Outreach to Most-at-Risk Populations through SIDC in Lebanon

Prevention for Most-at-Risk Populations

Packages distributed by outreach workers include male condoms, lubricant packs, material on HIV/STIs/hepatitis, and injecting equipment.

People who inject drugs (PWID), sex workers, and MSM are identified by the U.S. President's Emergency Plan for AIDS Relief as populations most at risk of HIV infection. Global guidance stresses the importance of tailoring gender-sensitive prevention, treatment, and care to these populations (Joint U.N. Programme on HIV/AIDS [UNAIDS] 2009a, 2009b; World Health Organization 2005).

Successful outreach to most-at-risk populations (MARPs) recognizes the sociocultural context and particularly the gendered norms in which MARPs live. It aims to strengthen access to basic services through a human rights-based approach, empowers clients to improve their socio-economic status, reduces violence, and educates service providers on intersections of gender and HIV risk as well as strategies to reduce stigma and discrimination. To achieve this, outreach workers raise awareness of how gender norms can increase HIV risk; deliver basic information on HIV, hepatitis, and other STIs; offer counseling to support positive behavior change, such as correct and consistent use of condoms and sterile injecting equipment; and distribute free condoms, syringes, and lubricants. Outreach workers also support clients' efforts to take charge of their lives by improving their condom negotiation skills, referring them to vocational training as appropriate, and discussing actions to take in cases of violence.

They also provide referrals to such key services as HIV testing or treatment. Outreach is most successful when conducted by peers or individuals who have access to and are trusted by the MARP communities. International experience shows that programs must also address structural issues that reinforce practices that directly or indirectly promote stigma, discrimination, and violence towards MARPs. Longer term programming aimed at addressing these lega and social constraints related to social and gender norms should complement outreach to MARPs.

The Lebanese Context

With a population of over 4 million, Lebanon has an estimated 3,000 persons living with HIV. Reported HIV cases indicate a 4:1 male-to-female ratio, with sexual transmission as the main mode of infection (87 percent; National AIDS Control Programme, Ministry of Public Health 2010). National adult prevalence is approximately 0.1 percent. However, what appears to be a low level of HIV is not necessarily the whole picture of HIV in Lebanon. As global experience shows, such national-level data may mask the potential for smaller but more intense epidemics within certain communities or regions of the country.

As in many parts of the world, those most vulnerable to HIV in Lebanon are likely to experience marginalization and stigma because of their sexuality, gender identity, or illegal behavior, such as drug use and sex work. Although there is no law against homosexuality, an article in the national penal code outlaws "sexual intercourse contrary to nature," which many consider to be a reference to homosexual intercourse. These populations also face serious stigma within their communities because they are seen to deviate from accepted gender, sexuality, and social norms.

National government and nongovernmental partners in Lebanon recognize this situation and the consequent increased HIV infection risk among marginalized populations. Indeed, research indicates high risk rates: 43 percent of female sex workers do not use condoms with irregular clients (clients who may only visit the sex worker once or infrequently), 43 percent of PWID did not use a condom during their last sexual intercourse with a partner (nonsex worker), and 62 percent of MSM report having sex only with sex workers, which indicates how pervasive male sex work is among MSM (National AIDS Control Programme, Ministry of Public Health 2008). This additionally demonstrates the overlap in risk among different MARP groups. The distinction between the groups may be blurred on many occasions. Social and economic pressures also increase the vulnerabilities of MARPs. For example, in one study only 15 percent of female sex workers said they would stop a sexual relationship when faced with violence, mainly because of their need for the income or their sense of disempowerment (National AIDS Control Programme, Ministry of Public Health 2008).

The national HIV strategy has designated MARPs— specifically MSM, PWID, and sex workers—a priority for Lebanon's HIV programming efforts, and there is a national push to include MARPs in such key processes as national strategic planning. The national HIV strategy highlights MARPs in three of its four priority areas: human rights, advocacy (to review policies and legislation related to MARPs), prevention (to promote voluntary counseling and testing [VCT], and to work on the prevention of HIV and STIs among the three MARPs), and surveillance (to develop second-generation surveillance strategies targeting MARPs).

SIDC: Outreach to Those Most at Risk

The SIDC outreach program began in 2001 as a collaboration with the National AIDS Program (NAP). A decade earlier, SIDC volunteers began noticing drug use issues in their districts and contacted the NAP, which trains youth on HIV and drug use. That same year, SIDC also established a hotline that later expanded into a counseling center. In 1996, SIDC collaborated with the U.N. Office on Drugs and Crime to conduct Lebanon’s first street-based study with drug users. In 1999, at UNAIDS’s request, SIDC began conducting outreach to PWID, sex workers, and MSM.

SIDC’s goal is to better understand these hidden communities, improve their access to services, and address social norms that render them vulnerable. An advisory committee that includes the Ministry of Interior, Interior Forces, and U.N. agencies supports SIDC outreach activities. A network of field workers affiliated with four main partner NGOs conduct the outreach (see Figure 1). Funding comes from different sources, starting with the United Nations in 2001; currently, the Drosos Foundation and the International HIV/AIDS Alliance provide funding. Some of the donors have funded the entire program, while others support only certain program elements or only activities related to one of the MARPs.

The key principles that govern program implementation include inclusiveness and partnership with the target population, peer education, harm reduction, flexibility and continuity of activities, capacity building, experience sharing, partnership development, and confidentiality.

Reaching Most-at-Risk Populations

Outreach workers offer handouts and referrals.

Most outreach workers are themselves either MSM, former sex workers, or PWID. Among the factors considered in their selection are communication, networking, and listening skills; their passion for and personal belief in the mission and principles of the program; their level of education; and their reliability.

The outreach workers receive standardized training from SIDC. Gender norms are an important feature of the training under the topics of vulnerability to HIV infection, sexuality definitions and nuances, stigma as it relates to gender and sexuality, and gender-based violence (detection, counseling, and referral). The outreach workers also conduct exercises on condom negotiating skills and on how to empower their clients and build confidence.

All outreach workers, regardless of the group they target or their NGO affiliation, use a unified monitoring system. Outreach workers complete a reporting form after each outreach session, entering standard data on their target group, discussions, and services given. The NGO coordinator transfers the forms to SIDC. SIDC analyzes the data, produces a unified report, and shares it with a wide range of partners and NAP. All data are  disaggregated by sex and gender, including male, female, and transgender; as well as by target population, including sex workers, PWID, and MSM. The goal is to help SIDC staff understand the gender dimensions of the target groups, such as whether certain locations are better suited to reach female clientele, or if male clients are more likely than female clients to ask for condoms.

Outreach workers establish relationships with individuals in their target group and chat with them about the services they offer. They find their clients through social networks and by visiting locations known to be frequented by their target populations. Selecting outreach workers who possess the appropriate skills, attitudes, and experience plays a big role in their ability and readiness to locate and gain the trust of individuals in the target group.

The outreach workers tell their clients about HIV, other STIs, and hepatitis, and engage their clients in discussions about safer-sex behavior, such as negotiating condom use and dealing with peer pressure to share needles. The outreach workers distribute male condoms, lubricants, and syringes, and inform their target group about where to access key health, legal, and social services, such as the SIDC mobile VCT van. The van is equipped with rapid HIV and hepatitis C testing kits and is staffed by a VCT counselor. The outreach workers work with the counselors to coordinate a schedule of site locations and timing that suits their target population.

Outreach workers also discuss violence with their clients: how to avoid it and how to address it. In some cases, an NGO may intervene to assist a client with violence-related issues. In some cases, Dar al Amal, the NGO dealing mainly with female sex workers, provides shelter for sex workers facing physical violence from their pimps. The NGO has mediated disputes between sex workers and their pimps and, when needed, brings in the police to protect the sex worker.

If appropriate or the client asks for it, the outreach worker also offers information and advice about vocational training and skill-building opportunities to enhance their income earnings, and may refer the client to one of the NGOs offering such training.

The outreach program is linked to a well-developed referral system, including a telephone hotline. A total of 52 NGOs are members of this referral system, offering a range of medical, legal, psychological, and social services. These services include, but are not limited to, raising awareness, testing, diagnosis, treatment of infections, drug addiction and rehabilitation services, social and psychological counseling, legal assistance, and vocational training. Referral NGOs all abide by a unified referral protocol. SIDC produced a user-friendly referral pack listing the NGOs, the services they offer, working hours, and contact details. The outreach workers use the packs to refer their target population to the appropriate NGOs. Referral NGOs complete monthly reporting forms and submit them to SIDC for overall program monitoring.

Finally, the outreach program is complemented by other activities aimed at changing, in the longer-term, the environment that contributes to making MARPs vulnerable. SIDC and its partners are conducting a legal review of the laws governing such risk behaviors as sex work and homosexuality. Continuous advocacy is conducted with officials, the media, and the public on these issues to challenge gender norms. In addition, some implementing NGOs document and research stigma associated with gender norms. Helem, for example, produced studies on stigma associated with sexual orientation in Lebanese universities and among health care providers, and it documents human rights violations and general homophobia in the country. SIDC and Dar al Amal participated in studies documenting the status of female sex workers in Lebanon, including their experience with gender-based violence and other violations of their rights. In partnership with government partners, they completed four studies documenting the situation of sex work in Lebanon, including a legal review, a quantitative and qualitative study of clients and pimps with a sample size of 400 individuals, a situation analysis of female sex workers, and a mapping of available services for sex workers in Lebanon.

According to program data, from 2003 to the end of 2009, SIDC and its partners trained a total of 80 peer outreach workers and 70 social and health care workers, and succeeded in reaching a total of 8,946 individuals within MARPs. This includes 2,509 MSM (including male sex workers), 3,550 female sex workers, and 2,854 PWID.

What Worked Well

Programming for multiple MARPs: One of the strengths of SIDC’s outreach program is that it covers three MARPs. This is an effective methodology because of the overlap between groups and the multiple risks that some of them are exposed to, such as drug use by sex workers, or sex work by MSM. This approach reduces transaction costs so that, for example, outreach workers can attend the same training sessions and use the same monitoring program and services referral pack. However, one issue is the correct selection of the NGOs and outreach workers who will work with each group. A peer outreach worker with one group may hold stigmatizing views or not have an in-depth understanding of other groups.

A strong NGO partnership structure: Another unique strength of the program is the two levels of partnership among the NGOs. The first level is depicted in Figure 1, where SIDC coordinates the management, administration, and logistics of the program (and implements part of it), and the other four NGOs (including SIDC) implement the program. The second level is the large referral network of 52 NGOs that ensures members know about each others’ work and benefit from each others’ comparative advantage to improve effectiveness and efficiency. Both partnership levels are governed by formal contracts outlining each partner’s roles and responsibilities, including reporting. An annual stakeholder meeting brings together all NGOs, the government, donors, and international partners. The meeting is an opportunity to provide updates on the program status and agree on the way forward.

Challenges

Lack of basic population data for MARPs: Coverage is difficult to measure, because no MARP national size estimations exist. Thus it is impossible to determine the proportion of MARPs being reached or whether SIDC’s monitoring system may be counting clients more than once.

Limited geographical range: In principle, outreach is supposed to reach MARPs throughout the country; however, program implementation outside the capital has been poor for a variety of reasons, including limited NGO and staff capacities and/or interest, and funding constraints. With only one VCT van, traveling to all parts of Lebanon on a regular basis is a major logistical and financial challenge.

The need for assessment data: While program monitoring does provide a picture of implementation status (number of persons reached, condoms distributed, tests conducted, and so on), it is impossible to ascertain behavioral and attitudinal changes in the absence of an impact or outcome assessment. The outreach program has been working for almost a decade to reduce these risks, yet no outcome/impact assessment has been conducted to date. SIDC is hoping to implement such an assessment in the near future to determine if its efforts have made a difference and to better adapt the program to the needs of the target population. Meanwhile, it relies on its programmatic data and limited studies conducted with the target groups.

The need for more in-depth gender analysis: While the SIDC outreach program is responsive to what is generally known about gendered behaviors and related risks for HIV transmission for MARPs, there is not a strong evidence base about how gender impacts health-seeking behaviors for all target groups. Monitoring data reveals challenges in reaching specific target populations who remain hidden, but there is little data to explain why. For example, the program only managed to reach two females who inject drugs in 2008 and 2009. Men who inject drugs experience stigma and fear, but females who inject drugs are further burdened with gender norms and expectations that make it even harder for them to seek services. Females who inject drugs may face double stigma if they are involved in sex work, a practice that may occur to enable the purchase of drugs. There have been attempts to reach females who inject drugs, including active searches by outreach workers and the recruitment of female outreach workers, but in vain. SIDC may be able to improve outreach efforts to these groups through targeted research relating to the gendered challenges of accessing health services.

Insufficient support from the government: The national HIV strategy clearly outlines programming with MARPs as a priority, and the NAP manager salutes SIDC and its partners’ outreach program as “outstanding.” There is full coordination and ongoing communication between SIDC and NAP on the implementation and progress of the program, and monitoring forms are fully aligned to national reporting, especially as it relates to such medical issues as VCT. However, the Lebanese government’s attitude is more accurately described as tolerant rather than supportive. While the Ministry of Interior is fully informed about the program, senior officials are publicly ambiguous about syringe distribution to PWID, although efforts are under way to change that policy and the government has recently signed a decree allowing opioid substitution therapy. In addition, while Helem is an NGO, it never received an official NGO registration number. Helem—which works primarily with sexual minorities—is legal by virtue of the Lebanese legal practice that if an organization does not receive a response from the Ministry of Interior to its registration application within two months, it automatically assumes legal existence. However, the absence of a registration number prevents Helem from opening a bank account and functioning normally as a legal entity.

Female condoms are not available: Although outreach workers are briefly informed about the female condom in their training, the device is not available for distribution through the government health system and is very expensive in the private market. Female condoms remain the only female-initiated barrier method and are highly effective in preventing HIV, other STIs, and unintended pregnancies. Some research in other countries indicates that female condoms may be preferred by men for anal sex (Kelvin et al. 2009), a significant mode of HIV transmission among MSM. There is a need to examine the feasibility and cost-benefit of introducing female condoms to this program.

A need for funding continuity and sustainability: From the onset of the program in 2001, SIDC has relied on donor support, which has been both limited and intermittent. Sometimes, the program has to split work into numerous categories to suit donor interest (e.g., only one population or only one element of the outreach program). This impacts both the quantity and quality of services provided. Instead of delivering integrated services addressing multiple needs of individuals, programming at times has to be segmented according to what is considered most relevant for a defined target group. In addition there are often delays between funding cycles impeding fieldwork, particularly when outreach workers do not receive transport compensation, which limits their movement and reduces or halts VCT van operations. Communication with the target population is also interrupted and, although it can be resumed once funding restarts, data indicate that it may take time to re-establish relations (such as in 2007 and again in 2010, as indicated in Figure 2).

Recommendations

Cultivate longer-term social change: Delivering information and services is essential to an outreach program. However, at the root of the marginalization and risk MARPs experience are structural and social factors that breed stigma, encroach on the rights of MARPs, and compromise their access to services. SIDC’s outreach program addresses structural factors in a number of ways, including the following:

• SIDC and partner NGOs are part of an initiative to review and propose changes to laws related to homosexuality and sex work.

• Advocacy and discussions with government, the media, and community members are normalizing the debate around such sensitive issues as gender norms and sexuality. For example, when it first opened, residents in the neighborhood of one drop-in center complained it was bringing MSM to their communities. After repeated discussions with the outreach workers and witnessing how the NGO functioned, the neighborhood residents reversed course and started referring MSM to the center.

• As an indirect effect of the outreach program, a group of outreach workers initiated a lesbian, gay, bisexual, transvestite, queer, and intersex (LGBTQI) NGO, Helem, which advocates for equality in access and rights of persons with alternative sexualities.

A strong NGO partnership helps address gender-based violence: Among the risks faced by all three MARPs is gender-based violence. For example, sex workers may be beaten up and threatened by clients and pimps, and MSM are confronted with physical abuse related to homophobia. Gender-based violence is therefore one of the key components of the program. Outreach workers are trained to detect it and offer counseling. However, some cases may require follow-up and more support. One NGO cannot address all the needs of all MARPs, so a strong partnership with other NGOs is essential to the success of the program. SIDC successfully brought together five NGOs to implement one common program in a strong partnership that supports the capacity of all involved. It created a second level of partnership among a wider group of 52 NGOs serving as referral centers to the target population for a wide range of services. This strong partnership reduces redundancies and promotes horizontal learning between the NGOs. Outreach workers can refer their clients to a number of NGOs offering services for victims of violence, among a variety of other services such as vocational training and legal assistance.

Keep an eye on changing needs: One of the key elements of this program is that it maintains a strong link with its target population, continually updating its services based on needs. One way to do that is to ensure constant collection of data. The outreach program established a basic but comprehensive monitoring system where all collected data are disaggregated by gender and sex. This enables planners to monitor program uptake by gender and sex and, for example, determine whether a certain service is being used more by men or by women. SIDC’s outreach program has evolved several times to respond to changing needs. It began in the late 1980s, when SIDC initiated a drug use prevention program. This eventually led to establishing an HIV hotline in 1991. The outreach program began qualitative research in 2001. Since then, it has gone through many changes before it arrived at its current form. Selection criteria for outreach workers changed, the content of their training was enhanced, the services delivered were upgraded (e.g., adding the mobile van), and the referral network was strengthened over the years. However, in order to enrich its monitoring, SIDC and its partners may look towards including program outcome and program impact indicators in their data collection in order to better understand program performance.

Deliver tangible, gender-sensitive services: Information is vital but not sufficient to guarantee behavior change. This program goes beyond sharing information to offer counseling and tangible services to the target population. MARPs receive free condoms and syringes, as well as free HIV and hepatitis testing both on the spot and through a referral network. Such tangible services are more likely to influence behavior change and strengthen the target populations’ trust in the program. It is important, however, to ensure that these services are gender-sensitive. For example, only the male condom is currently distributed. Outreach workers have little information about the female condom, and it is not advocated for in the general national context. Given the importance of female condoms in empowering women to protect themselves and the preference of female condoms for anal sex, it is vital that they be made available and that staff are better informed about them.

Reach out to the most vulnerable: There are MARP subgroups that are particularly vulnerable. This program is one of the first of its kind in the region to tackle the issue of equal access to services for transgender individuals. Implementing NGOs, especially Helem, are searching for innovative ways to reach this hidden and highly stigmatized group.

Another important group that requires special attention are females who inject drugs. Of the 2,854 PWID reached through this program, only 2 were female. Females who inject drugs are exposed to multiple risks: women are more vulnerable to HIV infection both biologically and socially (e.g., they have less negotiating power for safer sex), and they are more vulnerable to physical and sexual abuse.

Females who inject drugs consequently face both compounded risk and compounded stigma. Thus there is a need for more gender-responsive services. These may include recruiting and training female outreach workers (especially females who used to inject drugs), reviewing prevention and care materials to make them more gender-sensitive, working with drug-dependence treatment and rehabilitation services to encourage the admission of female clients and the delivery of a gender-responsive approach (e.g., taking into consideration issues related to motherhood, children, and reproductive health), and access to essential gender-sensitive prevention commodities such as female condoms. Given the difficulty many programs face in reaching females who inject drugs, consultation with other NGOs that have managed to reach these women in other countries may be particularly useful.

Work toward long-term funding: One of the key challenges of the Lebanon outreach program is intermittent, unpredictable, and limited funding that interrupts implementation. NGOs should take the initiative to forge a harmonized program with funding cycles that are at least two years long. Funding should last for no less than two years to avoid gaps in program implementation; any less, and outreach workers and program staff contracts become unstable and relationships within the field are interrupted. NGOs and donors should also look into the possibility of pooled funding to cut down on transaction and administrative costs.

Future Programming

SIDC is planning to expand its work with PWID by opening Lebanon’s first drop-in center offering counseling, testing, and other key services, including opioid substitution therapy, which SIDC is working with the government to introduce. SIDC is also planning to conduct an external evaluation of the outreach program covering all implementing partners and MARPs to help the organization scientifically assess its work over the years. The evaluation should facilitate resource mobilization to sustain the outreach program and perhaps help it develop into an ongoing national program, rather than a timelimited project working in only a few areas. Finally, SIDC is collecting all its training material into one training module on outreach to MARPs to support the work of partners in the region and beyond.

References

Kelvin, E. A., R. A. Smith, J. E. Mantell, and Z. A. Stein. 2009. Adding the Female Condom to the Public Health Agenda on Prevention of HIV and Other Sexually Transmitted Infections Among Men and Women During Anal Intercourse. American Journal of Public Health 99 (6):985-987. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2679779 (accessed July 2011)

National AIDS Control Programme, Ministry of Public Health. 2008. An Integrated Bio-Behavioral Surveillance Study Among Most at Risk Populations in Lebanon: Female Sex Workers, Injecting Drug Users, Men who have Sex with Men, And Prisoners. Beirut, Lebanon: Lebanese Republic Ministry of Public Health.

National AIDS Control Programme, Ministry of Public Health. 2010. UNGASS Country Progress Report, Lebanon. Beirut, Lebanon: Lebanese Republic Ministry of Public Health. (PDF, 316 KB) (accessed July 2011).

SIDC. 2010. Interview and correspondence with Ms. Nadia Badran, HIV/AIDS Program Coordinator, SIDC, and SIDC 2010 PowerPoint Presentation, “Outreach & Community Development HIV/AIDS Prevention Targeting Vulnerable Groups.”

UNAIDS. 2009a. UNAIDS Guidance Note on HIV and Sex Work.  (PDF, 238 KB) Geneva, Switzerland: UNAIDS. (accessed July 2011)

UNAIDS. 2009b. UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People. (PDF, 238 KB) Geneva, Switzerland: UNAIDS. (accessed July 2011)

World Health Organization. 2005. Policy and Programming Guide for HIV/AIDS Prevention and Care Among Injecting Drug Users. Geneva, Switzerland: World Health Organization.(accessed July 2011)

Acknowledgments

Sincere gratitude goes to the entire staff of SIDC, most notably Ms. Nadia Badran, HIV/AIDS Program Coordinator, who spent a lot of time providing information, responding to queries, and coordinating the field work conducted for this case study. Thanks to Mr. Elie Aaraj, SIDC Director, for an honest and rich history of the program, and Dr. Mustafa El Nakib, National AIDS Control Program Manager, for his time and support. Outreach workers provide the backbone of the program, and sincere acknowledgment is owed to them for their passion and hard work, and for taking the time to meet with the author and share their personal stories. A special thanks is owed to the anonymous people who inject drugs who invited the author to the confidential VCT van session, and to Mr. Charbel Zaccour, the VCT counselor on duty, as well as to Mr. Elie Daou, Injecting Drug User Outreach Coordinator, Mr. Dany Bilal, VCT van driver, and Mr. Talal, the MSM outreach worker who allowed the author to accompany their field work. Gratitude is owed to all interviewees and every individual who donated time to provide information for this case study, most notably the staff of Dar al Amal, Helem, NGO Forum Saida, Oui Pour La Vie, and SIDC. Thanks also to the PEPFAR Gender Technical Working Group for their support and careful review of this case study.

Recommended Citation

Aon, Maha. 2011. More Than Just HIV Prevention: Outreach to Most-at-Risk Populations through SIDC in Lebanon. Case Study Series. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.