very capable health care system offering a diverse spectrum of services to the general population. Marginalised populations, including people who inject drugs, have limited access to health care. There is a range of services designed for people who inject drugs; however, most of those are not participatory, rely on resource-intensive and unsustainable service models, have limited opening hours, and are characterised by other parameters that significantly restrict their relevance and accessibility. The Malaysian government has developed strong ownership over HIV prevention and care programming. Despite the significant HIV prevention efforts directed at people who inject drugs, the scale, spectrum and quality of services needs to be significantly improved. People who inject drugs have limited involvement in the development and implementation of programmes, and the emerging networks of people who inject drugs or people living with HIV are still weak, with limited influence on decision-making. The further development of such networks is restricted by challenges of access to substitution maintenance treatment such as complicated admission procedures, inappropriate dosage, and lack of adherence support. The existing programmes implementing by Malaysian AIDS Council (MAC) rely on limited data on the numbers of people who inject drugs as well as characteristics of sub-groups, the local drug scene and vulnerability factors, overdose prevalence, and other aspects which are important to inform effective harm reduction interventions. At the same time, it is known that people who inject drugs and their partners remain key to the dynamics of the epidemic in Malaysia. Injecting and sexual practices associated with high risk of HIV transmission are prevalent among people who inject drugs. People who inject drugs are not a homogenous population. There are subgroups with diverse characteristics and vulnerabilities. These groups of people who use drugs vary by their substance of choice, socio-demographic and cultural characteristics. There is particularly high prevalence of injecting drug use among three communities: deep-sea fishermen, palm-oil and rubber plantation workers, and those living in poor urban districts of Kuala Lumpur and other large cities. Programmes need to be designed to address peculiar characteristics and challenges of each sub-group. The programmes need to further investigate

37

24.

U  NAIDS (2009), HIV and AIDS estimates. Available at: www.unaids.org/en/Regionscountries/Countries/ Malaysia/

25.

U  NAIDS (2008), UNGASS Country progress report – Malaysia, 2008. Available at: http://data.unaids.org/pub/ Report/2008/malaysia_2008_country_progress_report_en.pdf

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factors such as high prevalence of homelessness among people who inject drugs, as well as high mortality rates (which are evident despite the low reported prevalence of overdose), and restricted access to ARV treatment by people living with HIV who use drugs. The current response to the HIV epidemic among people who inject drugs is characterised by the following challenges: 1. Limited intensity of information, education and communication (IEC) work aimed at initiating behavioural changes that decrease vulnerability to HIV and other harms related to injecting drug use. 2. Insufficient coverage of HIV prevention interventions among people who inject drugs, linked to underdeveloped outreach capacity. 3. Restricted access to clinical care services by people who inject drugs, including OST and ART and related support services, including those designed to ensure adherence.

Recommendations After close study of the HIV service delivery mechanisms in Malaysia, the following recommendations are made for Malaysian AIDS Council: n

n

n

There is a strong need to establish a solid system of collaboration between non-governmental organisations, the state, and health care institutions. Introduction of low-threshold HIV/STIs rapid testing may substantially increase the number of those tested who are either injecting drug users or commercial sex workers. Professionals working in voluntary counseling and testing, opioid substitution treatment, and other areas must be trained on various aspects of drug users’ behavior and risks to provide high-quality counselling and meet clients’ needs.

A better understanding of the drug scene is needed to tailor HIV prevention programmes to the needs of different sub-groups identified. This can be achieved via formative research or Participatory sites assessment as recommended by the World Health Organization (WHO); a methodology for this is described in the Alliance’s guide Developing HIV/AIDS work with drug users: a guide to participatory assessment and response.26 n

n

n

n

Give special attention to the development of gender-sensitive services that would address the specific needs of men and women who use drugs. Integrate HIV prevention services with services to prevent and treat hepatitis and TB. Develop overdose prevention and response strategies and collect reliable data on the number of overdose cases and the number of averted overdose cases in the country. Introduce programmes on sexual and reproductive health designed to meet the needs of vulnerable populations.

26. International  HIV/AIDS Alliance (2003), Developing HIV/AIDS work with drug users: a guide to participatory assessment and response, Brighton, UK: International HIV/AIDS Alliance. Available at: www.aidsalliance.org/ publicationsdetails.aspx?id=88

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A drug dealer with a selection of drugs at the site visited by outreach workers of MAC partner organisation, Malaysia. Š Slava Kushakov/International HIV/AIDS Alliance in Ukraine.

Results/Plans The CAHR programme in Malaysia has been designed to enhance the harm reduction services provided within the existing programmes funded by the government of Malaysia and the Global Fund, as well as to introduce new activities designed to increase the reach and quality of harm reduction interventions. These include the development of more sophisticated and targeted outreach techniques, accessibility of legal support and advice, as well as qualified psychological support. Another area of work for CAHR in Malaysia is to guide key national stakeholders towards improvements in policies and regulations as well as development, introduction, and consistent application of evidence-based standards guiding the delivery of harm reduction and HIV prevention services for people who inject drugs. The programme will help to shift the balance from aresource-intensive, agencybased service delivery model to a mobile and flexible outreach-based one. It will boost the capacity of the front-line service providers to effectively challenge and influence the behaviour of clients. Other intended improvements include the design and implementation of gender-sensitive services, optimisation of opening hours and regularity of service delivery, innovations in outreach (including secondary service delivery and peer-driven approaches), fuller utilisation of existing capacities, as well as significant geographical expansion.

Policy and environment Key findings In 1983, the Malaysian government introduced the Drug Dependants (Treatment and Rehabilitation) Act, which promotes a zero tolerance policy to drugs, including a two-year mandatory treatment and rehabilitation for anyone who is considered drug dependent. In 2000, Malaysia committed to achieving a drug-free society by 2015 . This resulted in an even more punitive approach. Due to the rapid spread

39

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of HIV among people who use drugs, in 2005, the National Anti-Drugs Agency (NADA), under the Ministry of Home Affairs, started to introduce harm reduction services and has been developing community-based treatment alternatives. The National strategy on HIV/AIDS 2006–2010 focuses on government-funded harm reduction programming. These interventions are carried forward in the National strategy on HIV/AIDS 2011–2015, though the national strategy does not include overdose prevention, hepatitis C testing or treatment, rehabilitation, or childcare. At the same time, drug policies and their enforcement undermine the efficiency of harm reduction programmes. The national drug policy, primarily based on the Dangerous Drugs Act (1952), strongly contradicts more progressive harm reduction policies. Drug use, possession, trafficking and production are criminalised. Technically, the possession of needles and syringes, especially used ones, can be used as evidence in court to prove drug crimes and facilitate convictions. Arrests often take place at MMT and needle and syringe exchange point (NSEP) sites. NADA and the Ministry of Home Affairs have expressed interest in revising drug policies and strategies for 2011–2015. However, their capacity to get the changes through parliament is limited due to weak political support for these changes and strong opposition from Muslim religious leaders. Civil society engagement in the national response to HIV is extremely limited due to the limited capacity of NGOs and civil society organisations.

Recommendations n

n

n

n

The laws for drug offences should be revised so that harm reduction services could be implemented more efficiently. The Malaysian AIDS Council’s capacity to do advocacy work on drug policy should be strengthened. There is a need to rapidly establish partnerships with national paralegal networks to support MAC’s drug policy efforts and engage other relevant stakeholders to build a stronger civil society voice. Law enforcement agencies and officers, as well as religious leaders, should be sensitised to understand the need to harmonise drug control and public health policies. There is an urgent need to raise awareness among opponents about the efficiency of harm reduction programmes. Standard operating procedures for MMT and NSEPs need to be revised. In particular, standard operating procedures for condom distribution should be developed. The MAC should work with relevant stakeholders, including the Ministry of Health and NADA, to ensure effective scale-up of ART provision, especially targeting people who use drugs. Cooperation with the Ministry of Labour needs to be established to develop incentives for potential employers to hire people who use drugs as part of their recovery programme.

Results/Plans A number of specific policy and advocacy-related actions to be carried out within the CAHR programme were determined: n

n

40

CAHR should support better collaboration between relevant stakeholders to acknowledge and address policy challenges for the development of harm reduction programmes, including those associated with the country’s zero tolerance drug policy. The programme will support the required revisions of existing standard operating procedures and the development of new ones, working with the

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Ministry of Health and NADA to develop and implement the ART access strategy for people who inject drugs, and supporting their involvement in further development of harm reduction activities in the country. n

n

n

Advocacy skills within MAC and partner organisations will be improved through advocacy training. The curriculum for law enforcement will be revised to ensure that it corresponds to harm reduction practices. Standard operating procedures on MMT, NSEPs and ART will be revised to ensure that they correspond to the needs of people who use drugs, particularly women.

Amran Ismail (left), founder of CAKNA, a CBO supporting people who use drugs, provides a needle exchange service at Mohammed Endut’s plantation, where people who use drugs are employed, Malaysia. Š International HIV/AIDS Alliance

Organisational development Key findings MAC is an umbrella not-for-profit organisation that currently unites 48 NGOs, community-based organisations and professional associations. It was established in 1992. In recent years, it has had a substantial annual budget (about $4 million) for programmes supporting most-at-risk populations and HIV-related policy and advocacy. Most programmes are funded by government ministries and international donors. MAC provided grants to 10 sub-recipients in 2010. MAC’s activities are regulated by its Constitution and the few operational guidelines (Employee handbook and Financial manual) that are in the process of review and approval. However, it should create a comprehensive organisational manual that also included recruitment policy and procedures, key organisational policies to be developed (e.g. code of ethics, conflict of interest, anti-fraud, whistle-blowing, HR/recruitment and employee rules), as well as granting procedures, and written procurement procedures (for health-related and other goods and services).

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Assessment and monitoring of sub-recipients is not regulated by any formal procedures. However, there are external documents that provide guidance for project monitoring and assessments – for example, the Site assessment guide for upscale of NSEP (Ministry of Health) and Malaysian needle and syringe exchange program pilot project: standard operating procedure for NSEP pilot sites (Ministry of Health). Due to multi-donor funding, MAC uses multiple categories and various requirements in terms of reporting and principles of financial data management.

Recommendations The assessment identified a number of areas where improvements are needed in MAC’s organisational structure. These include: shifting some operational decision-making from the executive committee to the secretariat level; creating a dedicated unit for procurement; clarifying or changing roles and responsibilities of various teams and structures; and simplifying the structure and adjusting it to the existing level of budget and workload in various programme areas. Another area identified for technical assistance is updating or developing organisational policies and procedures. MAC needs to develop written procedures on granting, describing all aspects of the grant management cycle.

Results/Plans The CAHR project workplan for Malaysia addresses recommendations for organisational development and includes two activities under Objective 2, namely to carry out organisational restructuring of MAC, and to develop and approve a Staff manual.

Beneficiaries at a needle exchange outreach programme in Terengganu, Malaysia. © International HIV/AIDS Alliance

Monitoring and evaluation Key findings MAC has well-established M&E activities due to its considerable experience in implementing state-funded HIV and AIDS activities, and providing the required reports. MAC’s M&E unit was established in 2008 and now has three staff members responsible for M&E. In general, the M&E systems in place are sound, and with some further improvements will constitute a solid basis for monitoring both the Global Fund and CAHR programmes (when the assessment visit was carried out, MAC was just about to take on its role as Principal Recipient of a grant from the Global Fund). 42

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The organisation’s data management processes are documented within its M&E Manual (although not specifically for syringe exchange projects); all the required forms and tools are present, such as data collection and reporting forms, data verification and system assessment sheet, etc. However, there are not enough monitoring visits to sub-recipients to check data quality. This is mainly due to limited number of M&E staff; programme staff carry out more frequent field visits but are not responsible for data verification. The main weakness of the M&E system within MAC was very limited data aggregation, analysis and use. Most forms and tools being used were designed to capture monthly data at sub-recipient level (the Ministry of Health required monthly reporting), with no systems in place that would allow for data aggregation across months and quarters for further analysis by MAC management. While the Access-based client database currently in use serves its purpose of keeping track of monthly data at sub-recipient level, it does not allow the generation of reports on individual clients reached across months. Sub-recipients and MAC itself have only a vague idea about the number of clients served during any quarter or even over the year, resulting in a high risk of double-counting in reported coverage figures.

Recommendations One of the key recommendations that emerged from the assessment visit was for MAC to utilise a client-based database that would allow data aggregation across periods of time and would be flexible enough to allow data analysis and produce various user-defined reports at the central level (e.g. calculating annual coverage, numbers of clients regularly reached with services, etc, avoiding double-counting). It was agreed that MAC would explore the SyrEx database developed and used in Ukraine as a possible way forward in this area. However, an improved service delivery monitoring system at MAC may lead to more conservative coverage estimates, which might be interpreted by stakeholders or donors as a decrease in coverage. In the event that this happens, it would need to be carefully interpreted and explained. It was also suggested that MAC revises its monitoring visits procedure so that programme staff conduct data verification at the sub-recipient level together with reviewing programme activities on a routine basis. M&E staff would only visit subrecipients for data quality assessment and the provision of technical support in problematic cases, as they currently do. This change would allow MAC to increase the number of verification visits and improve the quality of reported data. Another recommendation relates to the outdated and unreliable national key population size estimates being used in Malaysia. It was suggested that MAC carry out an exercise to estimate the numbers of people who inject drugs (as part of an integrated bio-behavioural surveillance (IBBS) survey to be carried out by Ministry of Health in 2012, or as a separate exercise).

Results/Plans The main result that emerged from the M&E capacity assessment at MAC was adaptation of the SyrEx database for use in Malaysia and its further roll-out among MAC sub-recipients. After a consultancy visit in June 2011, the SyrEx system was updated according to an agreed list of changes, with a remote training for MAC staff responsible for its implementation. As a result, MAC has implemented the SyrEx database system and it is now being used by staff and sub-recipients. Annual training sessions on SyrEx for MAC programme staff and sub-recipients were budgeted for during the assessment. The first training took place in the third quarter of year one of the CAHR project implementation. 43

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3. Strengths, weaknesses and applicability of the assessment and planning technique (APT) The following strengths and weaknesses of the APT were identified by the reviewers who conducted the five country assessments.

Strengths n

n

n

n

The assessment tool is a good source of information on a variety of issues; as it is mostly focused on broad areas, it allows the reviewer to elaborate on certain relevant topics, providing as many details as possible. The tool makes it possible not only to collect information but also to identify which aspects of interventions will require particular attention during programme planning and implementation. The tool provides a structure to collect information about the country situation, various aspects of service delivery and access to services, the drug-using community, etc. It also offers a scoring system to minimise individual bias during the assessment. The tool helps to collect information on structural issues (including drug use criminalisation, procedures, policies and laws related to services, policy discourse, key obstacles) and processes (including programmes, budget, stakeholders, drug law reform) related to drug use, HIV policies, human rights protection (legal aid services, human rights stakeholders, experience in policy changes) and organisational capacity (including representation in national bodies) for policy and advocacy.

Limitations and areas for improvement n

n

n

n

n

n

44

The main limitation is lack of a rigorous literature review on the situation in the countries prior to the assessment visits, which could greatly improve information reliability. Based on the areas of focus and the specific questions, the tool is currently less informative in describing elements of the political situation and social structure, nor does it provide a clear picture on the funding available in the country and the key components supported by donors. The scoring system used is definitely an asset but at the same time it limits the value or excludes non-quantifiable information that may be significant for a better understanding of the situation in any one country. Although information is collected from several sources and can therefore be cross-checked, interviewees (managers and clients) may try to show their programme in a better light than the reality. Information bias can be caused by different levels of experience, different backgrounds and levels of programme understanding. It would be useful to include joint themes and related actions across different sections of the assessment. For example, it is particularly important that the tool makes it possible to ensure that ‘Policy and environment’ priorities respond to the needs of programmatic areas. Taking into consideration that assessment processes often involve a number of unresolved issues which need to be followed up after the assessment, it is recommended to include space for “unresolved issues/issues requiring follow-up” in each section of the assessment.

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In general, despite these limitations, the APT proved effective in assessing the in-country situation and pulling together the necessary knowledge to proceed with programme planning and development of strategy on programme implementation. Apart from the assessments’ obvious role in CAHR programme planning in China, India, Indonesia, Kenya, and Malaysia, it is envisaged that completed assessments could help national as well as international stakeholders develop a quick picture of the country-specific situation in relation to HIV services for people who inject drugs, and assist significantly in planning future actions in order to address the gaps identified.

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4. Conclusion Using the assessment and planning tool in five diverse countries implementing CAHR project activities identified the value of the tool for rapid assessment, tightly linked to planning and implementation of services in relation to HIV and AIDS. In all of the areas that were assessed (risks and vulnerabilities associated with injecting drug use, the current and desired state of HIV and harm reduction services for people who inject drugs, monitoring and evaluation of interventions, HIV and drug-related policy and environment, and organisational development), the assessment team was able to capture unique and insightful information, much of which was rapidly translated into action points and implementation plans within CAHR, as well as broader strategic recommendations. Furthermore, conducting the assessment exercise allowed the teams to develop a technical support plan spanning the CAHR project timeframe and focusing on the most challenging areas identified during the assessment. CAHR project implementation benefited considerably from the assessment process; the success of using the tool also created potential for its further use in other contexts.

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Supporting community action on HIV, health and rights to end AIDS

“A well-designed rapid assessment tool allows for programmes to commence more quickly, armed with the in-depth knowledge about the context.�

International HIV/AIDS Alliance (International secretariat) Preece House 91-101 Davigdor Road Hove, BN3 1RE UK Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901 mail@aidsalliance.org Registered charity number: 1038860

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Reaching drug users with outreach services


Setting the scene: Assessing and planning with harm reduction partners