An assessment report on gender integration gaps and opportunities within KHANA s harm reduction program in Cambodia

Transcription

1 An assessment report on gender integration gaps and opportunities within KHANA s harm reduction program in Cambodia

2 TABLE OF CONTENTS LIST OF FIGURES... IV LIST OF TABLES... V EXECUTIVE SUMMARY... 6 INTRODUCTION Overview of Gender and Vulnerability to HIV/AIDS Gender Issues Among People who Inject Drugs (PWID) Regional Practices Cambodia Harm Reduction Program in Cambodia OBJECTIVE OF THE STUDY Methodology KHANA Background Harm Reduction Program for People Who Inject Drugs (PWID) Current Gaps, Emerging Opportunities Gaps Opportunities COUNTRY ASSESSMENT Findings from in country visit Findings from KHANA Mondul Meanchey (MMC) and Korsang Background Findings from Field Visit Findings from Gender Sensitivity Checklist Findings and Analysis of Gender-sensitive Indicators based on MMC and Korsang s data KEY ACTIONABLE AREAS & RECOMMENDATIONS BIBLIOGRAPHY ii

3 LIST OF ABBREVIATIONS/ACRONYMS AAMH Asia-Australia Mental Health AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy CBO Community Based Organizations CRC Cambodia Red Cross DIC Drop in Center EW Entertainment worker FHI Family Health International FP Focused Prevention FWID Females who Inject Drugs FWUD Females who Use Drugs GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HAARP HIV/AIDS Asia Regional Program HIV Human Immunodeficiency Virus HR Harm Reduction IFRC International Federation of Red Cross and Red Crescent Societies KMDC KHANA Meanchey Drop in Center KSP KHANA s Strategic Plan (KSP 15) ICP Integrated Care and Prevention IEC Information, Education and Communication IP Implementing Partner IPV Intimate Partner Violence LSHTSE Law on Suppression of Human Trafficking and Sexual Exploitation MARP Most-at-risk Populations MCH Maternal and Child Health MMC KHANA Mondul Meanchey MMT Methadone Maintenance Treatment MSM Men who Have Sex with Men MWID Males who inject drugs MWUD Males who use drugs NCHADS National Centre for HIV/AIDS, Dermatology and STD Control NGO Non-governmental Organization NSP Needle and Syringes Program NSP National Strategy Plan OI Opportunistic Infection OST Opioid Substitution Treatment OVC Orphans and Vulnerable Children PEPFAR The President's Emergency Plan For AIDS Relief PLHIV People living with HIV PRASIT Project for HIV and AIDS Strategic Technical Assistance PSI Population Services International PVHT People Vulnerable to Human Trafficking PWID People who Inject Drugs PWUD People who Use Drugs SAHACOM Sustainable Action against HIV and AIDS in Communities SRH Sexual Reproductive Health STI Sexually Transmitted Infections TasP Treatment as Prevention UHN United Health Network UNAIDS The Joint United Nations Programme on HIV and AIDS UNODC The United Nations Office on Drugs and Crime USAID The United States Agency for International Development WHO The World Health Organization iii

4 LIST OF FIGURES Figure 1: Mode of Transmission of new HIV infections in Cambodia, 2012 (n=1202 new infections) Figure 2: Gender related interventions within Harm Reduction Program under Cambodia s Third National Strategic Plan for a Comprehensive and Multi-sectoral National Response to HIV and AIDS, Figure 3: Service Coverage of KHANA s program, Figure 4: Scoring of MMC and Korsang using Gender Sensitivity Checklist Figure 5: Coverage of KHANA NSP program versus national target, as of June Figure 6: Number of PWUD/PWID who accessed an NSP over the 18 months period, by sex Figure 7: Number of PWUD/PWID reached through Outreach and DIC, January June Figure 8: Proportional of new clients towards the reported clients in 18 months period, by sex Figure 9: Number of NSP occasions of service (total contacts) in 18 months period Figure 10: Ratio of the number of NSP occasions of service in specified reporting period per 100 PWUD/PWID Figure 11: Number of needles syringes distributed per PWID Figure 12: Number of condom distributed per PWUD/PWID per 6 months period Figure 13: Proportional of PWUD/PWID referred to other health services, Jan 12 June Figure 14: Number of PWID on MMT at a specified date or over the specified reporting period (Jan 12- June 13) iv

5 LIST OF TABLES Table 1: Estimated adult and women (15+) living with HIV in South-East Asia, Table 2: Epidemiology of HIV, Harm Reduction Responses and Policy in South-East Asia Table 3: Gender-sensitivity harm reduction services for FWUD/FWID Table 4: National policies, strategies or programs that currently facilitate access to HIV programs and services for women and girls, people living with HIV and mostat-risk populations in Cambodia Table 5: Harm Reduction Program in Cambodia Table 6: A review of KHANA s Strengths and Achievements Table 7: Identified gaps and recommendations for the indicator achieved related to Harm Reduction Program among PWUD/PWID under KSP Table 8: Standard Package of Activities for People who Use Drugs, implemented by KHANA Table 9: Comparison table of the number of PWUD/PWID (both male and female) accessed to STI services, ARV/OI & monitoring and TB treatment & monitoring, January 12 June v

6 EXECUTIVE SUMMARY Gender inequalities, harmful gender norms and gender-based violence continue to contribute to HIV-related vulnerability. Globally, HIV prevalence among young women aged years is approximately two-fold compared to males of the same age, which reveals that women are more likely to acquire HIV at an early age In comparison to men. Notably, women who have experienced intimate partner violence (IPV) are 50% more likely to be living with HIV. Most of the countries that conducted midterm reviews of their national AIDS response acknowledged the central importance of addressing gender inequalities. Since the UNAIDS Agenda launch in 2010, Cambodia, Indonesia, Myanmar, and Thailand are a few of the South-East Asian countries which have undertaken more actions and made more progress for women, girls, gender equality and HIV. The findings indicated that the efforts undertaken a wide variety of actions across all three recommendations of the Agenda (i.e. knowing the HIV epidemic, translating political commitments into scaled up action and creating an environment for the fulfillment of women s and girls human rights) are producing results. Cambodia is one of the few countries to achieve the Millennium Development Goal of halting and reversing the spread of HIV, with prevalence falling from 1.75% in 1998 to a projected 0.7% in This is a key milestone for the country particularly given high levels of poverty and inequality, devastation of infrastructure during decades of war and heavy reliance on foreign aid. Heterosexual sex remains the main mode of HIV transmission in the country, but many infections also occur among people who inject drugs (PWID) and men who have sex with men (MSM). Poverty, gender inequality and changes in sexual behaviour continue to drive the HIV epidemic. KHANA currently is the largest national NGO focusing on HIV and AIDS in Cambodia. In 2011, KHANA worked in 19 out of 24 provinces and municipalities in the country through a network of 38 implementing partners to implement prevention, treatment, care and support programs. The Harm Reduction program for PWID is provided by KHANA and its Implementing Partners (IPs) through two different models, namely; Services as outlined in the Standard Package of Activities for people who use drugs (PWUD) and KHANA Meanchey Drop in Center (KMDCfrom here onwards refers to MMC). However, the issue gap of gender integration into Harm Reduction Program has not been addressed. The main objective of the study is to provide recommendations to improve and update KHANA s Gender Strategy 2010, by accessing and analyzing the gaps and opportunities for gender integration within KHANA s harm reduction response in 6

7 Cambodia. The study thus will help to build the capacity of KHANA s Policy Team, Harm Reduction program staff, and other relevant staff of KHANA and its implementing partners to advocate for greater gender integration into harm reduction programs in the country. Based on the desk review, key findings for gender integration gaps and opportunities within KHANA s Harm Reduction Program are summarized as follows: GAPS Gap#1: Gap #2: Gap #3: Gap #4: Gap #5: Gap #6: Gap #7: Gap #8: Gap #9: Gap #10: Gap #11: Gap #12: Lack of gender-based approach in KHANA s standard packages of activities for people who inject drugs (PWID). Lack of sensitivity in addressing gender differences among people who inject drugs (PWID). Lack of gender-sensitive Monitoring and Evaluation of Harm Reduction program. Lack of funding specifically for women-related programs. Lack of individual and institutional strengthening to enable KHANA to fully implement a rights-based approach and mainstream gender and sexuality. Lack of capacity to conduct sexual reproductive health component in the service package, for example, family planning and antenatal care for pregnant females who inject drugs. No research evaluating the impact of gender integration on Harm Reduction Program. Lack of availability of female condoms (and lubricant) in the KHANA s Focused Prevention (FP) program. Lack of connection with services for gender-based violence. Lack of integral Harm Reduction Programs for females who inject drugs (FWID) who are also entertainment workers. The high mobility of the peer outreach workers is a challenge. Additional funding outside the core service program to fund people who inject drugs (PWID) is required. 7

8 Gap #13: Gap #14: Increased workload of field worker in data collection. Lack of free legal aid for females who use drugs (FWUD), including females who inject drugs (FWID) and female sexual partners of people who inject drugs (PWID). OPPORTUNITIES Opportunity #1: Evidence based on the KHANA Meanchey Drop in Center (referred as MMC) and Korsang, integration of gender perspective into DIC services. Opportunity #2: Gender issues were identified in KSP 15. Opportunity #3: Recognition of violence as a cause and consequence of HIV in the National Action Plan to Prevent Violence against Women (2nd NAP-VAW). Opportunity #4: Receive free health care through the Ministry of Health s Health Equity Fund (HEF) scheme. Opportunity #5: Creating enabling environment for Harm Reduction Program through Police Community Partnership Initiative (PCPI). Opportunity #6: Recommendations from Cambodian National Health Sector Response to HIV Review

9 KEY RECOMMENDATIONS 1. Increase gender equity in Harm Reduction Program a) Recognizing that women s, men s, TG s, MSM s, girls and boys needs differ is the first step to finding ways of tailoring responses to those needs. Engaging and involving all form of people who inject drugs (PWIDs) and people who use drugs (PWUDs), and their sexual partners in program design, implementation, and evaluation not only improves program outcomes but also enhances self-esteem and helps reduce stigma by demonstrating the value of the contribution of womens, mens TGs, MSMs, girls and boys life experience. 1 b) Implementation of gender-responsive services requires that all program staff undergo ongoing, not one-off, gender-sensitization training on the concerns and needs of each PWID/PWUD. c) Services must have a more gender-based approach by scheduling flexible hours, implementing drop-in and outreach services and having services available in the evening and on weekends 2, setting minimal rules for use of services, and creating women or men-only spaces or hours 3 (where possible, offer safe space for clients who access the drop in center as couples ). d) Develop mother and father targeted program (a safe space for families who live on the streets) in Harm Reduction Program such as providing child care where their children are able to stay when parents are accessing the services in the program or required to earn a living. 4 e) Financial, procurement, and distribution barriers to wide distribution of female condoms and lubricant must be addressed to enable FWID/FWUD or female partners of MWID/ MWUD to exercise more control over HIV prevention with partners unwilling to use a male condom. 1 Spratt, Kai Technical Brief: Integrating Gender into Programs with Most-at-Risk Populations. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. 2 Currently, the Drop in center and Outreach Workers provide services to clients 5 day a week (from morning to evening) to PWID/PWUD. On weekends and nation holidays, services are available to MMT patients. KHANA also provides motor drive to transport client to access MMT on daily basis. 3 In Drop in center, KHANA has allocated space for clients (both males and females) to rest, shower, lundry and access to IEC. However, it is hard to separate their male and female partners for a different space when they accessed the services as a couple. 4 Currently, the project opens for all target groups including their children in providing primary health care. However, KHANA recognizes funding gap that prohibits expansion or sustainability of such intervention into current program 9

10 2. Increase gender-based violence and impact mitigation program in Harm Reduction Program 3. Increase FWUD & FWIDs legal protections a) Programs working with FWID or FWUD should incorporate physical and sexual abuse, rape and violence prevention, mitigation, and social support into all their programs. Conflict resolution programs within the communities should also be developed to mitigate violence between individual PWIDs (in addition, explore feasibility of post-exposure prophylaxis (PEP) for rape victims, within Cambodian context). a) Facilitating partnerships between police and national security agencies and HIV prevention initiatives for FWID and FWUD to reach agreement on mutually acceptable harm reduction strategies is critical for creating environments conducive to risk reduction- which should also be offered to men, MSM, TG, boys and girls who use drugs. b) The prevention program should include free legal aid to help both PWUD and PWID (across gender) resolve problems with documents, access to social support, legal problems, being raped and etc. 4. Increase coverage of harm reduction program by including intimate partners 5. Include contraceptive methods (other than condoms) a) Prevention programs should highlight gender difference as a prominent context for injection risk behavior and emphasize the avoidance of syringe sharing and other risk behaviors with intimate partners (including men, women, TG, MSM, boys and girls). Programs for intimate partners and families of PWIDs should be conducted simultaneously with interventions for PWIDs. a) Even though WHO, UNAIDS and UNODC have not included contraceptive care beyond the inclusion of condoms- adding a service package which included pregnancy tests, pre-postnatal care or links between harm reduction, drug treatment and prevention of vertical transmission could help FWID and FWUD prevent from unplanned pregnancies and improving pregnancy outcomes. 5 b) Equally important is to sensitize SRH issues among men, women, MSM, TG, girls and boys. 5 Currently, MMC provides Urine HCG test for pregnancy, contraceptive method for family planning and referral to other health services as required. 10

11 INTRODUCTION Overview of Gender and Vulnerability to HIV/AIDS Globally there is an estimated 35.3 ( ) million people living with HIV/AIDS in 2012, of which half of them (17.7 million) were women. 6 Gender inequalities and harmful gender norms continue to contribute to HIV-related vulnerability. Apart from the greater physiological vulnerability of women to HIV, gender inequalities also include vulnerability to rape, sex with older men and unequal access to education and economic opportunities. Indeed, women are more likely to acquire HIV at an early age when compared to men This results in a global HIV prevalence among young women aged years (0.5%) approximately twofold compared to males of the same age (0.3%). 7 Almost all countries (92%) 8 that conducted midterm reviews of their national AIDS response acknowledged the central importance of addressing gender inequalities. However, mid-term reviews indicated that less than half of countries allocate funds for women s organizations, broadly integrate HIV and sexual and reproductive health services or have scaledup initiative to engage men and boys in national responses. 9 Gender-based violence is a global phenomenon and a serious violation of human rights. Notably, gender-based violence also increases the risk of HIV infection. Between 9% and 60% of women aged 15 to 49 years reported having experienced intimate partner violence (IPV) in the last 12 months and they are 50% more likely to be living with HIV. 10 Women from key populations, namely females who inject drugs (FWID), female sex workers and transgender women, are particularly likely to experience violence. Results of violence will lead to the compounding effects of multiple forms of stigma and mistreatment. 11 Moreover, gender norms blame and shame women for being vectors and responsible for spreading HIV, and for having engaged in assumed immoral behavior. Gender norms often assume that if a woman has acquired HIV, it is because she has behaved in a way that has 6 UNAIDS. (2013). Global report: UNAIDS report on the global AIDS epidemic Ibid. 8 Total of 109 countries participated in the mid-term review. 9 UNAIDS. (2013). Global report: UNAIDS report on the global AIDS epidemic Ibid. 11 Ibid. 11

12 transgressed the norms of what proper women should do. These norms fuel stigmatizing responses of blame and shame directed toward HIV positive women. 12 Gender Issues Among People who Inject Drugs (PWID) There are estimated 15.9 million (range million) people who inject drugs (PWID) around the world. In 2010, nearly half (47%) of people who inject drugs living with HIV in low- and middle-income countries came from five nations China, Vietnam, Malaysia, Russia and Ukraine. 13 Most data on gender differences in the risk behaviors of people who inject drugs (PWID) come from studies conducted in the United States and Europe, and the understanding of how well these differences generalize to low-resourced countries is limited. 14 A recent study further revealed that a quarter of survey countries indicated that they do not procure and distribute female condoms, while 37% make female condoms available to women from key populations, and 37% make them available to all women. Data suggests that the provision of female condoms has been undertaken separately from linking HIV and sexual and reproductive health services, as there is consistency in delivery in less than half of countries. 15 Regional Practices In 2012, of the estimated 1.6 million adult aged 15 above living with HIV in South- East Asia, 37.5% were women (Table 1). Among the region, Indonesia has the highest estimated adult and women aged 15 above living with HIV (540,000 and 210,000 respectively) whereas Lao PDR has indicated the lowest estimated number (10,000 and 4,700 respectively). 12 Anne Eckman, Blakley Huntley and Anita Bhuyan. (2004). How to Integrate Gender into HIV/AIDS Programs: Using Lessons Learned from USAID and Partner Organizations, May Interagency Gender Working Group Task Force Report. 13 International Harm Reduction Association. (2012). Global State of Harm Reduction Report 2012: Towards an integrated response. 14 Spratt, Kai Technical Brief: Integrating Gender into Programs with Most-at-Risk Populations. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order UNAIDS. (2012). UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV Mid-Term review - Final report. 12

13 Despite Malaysia having the highest estimated number of people who inject drugs (170,000), the HIV prevalence rate among PWID is reported at the lowest rate of 8.7% among the region. Four out of the nine countries in the region have reported more than 20% HIV prevalence among PWID namely Indonesia, Cambodia, Myanmar and Thailand. Notably, the estimated number of PWID in Cambodia was only 2,000, of which 10% are women 16. Out of the nine countries in the region, only Philippines has data disaggregation by gender for HIV prevalence. Most of the South-East Asia countries have initiated harm reduction response namely Needle and Syringes Program (NSP) and/or Opioid Substitution Treatment (OST) except Singapore. Notably, Singapore is the only country in the region which does not explicit supportive reference to harm reduction in national policy documents. Indonesia, Myanmar, Thailand and Cambodia on the other hand are few of the countries which have undertaken more actions and made more progress for women and girls, gender equality and HIV since the UNAIDS Agenda 17 launch in This finding indicated that the efforts undertaken through a wide variety of actions across all three recommendations of the Agenda namely (a) Knowing, understanding and responding to the particular and various effects of the HIV epidemic on women and girls; (b) Translating political commitments into scaled up action to address the rights and needs of women and girls in the context of HIV, and (c) An enabling environment for the fulfillment of women s and girls human rights and their empowerment, are producing results. 18 Table 1: Estimated adult and women (15+) living with HIV in South-East Asia, Region/Country Estimated adults (15+) living with HIV Estimated women (15+) living with HIV South-East Asia 1,604, , Based on the Global State of Harm Reduction 2012 Cambodia 72,000 40,000 Indonesia 540, ,000 PDR Lao 10,000 4,700 Malaysia 79,000 11,000 Myanmar 190,000 63,000 Philippines 13,000 2,100 Singapore Thailand 450, ,000 Viet Nam 250,000 71,000 Source: Global AIDS Report, UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV (hereafter referred to as the Agenda). 18 UNAIDS. (2012). UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV Mid-Term review - Final report. 13

14 Table 2: Epidemiology of HIV, Harm Reduction Responses and Policy in South-East Asia. South-East Asia with reported injecting drug use People who HIV prevalence inject drugs 1 amongst people who inject drugs, Availability of Harm data reduction disaggregation response 1 by gender 2 for HIV prevalence NSP OST Explicit supportive reference to harm reduction in national policy documents Cambodia 2,000 a 24.00% b N Y Y Y Indonesia 105, % N Y Y Y PDR Lao 1,700 n/a N Y N Y Malaysia 170, % d N Y Y Y Myanmar 75, % N Y Y Y Philippines 15, % Y Y N Y (M: 12.87%; F: 26.98%) Singapore n/a n/a n/a N N N Thailand 40, % N Y Y Y Viet Nam 158, % c N Y Y Y Note: Source: IHRA, 2012; Country Global AIDS Response Progress Report, a. From Cambodia s National Center for Dermatology, HIV/AIDS and STD (NCHADS), b. From 2007 Drug User Prevalence Survey, Cambodia. c. Only for males who inject drugs, Viet Nam. d. Data from harm reduction services outlet (2011), Malaysia. 1. Data sourced from International Harm Reduction Association. (2012). Global State of Harm Reduction Report 2012: Towards an integrated response. 2. Unless otherwise stated, data are sourced from respective Country Global AIDS Response Progress Report

15 CASE STUDY: MEETING THE NEEDS OF WOMEN WHO USED DRUGS IN MALAYSIA The CAHR project is working with the Malaysia AIDS Council (MAC) and has carried out research to better ascertain the needs, risk factors and barriers to treatment faced by women who use drugs. This research will form the basis of a pilot project to address these issues. The research, conducted by the Centre of Excellence for Research in AIDS at the University of Malaya, surveyed 104 women who use drugs in Kuala Lumpur. The majority were aged between 31 and 50 years, ethnically Malay, and had received some secondary school education. Almost two out of ten women engaged in sex work, and nearly all women interviewed had been detained in the past. Most were detained by the police. The main substances they reported using were methamphetamines, alcohol and heroin. A quarter of participants were on methadone. The research showed that they were especially vulnerable to sexual violence and HIV. One in five women reported having been physically threatened, 27% had been sexually molested as a child and one in five had been forced to have sex. Reducing this vulnerability to sexual violence will be a key part of the pilot program. The pilot program will also look at improving the lives of women who use drugs through: Drug management services including methadone therapy; HIV prevention and reducing the risks related to sex work; Sexual and reproductive health services; Care for children or women who use drugs; Support for those living with HIV; Income generation and Advocacy support. EXPLORING GENDER NEEDS IN INDONESIA: THE STIGMA FOUNDATION The STIGMA Foundation (SF), a nongovernmental organization (NGO) run by and for IDUs in Jakarta, Indonesia, has been proactive in its strategy to reach female IDUs. In 2009, after five years of implementing a peer outreach program and an NSP, SF had reached 3,000 IDUs, of which only 200 were women, not all of whom were accessing services. SF staff knew from their own experience that cultural norms restrict women more to the household and expect women to focus on the domestic roles of wife and mother. SF realized that there is a dearth of research in Indonesia on women IDUs. For example, there is little data about the constraints that affect women s access to NSP, methadone maintenance treatment, or drug rehabilitation services. Furthermore, there is no information in the national language, Bahasa Indonesia, for female IDUs on the effect of antiretroviral therapy (ART) on sexual and physical changes associated with treatment, or on the ability of female IDUs to pay the cost of ancillary ART services. SF has started a newsletter called Angels that is dedicated to issues of women IDUs. In addition, SF produces short leaflets on specific topics such as the impact of ART on women, arrest procedures, and tips for women facing gender-based violence (GBV). Source: Spratt Kai. (2010). Source: International HIV/AIDS Alliance website, 2013.Available at

16 Table 3 depicts on examples of existing gender-sensitive harm reduction services to provide a menu of options to improve and expand care for FWUD/FWID. Ideally, services should be targeted according to the documented needs of women, men, boys, girls, MSM and TG in a given context. Women, men, boys, girls, MSM and TG should always be involved in the design and implementation of respectively program, to ensure that program are effective, appropriate, and respectful of the human rights of them. Table 3: Gender-sensitivity harm reduction services for FWUD/FWID. Source: Global State of Harm Reduction,

17 Cambodia The National Centre for HIV/AIDS, Dermatology and STD Control (NCHADS) report on Estimations and Projections of HIV/AIDS in Cambodia 2012 estimated that there were 40,1779 women living with HIV in 2012, of which represented 54% of the total adults living with HIV. 19 Since 2007 the number of females newly infected has surpassed the number of newly infected men where 43 % of new infections were women in This rate is expected to continue to decrease gradually. 20 The HIV prevalence among people who inject drugs (PWID) was 24%, of which 50% were among female. 21 Condom use among all sexual partners is lower among PWID compared to other users. The PWID community is estimated to be mostly confined to Phnom Penh. Cambodia is one of the few countries to achieve the Millennium Development Goal of halting and reversing the spread of HIV, with prevalence falling from 1.75% in 1998 to a projected 0.7% in This is a key milestone for the country, particularly given high levels of poverty and inequality, devastation of infrastructure during decades of war and heavy reliance on foreign aid. 23 Cambodia's decline in HIV prevalence was due to a rapid and coordinated response by the government in collaboration with non-governmental organizations and civil society. Infections among direct and indirect sex workers fell after the promotion of 100% condom use. 24 The mode of transmission of almost half of the new HIV infections were estimated from heterosexual, non-commercial sexual relationships (i.e., intimate partner transmission) in 2012 (Figure 1). Apart from infected through injecting drugs, new HIV infections from all transmission routes are expected to have declined as 19 Cambodia s National Center for Dermatology, HIV/AIDS and STD (NCHADS). (2013). Gender Assessment: Access to HIV Services in Cambodia, November The National AIDS Authority. (2012). Cambodia Country Progress Report: Monitoring the Progress towards the Implementation of the Declaration Of Commitment on HIV and AIDS. Reporting Period: January 2010 December Ministry of Health/ Cambodia s National Center for Dermatology, HIV/AIDS and STD (NCHADS). (2013). Review of the Cambodian Health Sector Response to HIV. Version 19 August Cambodia s National Center for Dermatology, HIV/AIDS and STD (NCHADS). (2013). Gender Assessment: Access to HIV Services in Cambodia, November International HIV/AIDS Alliance Website. (2013). Cambodia. Available at website: 24 Ibid. 17

18 compared to The largest decline is being expected for mother-to-child transmission. Figure 1: Mode of Transmission of new HIV infections in Cambodia, 2012 (n=1202 new infections). Men and Women who inject drugs, 10% Female Sex Work, 30% Mother-to-child transmission, 9% Male-to-male sex, 1% Heterosexual, non-commercial sexual relationships (i.e., intimate partner transmission), 50% Source: NCHADS, Poverty, gender inequality and changes in sexual behaviour continue to drive the HIV epidemic. 25 Women in Cambodia may be vulnerable to HIV infection for several reasons: 1) the sexual transmission of the virus is estimated to be four times more efficient from men to women than from women to men; 2) women have difficulty refusing unsafe sex or negotiating safer sex due to gender based social and economic inequalities; 3) social norms allow men to have many sexual partners, which places even monogamous women at risk. Many prevention initiatives focus on women only if they are entertainment workers or garment factory workers, despite more than a decade of evidence that other women are vulnerable primarily through sexual contact with HIV-positive husbands. 26 In Cambodia, drug use is widely stigmatized. As a result, females who use drugs (FWUD) are particularly being stigmatized because they are perceived misbehave 25 International HIV/AIDS Alliance Website. (2013). Cambodia. Available at website: 26 Roberts J. (2008). Preventing Spousal Transmission of HIV/AIDS in Cambodia: The Situation and the Strategies. 18

19 under the cultural norms by engaging in gender inappropriate behaviour. 27 Consequently, discourage FWUD access to health care, including drug-related and maternal health services. Therefore, high levels of social stigma and criminalization among PWID community prevent them from seeking and accessing HIV-related services. 28 A recent study conducted by FHI highlighted that one third of respondents reported having been verbally threatened by police or local authorities in the previous six months and that men and women living with drugs experienced significantly more verbal threats than any of the other MARP groups. 29 Table 4 highlighted the relevant national policies, strategies or programs that currently facilitate access to HIV programs and services for women and girls, people living with HIV and most-at-risk populations. Table 4: National policies, strategies or programs that currently facilitate access to HIV programs and services for women and girls, people living with HIV and most-at-risk populations in Cambodia. Name of national policy, strategy or program relevant to HIV-related service delivery How does the national policy, strategy or program facilitate equitable access to HIVrelated services for women and girls, mostat-risk populations and/or people living with HIV? Law on the Prevention and Control of HIV/AIDS (2002) and its Implementing Guidelines (2005) Provides a strong human rights-based framework, including prohibition on HIV-related discrimination and a special emphasis on gender equality across HIV program. Addresses a range of issues that affect access to HIV services including provision of HIV education and information; testing and counselling with informed consent and confidentiality; and access to non-health support services. The law also requires the State to provide primary health care services for all PLHIV free of charge. 27 UNODC (2004). Drug Use Treatment Toolkit. Substance Use Treatment and Care for Women: Case Studies and Lessons Learned. Vienna. 28 WHO (2009). Integrating gender into HIV/AIDS programmes in the health sector. Tool to improve responsiveness to women s needs. Gevena. 29 Ministry of Interior and FHI 360 (2013). Baseline Survey on the Enabling Environment for Most At Risk Populations in Phnom Penh, Cambodia Phnom Penh. 19

20 National Strategic Plan for Comprehensive and Multisectoral Response to HIV/AIDS (NSP-III) National Strategy for Reproductive and Sexual Health in Cambodia nd National Action Plan to Prevent Violence against Women (2013) National Social Protection Strategy (NSPS) SOP for Boosted Continuum of Prevention to Care and Treatment (2012) * key component of the Cambodia 3.0 strategy Includes a focus on gender equity and empowerment, with special reference to addressing the underlying gender norms that fuel the epidemic. The NSP-III emphasizes human rights based approaches and the meaningful engagement of men and women, girls and boys living with HIV as well as MARPS, recognizing the diversity of needs and experiences within these communities. The NSP-III also states the importance of understanding links between gender, HIV and uptake of services and building this into trainings, programs and policies. Gender equality stated as a goal and includes human rights, empowerment and gender equity (including equitable access to health services) as guiding principles. The strategy promotes multisector partnerships, community involvement and evidence-based approaches for improving service delivery. Specifically recognises violence as a cause and consequence of HIV and the vulnerabilities of women and girls living with HIV, female sex workers, entertainment workers (EWs), transgender women and females who use drugs to gender-based abuse and violence. Identifies entry points for linking violence response services with HIV services. Defines men and women, girls and boys living with HIV (although notably not those within MARPS communities) as part of the special vulnerable groups. Under Phase 1 of the NSPS, efforts are being made to integrate and strengthen HIVsensitive provisions within the country s main social protection schemes. Promotes peer-based interventions and a multisectoral approach engaging non-health services (such as legal aid and rape crisis services) as well as health services. Program strategies include strengthened policy frameworks, coordination, outreach and service linkages to support improved service provision for men, women and transgender MARPs, particularly EWs. 20

21 Concept Note on Treatment as Prevention (TasP) (2012) * key component of the Cambodia 3.0 strategy SOP for HIV, STI, and TB-HIV Prevention, Care, Treatment and Support in Prisons (and Correctional Centers) (2012) National Guideline for STI and HIV/AIDS Response Among MSM, Transgender and Transsexual People (2011) Police Community Partnership Initiative (PCPI) Promotes the equitable treatment of PLHIV and addressing the gender dimensions of TasP for PLHIV, MARPS and their sexual partners (e.g., couples HIV testing and counseling, issues around partner disclosure, the importance of appropriate, gender-responsive counseling by healthcare workers). Promotes peer-based interventions and a multisectoral approach to the provision of HIV information to male and female prisoners. States that prisoners and detainees in need of HIV care and treatment and (for female prisoners) antenatal care services will be referred to the relevant services at the nearest provincial/referral hospitals. Recognizes the rights of citizens to full and free expression of sexual identity. It also states that MSM, TG and transsexual people have the right to comprehensive access to HIV services, free of stigma and discrimination. Program clarifies implementation of the Village Commune Safety Policy, the LSHTSE and addresses the specific concerns and access barriers for PLHIV and MARPS. The PCPI also supports the coordinated implementation of health and non-health related HIV services for men, women and transgender MARPS. Source: NCHADS, 2013 Under the Cambodia s National Strategic Plan , the gender norms and inequalities that drive HIV risk has been addressed. Gender-responsive approaches will be integrated into the activities that support the goals, objectives and strategies of the National Strategic Plan. Sex-disaggregated data will also be used for monitoring and evaluation. Understanding the links between gender, HIV and uptake of services will be built into trainings, programs and policies. 30 The figure below depicts the interventions relates to Harm Reduction Program for PWID under Cambodia s Third National Strategic Plan for a Comprehensive and Multi-sectoral National Response to HIV and AIDS, National AIDS Authority (2010). National Strategic Plan For a Comprehensive & Multi- Sectoral Response to HIV and AIDS in Cambodia. 21

22 Figure 2: Gender related interventions within Harm Reduction Program under Cambodia s Third National Strategic Plan for a Comprehensive and Multi-sectoral National Response to HIV and AIDS, Harm Reduction Program in Cambodia The Government of Cambodia has officially begun to recognize that harm reduction has been an essential approach to preventing HIV among PWID since As a result, several programs aiming to control and prevent HIV among PWID have been implemented in Cambodia, mostly in the capital, Phnom Penh. Table 3 depicts a list of harm reduction program which have been implemented in Cambodia. However, a recent assessment study revealed that the service coverage levels for key harm 22

23 Korsang KHANA Family Health International (FHI) 360 The Friends- Internation al Phnom Penh Program reduction interventions such as needle and syringe exchange programs remain inadequate. 31 Table 5: Harm Reduction Program in Cambodia. Organization/ Implementer Project name Harm Reduction Program Kaliyan Mith The Drug Prevention and Rehabilitation Project in Chom Chao developed a network of organizations for best practice continuum of care project for children and youth. Project for HIV and AIDS Strategic Technical Assistance (PRASIT), funded by USAID ( ) This project respond effectively to the needs of those who engage in multiple or overlapping risk behaviors, such as injectors/non-injectors who buy/ sell sex and EWs/MSM who use drugs. The project approach is to integrate drug use-related HIV prevention and harm reduction (HR) into the SMART girl and MStyle programs. Drug use support groups and drug use case management and counseling services are made available at SMART girl and MStyle drop-in centers. HIV/AIDS Asia Regional Program (HAARP), funded by Australian Aid ( ) HAARP project s goal of reducing the spread of HIV associated with PWID among male and female in Cambodia through, Supporting the government to increase the uptake of methadone maintenance treatment. Contributing to the creation of an enabling and non-stigmatizing environment for HIV prevention and treatment among PWID. Focused Prevention Program (funded by International HIV/AIDS Alliance) Focused Prevention (FP) Program prioritizes the needs of those most at risk of infection namely sex workers, PWID or MSM. The program provides outreach and peer education, and challenges community norms and stigma. Sustainable Action Against HIV and AIDS in Communities (SAHACOM) (funded by USAID, ) Program components include (a) Improved Coverage, quality and sustainability of comprehensive and integrated services for PLHIV (including MARPs) and OVC, which have successfully linked communities with public health and non-health services. (b) Improved uptake of innovative and targeted HIV prevention interventions and services to MARPs, with a particular focus on under-served and neglected groups (c) Strengthened capacity and leadership of NGOs and communities (especially those representing MARPs and PLHIV) leads to their meaningful participation in delivery quality and sustainable community based HIV prevention and care services within the national response. Drop-in Center (Supported by KHANA) Provides awareness of HIV prevention among PWID and providing support to reduce the human rights violations they are experiencing but other holistic support such as a safe place to rest and receive care means that PWID can develop their livelihoods. 31 Cambodia s National Center for Dermatology, HIV/AIDS and STD (NCHADS). (2013). Gender Assessment: Access to HIV Services in Cambodia, November

24 Cambodian Red Cross (CRC) Asia-Australia Mental Health (AAMH) with the involvement from the National government a, International Organizations and Donors b, Non-government and International Organization Partners c United Nations Office on Drugs and Crime (UNODC) The President's Emergency Plan For AIDS Relief (PEPFAR) Population Services International (PSI) Cambodia National Center for HIV/AIDS, Dermatology and STI (NCHADS) (Principal Recipient) Continued achievement of Universal Access of HIV/Sexually Transmitted Infections Prevention, Treatment and Care services in Cambodia (funded by GFATM, ) Programs for people who inject drugs (PWID)/ people who use drugs (PWUD) includes, i. Prevention program prevention program activities, outreach education; ii. Condom distribution and referral to STI, VCT, OI/ART services; iii. HIV testing and counseling; iv. Antiretroviral Therapy (ART); v. TB diagnosis, prevention and treatment. United Health Network (UHN) PSI Cambodia helped create and sustain a network of local partners to work in HIV/AIDS, reproductive health and child survival. PSI Cambodia ensures that local partner NGOs have the resources, skills, techniques, and products to conduct social marketing and targeted behavior change interventions with at-risk populations such as men who have sex with men (MSM), direct and indirect sex workers, PWID and PLHIV. The UHN program currently provides HIV/AIDS sub-grants to 18 NGOs to conduct social marketing activities aiming to increase access of condoms and lubricant at high risk venues, and conduct targeted behavior change Interventions with high risk populations. HIV/AIDS prevention, treatment and care programs (funded by U.S. government, ) PEPFAR does not deliver services directly. Instead, support focuses on provision of technical support, and may include development of innovative program approaches and technically sound guidelines, and policy and advocacy, especially to enable key populations to access HIV services. Advocacy Provide technical assistance to countries to develop evidence informed and costed AIDS strategies and Action Plans including the needs of injecting drug users, prison population and people vulnerable to human trafficking (PVHT). Asia-Pacific Community Mental Health Development Project - Methadone Maintenance program (MMT) Non-governmental and International Organization Partners c plays a key part in implementing the project. i. Inform PWID community about the availability of Methadone; ii. Help PWID get access to MMT clinics for assessment and regular dosage; iii. Help manage PWID experience of treatment; iv. Follow up MMT clients to ensure they continue with counseling in the community setting; and v. Provide technical setting with case-management and prevention of relapse. Harm Reduction Program Harm Reduction program provide service to PWID includes, i. Prevention, referrals for diagnosis, and the treatment of tuberculosis; ii. Provision of free, good quality condoms; iii. Outreach with targeted information, education, and communication; iv. Voluntary HIV counseling and testing; v. Prevention of sexually-transmitted infections; vi. Referral to antiretroviral treatment; Notes: a. Includes The National Program for Mental Health, The Ministry of Health and The Secretary General of the National Authority for Combating Drugs. 24

25 b. Includes The World Health Organization (WHO), Joint United Nations Program on AIDS (UNAIDS), United States Office on Drugs and Crime (UNODC), AusAID. c. Korsang, Kalyan Mith, KHANA, Family Health International (FHI 360), Friends International Source: 1. Friend International website. (2013). Available at 2. Family Health International (FHI) 360 website. (2013). Available at 3. International HIV/AIDS Alliance website. (2013). Available at 4. Cambodia Global Fund Grant Portfolio website. (2013). Available at 5. PSI website. (2013). Available at 6. PEPFAR website. (2013). Available at 7. Asia Australia Mental Health (AAMH). (2011). Asia-Pacific Community Mental Health Development Project - Summary Report 2011: Partnerships 8. International Federation of Red Cross and Red Crescent Societies (IFRC). (2010). IFRC Advocacy Report. Out of harm s way: Injecting drug users and harm reduction, December OBJECTIVE OF THE STUDY The main objective of the study is to provide recommendations to improve and update KHANA s Gender Strategy 2010, by accessing and analyzing the gaps and opportunities for gender integration within KHANA s harm reduction response in Cambodia. As such, the study will help to build the capacity of KHANA s Policy Team, Harm Reduction Program staff, and other relevant staff of KHANA and its implementing partners to advocate for greater gender integration into Harm Reduction Programs in the country. Methodology The assessment study included desk review and country assessment. The final output delivered to the beneficiary is the update of KHANA s Gender Strategy

26 Desk Review Total of 55 studies and report were reviewed, comprised of four major levels namely global, country, organization and technical guide. Each level involved comprehensive search of particular sources of documents which describe integrating gender within KHANA s Harm Reduction Program in the HIV/AIDS context. Conduct Country Assessment The consultant conducted a three days country assessment to collect data from MMC and Korsang as well as interview KHANA s staff. Update KHANA s Gender Strategy The desk review comprised four major levels namely global, country, organization and technical guide. Each level involved a comprehensive search of particular sources of documents which describe integrating gender within KHANA s Harm Reduction Program in the HIV/AIDS context. Total of 55 documents listed below were reviewed by the consultant. However, only relevant findings from those documents were presented in this report. 26

27 Global level Country level Organizational level Technical guide Global State of Harm Reduction Report UNAIDS report on the global AIDS epidemic UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV. Country Global AIDS Response Progress Report. National Strategic Plan for HIV/AIDS International HIV/AIDS Alliance website ance.org/ Gender Assessment: Access to HIV Services in Cambodia, 2013 Related website where Harm Reduction Program is implemended in Cambodia, such as Friends- International, FHI 360, Global Fund, PSI Cambodia, PEPFAR, UNODC abd Asia-Australia Mental Health. KHANA s Gender Strategy Harm reduction model of comprehensive drop in center for people who use drugs, The standard package of activities for drug users and injecting drug users, KHANA's website org.kh/ Project Evaluation report. Integrating Gender into Programs with Most-at-Risk Populations. WHO, UNODC and UNAIDS Technical Guide UNAIDS Core Indicators 2009 UNAIDS Guidelines - Operational Guidelines for M&E of HIV programs for PWID. The assessment study focused on data collection from both Needle and Syringes Program (NSP) and Methadone Maintenance Therapy (MMT) for KHANA Mondul Meanchey (MMC) and Korsang. During the process, the Gender Sensitivity Checklist was used to assess the sensitivity of MMC and Korsang in three perspectives, namely project development, project implementation and organization structure (for details please refer to the Assessment Tool). The consultant has integrated face to face interviews with KHANA s team members during the field observation from 11th to 16th December The interview was mainly focused on assessing how much of the indicative work plan for gender strategy from 2010 was adapted. The findings were mainly generated from the discussion and interviews with one senior management team member, two technical advisers, two middle management team members and one junior team member. However, the following findings were only reflective of the responses generated from those who were available for such interactions because there were only few team members available for the interviews during the assessment period due to other obligations. 27

28 KHANA Background KHANA was established in 1996 as as a project of the International HIV/AIDS Alliance in providing integrated HIV prevention, care and support services at the community level in Cambodia. Since 1999, KHANA has become an independent non-governmental organization and was officially registered in Cambodia in At present, KHANA is the largest national NGO focusing on HIV and AIDS in Cambodia. In 2011, KHANA worked in 19 out of 24 provinces and municipalities in the country and 38 implementing partners to implement prevention, treatment, care and support program (Figure 2). 32 KHANA builds the capacity of the implementing partners (IP) to implement programs, carry out evaluations and manage resources through technical support visits, training, workshops and exchange visits. KHANA also served as the Alliance Regional Technical Support Hub by providing technical support for civil society organizations in South East Asia and the Pacific. 33 Figure 3: Service Coverage of KHANA s program, Source: KHANA website, L., H. Sopheab, Tuot S. (2012). Social Return on Investment Doing more with less : Evidence based operaitonal research on the KHANA integrated care and prevention project in Cambodia. Phnom Penh, KHANA 33 International HIV/AIDS Alliance Website. (2013). Cambodia. Available at website: 28

29 KHANA programs focuses on providing: 34,35 o Integrated Care and Prevention program focuses on the provision of home-based care services to people living with HIV (PLHIV), orphans and vulnerable children (OVC) and their families. Services include referrals to health care, positive prevention information, access to income generating activities, nutritional assistance, support for antiretroviral treatment adherence, self-help groups and support for school attendance. o Focused prevention (FP) program addressed the needs of most at risk populations (MARPs) such as men who have sex with men (MSM), people who use drug (PWUD)/ people who inject drugs (PWID), sex and entertainment workers (EW) and male clients of sex workers. o Impact mitigation through livelihood support and food security interventions for PLHIV, OVC and their families. o Improving policy through working in close cooperation with the government s national AIDS program and bring the voice of the affected communities to national and international policy forums. Table 6: A review of KHANA s Strengths and Achievements. STRENGTHS The largest local non-governmental organization implementing HIV/AIDS program in Cambodia. Consist of 38 implementing partners to implement prevention, treatment, care and support program in 19 of the country s 24 provinces and municipalities. Know and have more than 15 year experiences on HIV/AIDS and response. Maintain close cooperation with the government s national AIDS program, KHANA staff serves position in seven ACHIEVEMENTS Secured $13.4 million of funding from USAID for implement the program: Sustainable Action against HIV and AIDS in Communities (SAHACOM) for five years from October 2009 onwards. 1 The Social Return on Investment for the Integrated Care and Prevention (ICP) program when using the total inputs invested into the program was 96%; for every $1 invested, $1.96 was generated in social, health and economic value. The proportion of value according to beneficiary type was 2 34 International HIV/AIDS Alliance Website. (2013). Cambodia. Available at website: 35 KHANA. (2012). The KHANA Gender, Sexuality and Diversity Strategy. Phnom Penh, May

30 government HIV/AIDS technical working groups and two regional committees. A wide network and partnership with internal and external stakeholders and have effective advocacy and leadership towards program implementation. Host the Alliance Regional Technical Support Hubs by providing technical support for the civil society organizations in South-East Asia and the Pacific. Developed KHANA Gender Strategy (a) PLHIV/OVC households (51%), (b) PLHIV (32%), (c) OVC (9%), (d) The wider community (3%), (e)health service (2%), and (f) PLHIV caregiver (2%). Developed Standard Package of Activities for PLHIV, OVC, MSM, EW and PWUD. Grassroot education and prevention program that reach the populations and places where government is unable to reach. Provided services through ICP to more than 15% of PLHIV in the country and 17% OVC of national total (13,757 PLHIV and 21,670 OVC respectively). 1 Reached 165,387 MARPs through HIV prevention activities (more than 50% of all estimated PWID in Cambodia are reached through its Harm Reduction Program). 1 Supported 14,446 people receiving antiretroviral treatment. 1 Achieved a good progress in the first term of KSP15 by playing a vital role in strengthening community health systems and making enormous gains towards the set target, even surpassing some of the targets set for Source: 1. International HIV/AIDS Alliance Website. (2013). Cambodia. Available at website: 2. Tong, L., H. Sopheab, Tuot S. (2012). Social Return on Investment Doing more with less : Evidence based operational research on the KHANA intergrated care and prevention project in Cambodia. Phnom Penh, KHANA. 3. Revised KHANA Strategic Plan: (Boosted KSP15), August

31 The KHANA s Strategic Plan (KSP 15) provided a roadmap through integration of HIV with other health issues and livelihoods. The plan is also consistent with the Cambodia's National Strategic Plans based on the following four goals: 36 1) Improve integrated HIV programming; 2) Improve community health outcomes in relation to sexual and reproductive health, maternal and child health and tuberculosis; 3) Support secure livelihoods; and 4) Strengthen management capacity and technical excellence in community HIV, health and development responses. Wider health and development needs of the communities, such as those relating to climate change, gender-based violence and non-communicable diseases were addressed in the Boosted KSP15. The Objective 2 (under Goal 2) has identified the integration of gender mainstreaming into Sexual Reproductive Health (SRH) and Maternal and Child health (MCH) programming, especially in addressing genderbased violence, and promote consistent messaging. Table 7 identified the gaps and recommendations for the indicator achieved related to Harm Reduction Program among PWUD/PWID under KSP 15. The gaps of the indicator related to Harm Reduction Program are 1) Lack of data disaggregation (male, female and TG) when presenting the data for MARPs; 2) Limited data on size estimation of FWUD and FWID which lead to the difficulty in calculate the coverage of FWUD and FWID; 3) Lack of policy forum on harm reduction attended by staff; and 4) Lack of data on abortion among FWUD and FWID. Data need to be collected because FWUD sometimes have reduced access to prenatal care due to pressure to have abortions and high levels of stigma. Thus, this can lead to reduced levels of prevention of mother-to-child transmission (PMTCT) services among women living with HIV who inject drugs, among other negative effects. 36 KHANA website at (2013). 31

32 5) No data on Intimate partner violence (IPV) being collected. IPV is more commonly reported among women who inject drugs than among women in the general population. Violence has an immediate effect on a woman s ability to practice safer sex and safer drug injecting, and can contribute to continued drug use. 32

33 Table 7: Identified gaps and recommendations for the indicator achieved related to Harm Reduction Program among PWUD/PWID under KSP 15. Indicator Baseline (Q unless specified) Midterm (Q unless specified) Target (Q4 2015) Gaps Recommendations Goal 1: Improve integrated HIV programming Objectives 1: To reduce the number of new HIV infections through scaled targeted prevention. Objectives 2: To provide care and support to people living with and affected by HIV and AIDS, and orphans and vulnerable children. % MARP reached with HIV prevention interventions in the last quarter >70% >80% >90% Coverage of NSP program remains inadequate especially for PWID in Phnom Penh. (Note: PWUD: 53% and PWID: 26% based on MMC and Korsang data.) Scare-up Harm Reduction Program especially among PWID. Availability of size estimation of FWUD and FWID data to calculate the coverage of Harm Reduction Program among FWUD and FWID. Data need to be disaggregated to include Transgender and MSM as well as age. % PWUD reported maintaining correct and consistent condom use with any sex partner in the past 12 months. % PWID consistently practicing safe injection techniques (never sharing needles and syringes with N/A 53.7% >60% No data on consistent condom use among PWID. 33 No breakdown of the sex partners by sex (MSM, TG and Women) 60% 63% >65% No data disaggregated by sex. Data disaggregated by male condom and female condom. Data disaggregated by male, female and transgender.

34 other PWID)in the past 12 months # of policy forum on harm reduction participated by KHANA staff in the last 12 months N/A N/A 12 No forum participated by KHANA staff from 2011 Q Human Resource Department to search policy form on harm reduction for staff to attend, at least 6 forums in GOAL 2: Improve community health outcomes in relation to Sexual and Reproductive Health, Maternal and Child Health and Tuberculosis. Objective 1: To strengthen community understanding of sexual and reproductive health, maternal and child health- and other emerging health issues. Objective 2: To support family and community level behavior change, and increase access to and uptake of services for sexual reproductive health, maternal and child health and other emerging health issues. Objective 3: To support community participation and strengthen linkages in TB and HIV programming. % EW who underwent abortion in the past 12 months utilized safe abortion services (health facility or NGO clinic) N/A >20% >60% Lack of indicator to capture the data on abortion for FWUD and FWID. Data on abortion among FWUD and FWID to be captured. % MARP received referral support for STI screening/testing (health facility/community) in the last quarter. N/A >20% >90% Less than half of the target was achieved under referral support for STI screening. Appointments with a gynecologist, other medical specialists at the harm reduction site. 37 % MARP and PLHIV attended education sessions on HIV, STI, SRH, MCH or TB at least once in the last 6 months. N/A >70% >80% n/a Session on HIV should also cover topics including drug use and relationships; physical and sexual abuse; rape and violence prevention; ways of discussing and negotiating safer sex; alcohol and drug use and HIV risk. Source: Revised KHANA Strategic Plan: (Boosted KSP15), August Although NGOs conducts regular counseling, STI screening/ testing and treatment among MARPs and referral to health facility, the funding for referral services, staffing and capacity building for peer is limited. Normally, it depends on the service which available for them at the health facility. 34

35 Harm Reduction Program for People Who Inject Drugs (PWID) The Harm Reduction program for PWID s are provided by KHANA and it s Implementing Partners (IPs) through two different models. Firstly, through KHANA s Focused Prevention (FP) Program which prioritizes the prevention needs of PWID by using innovative approaches to ensure that they have access to a full range of services as outlined in the the Standard Packages of Activity (SPA) for people who use drugs (PWUD). Each SPA is divided into four sections: prevention, impact mitigation and health, capacity building, and supporting environment. The details of the activities under each section are outlined in Table Another project, the KHANA Meanchey Drop in Center (MMC) provides a wide range of activities and services for people who use drugs (PWUD) and people who inject drugs (PWID). This service provided include: peer networks; referrals to methadone maintenance treatment (MMT); a learning center for medication prescription and counseling; a research center for drug related health issues, HIV and others health problems; a center for Information, Education and Communication (IEC); and provision of capacity building support for Implementing Partners Standard Package of Activities, Drug Users. (2008). USAID and KHANA. 39 Harm reduction model of comprehensive drop in center for people who use drugs, USAID, Australian Aid and KHANA. 35

36 Capacity building Impact mitigation and health Prevention Table 8: Standard Package of Activities for People who Use Drugs, implemented by KHANA. Sections Key areas of focus Activities General: drug use Provide education to the community about the effects of drugs (yama, ATS, glue, alcohol, heroin) and drug and link to HIV use, especially the links between drug use and HIV infection. Harm reduction and risk perception for existing drug users Government treatment programs Life skills Self-Help and Support Groups Provide harm reduction information to DU and PWID through outreach, peer educators and support groups Refer IDU to needle exchange programs, if available Provide active referrals for all PWID and DU to VCCT (provide transport to pre and post testing and counseling) For PWID and DU known to be selling blood, provide counseling and immediate referral to VCCT Collaborate with government treatment centers and NCHADS to deliver HIV prevention messages to patients in centers Collaborate with centers to provide referrals for patients to VCCT Encourage treatment centers to conduct assessment upon entry and follow-up after care Provide life skills training to community PWID and DU through schools and outreach activities Provide outreach in easily accessible venues and at various times of day (morning and evening sessions, offer in parks, temples and other public spaces) Encourage behavior change throughout the curriculum, rather than only providing information, through interactive and participatory lessons (role plays, games, group discussions etc) Conduct life skills training of trainers with peer educators, teachers, community leaders, PLHIV groups Train monks and religious leaders to provide Life Skills information to DU, especially youth DU Offer self-help and support groups for current and former PWID and DU Enable SHG to provide prevention education during support sessions by training group leaders in HIV prevention education Offer drug use support to PWID and DU already participating in support groups/services for other key populations (SW, MSM, PLHIV, etc) BCC/IEC Incorporate information on drug use and HIV as part of general HIV prevention messages Basic medical care and treatment Develop drug use prevention IEC materials, in collaboration with other organizations working with PWID and DU, to emphasize prevention Create and build on existing HIV BCC efforts to include drugs and HIV messages Target messages to PWID and DU at common hangouts, pharmacies, treatment centers, blood collection facilities, etc Provide referrals for PWID and DU to VCCT and other health services, including Hepatitis B vaccine and Hepatitis C testing and treatment Provide education and referrals for PWID to needle and syringe programs, and needle and syringe cleaning training HIV+ drug users Link with HCT and PLHIV services Link with treatment centers Psychosocial support Provide psychosocial counseling to PWID and DU within the community through HCT, trained counsellors, peer educators and/or SHG/support groups Facilitate monks and religious groups to provide counseling services to PWID and DU Self-help and Support groups Offer self-help and support groups for drug users Harm reduction and Provide harm reduction information to PWID and DU through outreach, peer educators and support groups risk perception for existing drug users Refer all willing PWID to government treatment centers and methadone clinics Government treatment programs Encourage treatment centers to conduct assessment upon entry and follow-up after care Outreach and peer educator training Offer regular trainings and skills building opportunities for DU peer facilitators and peer educators to improve outreach efforts, maintain interest and keep information up to date and accurate Ensure peer educators and outreach workers who are former PWID and DU receive services and support to promote prevention and harm reduction among themselves as well as within the community Access to education For former drug using youth, support their access to education Economic improvement Sensitivity and advocacy training Seek to improve the financial situation of former DU by providing them with access to IGA and employment assistance in the community Employ former DU in the program as outreach workers, peer educators or program assistants, when possible Train community stakeholders, including monks and spiritual leaders, on the needs of PWID and DU and their families on the importance of advocating for their needs and reducing stigma and discrimination 36

37 Supporting environment Community support and Sensitivity training Provide sensitivity training on drug users and drug use to law enforcement, community leaders, local authorities, teachers, parents, traffic police and religious leaders Reduce stigma and discrimination by providing sensitivity training and education in school on drug use and drug users National policies Support the approval of the National Minimum Standards for Treatment Centers Support and contribute to the development of a national strategic plan for drug use Lobby with local representatives to review and provide input on national standards and policies for PWID and DU Advocate for a comprehensive national plan on HIV prevention, care and treatment, including information on and for PWID and DU and based on the principles of harm reduction Advocacy Advocate for access to healthcare, treatment and education Lobby local leaders to improve services at government treatment centers Advocate for expansion of needle and syringe exchange Programs Source: Standard Package of Activities, Drug Users. (2008).USAID and KHANA. 37

38 Current Gaps, Emerging Opportunities Based on a gender, sexuality and diversity rapid assessment, KHANA has developed a Gender Strategy to boost gender integration in This strategy addresses gender-related gaps and issues in programming, institutional culture and organizational practice. Nevertheless, the integration of gender-based approach for newly developed program such as Harm Reduction, Policy and Advocacy is still not comprehensive. A recent comment from an independent consultant from European Commission further highlighted that the Asia Action project 40 conducted by KHANA has not integrated gender-based approach (particularly women users) into the Harm Reduction Program, which indicated the issue gap of gender integration into Harm Reduction Program, has not been addressed. Based on the desk review, key findings for gender integration gaps and opportunities within KHANA s Harm Reduction Program are summarized as follows: Gaps Gap #1: Lack of gender-based approach in KHANA s standard packages of activities for PWID. None of the activities outlined in the standard packages of activities has taken into consideration gender sensitivity. For example, no programs and services specifically addressed to women such as females who inject drugs (FWID), partners of PWID (both male and female) and etc. Gap #2: Lack of sensitivity in addressing gender differences among PWID. Women s initiation into drug use interconnects with wider social factors, including drug use in the family, peer group influence, and sexual relationships with male who inject drugs (MWID). Mostly, women are initiated to drug use by their drugusing spouses or sexual partners where they are more likely to share prefilled syringes and other equipment. Programs focused on increasing FWID access to HIV programs need to also empower FWID to negotiate equipment sharing norms and safer injection behaviors with their sexual partners and within their social networks. Gender norms influence men s injecting behavior and sexual risk behaviors as well. Studies in the United States have shown that male norms of dominance may inhibit men s willingness to insist on protected sex or safe injecting. Men are more likely 40 The European Commission through the International AIDS Alliance has supported KHANA to implement a regional harm reduction project known as Asia Action for Harm Reduction. The Asia Action of KHANA utilizes rights base approach to support people who use drugs and people who inject drugs to have safe access to health services and rights through working with police to create enabling environment, and build capacity of people who use drugs to advocate for themselves. 38

39 than women to engage in injecting drug use with friends or with strangers in places like shooting galleries. Among men, needle sharing often occurs during activities with other men, reinforcing masculine norms and making unsafe injecting a more accepted behavior. The willingness to share needles, despite the awareness of its potential risk of HIV transmission, can be perceived as fearlessness, generosity, loyalty, and solidarity toward peers. Because gender norms vary in different contexts, in some settings men may inject first because women are expected to defer to men; in other settings, men inject after their partners because men are expected to take a greater risk. Pregnant FWIDs, who could be also infected with HIV, form an additional subgroup of FWIDs with specific unmet needs. Pregnant women who use drugs may face criminal charges for causing harm to their unborn children and thus avoid prevention and treatment programs. 41 As such, gender sensitivity should be integrated during the planning process of Harm Reduction Program. Gap #3: Lack of gender-sensitive Monitoring and Evaluation of Harm Reduction program. There is a particular need to recognize and address the impact indicator of the project as a result of integrating the gender issue into the Harm Reduction Program for both male who inject drugs (MWID) and FWID and their sexual partners. On the other hand, increased reporting of sex disaggregated data is not enough, especially if the data are not used to inform policy and program decisions that can address gender sensitivity. These data need to be of quality, interpreted along with a continuum of relevant indicators, understood by key stakeholders, fed back into programs, and used for decision making of policies, resource allocation and planning. All of these will result in establishing a comprehensive gender-sensitive HIV monitoring and evaluation systems. Gap #4: Lack of funding specifically for women-related program. Donor support for women related projects remains weak, as does funding allocation specific for women related program such as FWID and partners of male who inject drugs (MWID). Gap #5: Lack of individual and institutional strengthening to enable KHANA to fully implement a rights-based approach and mainstream gender and sexuality. Gap #6: Lack of capacity to conduct sexual reproductive health component in the service package, for example, family planning and antenatal care for pregnant females who inject drugs. Currently,. MMC provides sexual reproductive health component in the service package according to the availability 41 Spratt, Kai Technical Brief: Integrating Gender into Programs with Most-at-Risk Populations. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. 39

40 of funds. MMC provides family planning service (such as contraceptive pills, condom), counseling related to sexual reproductive health, antenatal care and referral to heath facility, MSI and NGOs clinic. Gap #7: No research evaluating the impact of gender integration on Harm Reduction Program. Because most of the research on gender, vulnerability, and HIV has been conducted in country level, it is important to conduct evaluation after the project is implemented to assess to what extent does the effect of gender issue in Harm Reduction Program. Gap #8: Lack of availability of female condoms (and lubricant) in the KHANA s Focused Prevention (FP) program. KHANA found that it is not easy to access female condom in Cambodia because the cost of female condom is expensive and therefore availability is not feasible. Gap #9: Lack of connection with services for gender-based violence. Gender based violence is an obstacle for service accessibility, which correlates with the risk from HIV exposure, Harm Reduction Program should be connected to programs providing protection from gender based violence. Gap #10: Lack of integral Harm Reduction Programs for females who inject drugs (FWID) who are also entertainment workers. FWID who engaged in sex work need services related both to their work and to their use of drugs and those services should be provided by one team in one space. Having in mind that acknowledging entertainment workers as PWID may be a problem in their negotiation /finding clients, it is better that service related to drug use should be discretely integrated in the sex worker targeting program. Gap #11: The high mobility of the peer outreach workers is a challenge, as is the fact that some of them have difficulty in reading and writing 42. Furthermore, they have been constantly exposed to blood borne infections, especially HIV and Hepatitis, since a high proportion of PWUD/PWID were either HIV positive or had Hepatitis. Therefore, all KHANA outreach workers received Hepatitis B and Hepatitis C screening and Hepatitis B vaccination. Furthermore, KHANA also allocated budget for post exposure prophylaxis for outreach workers who were reported needle stick injury. On the other hand, peer outreach workers, who are also PWUD/PWID themselves, may be vulnerable to wrongful arrests for crimes committed by other PWUD/PWID. Hence, KHANA has provision of safety package to all outreach workers- such package includes boots, gloves, clam to pick up needle and syringes, safety guideline and checklist. Additionally, outreach worker normally work as a 42 KHANA reveals that it was hard to recruit outreach worker s who has ability to read and write based on the availability of incentive/allowance. 40

41 group in the community so that they can assit each other when they are questioned by authorities. Gap #12: Additional funding outside the core service program to fund people who inject drugs (PWID) is required. Some of the FWID share household income so when they attend a health educational sessions at the MMC facility, it is vital to provide transportation support for them. This is because travel costs could be the main barrier preventing PWUD/ PWID from attending such sessions. Aside from that, FWID should be compensated for their time away from their jobs. Gap #13: Increased workload of field worker in data collection. When working with an increased number of PWUD/PWID, collecting routine data (including sex disaggregated data) from the fieldwork can become overwhelming. There are too many indicators to be collected from the field, and the indicators need to be sent quarterly to Ministry of Health and M & E Unit. Reports must be submitted to the donor agency every other quarter (semi-annually). Gap #14: Lack of free legal aid for female who inject drugs (FWUD), including females who inject drugs (FWID) and female sexual partners of people who inject drugs (PWID). The free of charge legal aid for FWUD, including FWID and female sexual partners of PWID shall enable access to legal remedies in case of violence, abuse, exploitation, unjust imprisonment or losing custody over their children. This is of special importance for the respect of their rights, but also as a preventive measure, because it sends a message to FWUD that they cannot be abused, without the perpetrator being punished. Opportunities Opportunity #1: Evidence based on the KHANA Meanchey Drop in Center (referred as MMC) and Korsang, integration of gender perspective into drop in centre (DIC) services. MMC has been a role model in integrating gender perspective into the DIC services, such as recruiting female ex-drug user as staff and volunteers in Harm Reduction Program. This will contribute towards FWID feeling more comfortable and less stigmatized. Many of these women encounter different forms of stigma and discrimination when trying to access services due to the social and cultural norms present in the Cambodian context. Women associated with drinking, smoking, gambling or using drugs are strongly disapproved of, and it has been observed that female PWUD/PWID are less likely to be supported by their families. They have particular needs regarding SRH, access to health services, skills for the negotiation of condom use and needle sharing with partners. This will contribute to the increase in the percentage of women using the program s services. 41

42 Currently, MMC has 3 male members and 1 female member of staff. There are also 8 male and 4 female peer outreach workers. The four female outreach workers have built trusting relationships with female PWUD/PWID and motivate them to access MMC services and existing community health services. The services provided to FWID include; provision of a safe space, provision of single sex bathroom facilities, the option to choose between a male medical doctor and a female nurse when receiving a consultation, treatment, counseling, primary health care, body hygiene, or pregnancy test. Health services are provided free of charge to FWID and MMC clinic has a female nurse available to provide care for female clients. For example, established women self help groups, specialized counseling sessions and women where female outreach workers may help female who inject drugs (FWID) to a large extent, will in turn decrease the factors contributing to risky behavior. It is especially significant to introduce activities for education completion, job seeking training and assistance in finding employment, which would make them financially independent. Currently, the project offers life skill such as vocational training and employment sector referral to project clients and outreach workers. Examples of such life skills are: concept on producing liquid soap for dish or other cleaning materials for women who are interested- in addition the center also provides music lessons and basic lesson on how to operate a computer. Opportunity #2: Gender issues were identified in KSP 15. The capacity to do this in relation to reaching FWID and the female partners of MWID is expanding. Opportunity #3: Recognition of violence as a cause and consequence of HIV in the National Action Plan to Prevent Violence against Women (2nd NAP-VAW). The second National Action Plan to Prevent Violence against Women (2nd NAP-VAW) has highlighted the vulnerabilities of women and girls living with HIV, female sex workers, entertainment workers, transgender women and female who use drugs (FWUD) to gender-based abuse and violence. Activities and interventions cited includes access to post-rape care (e.g., post-exposure prophylaxis, emergency oral contraception and STI treatment) as well as nonhealth services such as legal redress which are particularly relevant for men, women and transgender MARPS. Therefore, collaboration and coordination between the Ministry of Women s Affairs and the Ministry of Health (including NCHADS) is critical in terms of improved health-care utilization. Opportunity #4: Receive free health care through the Ministry of Health HEF scheme. A recent focus group conducted in Phnom Penh with males and females who use drugs (MWUD and FWUD) and female EWs reported that they had 42

43 been able to successfully acquire an Equity Access Card (economical group distinction) and receive free health care through the Ministry of Health Equity Fund scheme, including family planning services. Opportunity #5: Creating enabling environment for Harm Reduction Program through Police Community Partnership Initiative (PCPI). The establishment of Police Community Partnership Initiative (PCPI) has led to positive results and appears to have positive changes in MARPS ability to access services, with improved police attitudes towards MARPs and a reduced fear of police among MARPs. 43 The PCPI creates partnerships through capacity building and facilitated dialogue and problem solving at the community level, such as involving local authorities, health care providers and NGO staff in conducting sensitization information sessions for police on the HIV prevention needs of MARPS and the role of law enforcement authorities in supporting HIV prevention efforts. Opportunity #6: Recommendations from Cambodian National Health Sector Response to HIV Review a) Prioritize outreach and services to females who inject drugs (FWID), males who inject drugs (MWID) who are also MSM and transgender persons at very high risk of acquiring HIV and transmitting infections to new partners in Phnom Penh and other identified urban areas, as a first step to ensure high service coverage of MARPs within the Boosted Continuum of Prevention to Care and Treatment (CoPCT). b) Scale up harm reduction services to improve the accessibility of service among men, women, boys, girls, MSM and transgender people who inject drugs, which include scaling up needle-syringe program coverage and related services to PWID across Phnom Penh, working with local authorities to improve access and reach hidden populations. Methadone maintenance program within Phnom Penh should also be expanded to ensure wider coverage. 43 Thomson N., et al. (2012). The village/commune safety policy and HIV prevention efforts among key affected populations in Cambodia: finding a balance. Harm Reduction Journal, 9:31. 43

44 COUNTRY ASSESSMENT Findings from in country visit Face to face interviews with KHANA s team members reveal that KHANA has made progress in implementing its gender strategy 2010, yet the observations highlighted below acknowledged that more work needs to be done. KHANA has adapted specific transparent mechanisms to promote gender-ratio especially within new recruitment process. However, the process is not abetting towards the required outputs. Due to limited capacity among the locals, KHANA human resource department are unable to balance the genderratio during the recruitment process. As a result, KHANA organization structure is still dominated by male employees. Notably, there are few MSM but no TG employed under KHANA. - Therefore it is recommended that KHANA applies strategic and practical approach in managing recruitment process that ensure adequate employment across gender. Stringent work policy prohibits employment of PWUD. - KHANA as a regional partner needs to advocate to donors to adapt its operating polices, especially in recruitment process when it comes to managing or supporting program for marginalized population. There are currently two female managers in the management level and one female at the senior management team. However, there is lack of female at the junior management level. - Even though KHANA is adapting a transparent recruitment process, a lack of capacity locally has hindered the process of balancing gender-ratio in recruitment process. Hence, it is recommended that KHANA adapts an internship mechanism and develop capacity by recognizing the primacy of learning by doing. Findings from KHANA Mondul Meanchey (MMC) Korsang and Background KHANA Mondul Meanchey (MMC) was established by KHANA in 2010 as a center of excellence to showcase good practice in harm reduction, provide capacity building and training, and document issues and trends related to HIV and drug use. A license was approved by NACD to KHANA in 2011 to provide needles and syringes to the PWID in Phnom Penh through MMC premises and the coverage was expanded for needle and syringes provision through outreach services from May 2012 to April Korsang was supported by MMC in NSP distribution because the NSP license 44

45 for Korsang was not approved. Through the cooperation of these two centers, the coverage of NSP was expended. Both KHANA Mondul Meanchey (MMC) and Korsang recruited PWID/PWUD as community peer outreach workers in the project in order to strengthen the involvement of PWID/PWUD and to build trust and confidence in the program. As of June 13, there are two peer educators each at MMC and Korsang to reach out females who use drug (FWUD) and females who inject drugs (FWID). Findings from Field Visit It is noted that MMC and Korsang is applying required standards that demonstrate best practice that harmonize local needs of PWUD and PWID. A comprehensive approach of Harm Reduction Program is fully integrated for women and men. Nevertheless, more efforts are required to ensure gender integration such as gender indicator, gender awareness and capacity building encompassing gender sensitivity issues are incorporated into the program. Specifically, the KHANA team needs to be sensitized towards the needs of MSM, TG, girls and boys; so that they have adequate knowledge to ensure referrals is available and relevant to the needs of respective clients. Currently both the program operates on AusAID funds; as a result MMC is obligated to apply strategies that are stringent to HIV/AIDS Asia Regional Program policies (program which is only funds interventions for PWID, whereby local evidence indicates that injecting is low within Cambodian context). Therefore, such donor driven approaches needs to be managed efficiently so that the program is sustainable and abides by quantifiable needs of PWUD/PWID within Cambodian context. Additionally, an annual Rapid Assessment and Response (RAR) strategy needs to be integrated to ensure evidence guides relevant interventions for PWUD or PWID within local context. Findings from the field visit have also identified programs that are managed in small vicinities are inadequate to address TG, MSM, girls and boy s needs. On the other hand, MMC clients also comprised of young couples - who hang around in the vicinity together. Therefore, it is recommended that MMC should convert the women section (since the women section is not being fully utilized) to couples corner, which provides couple interventions strategies such as couple counseling and couple HIV testing, so that the time the couple spent at the center is maximized. Currently the program manager affirms that such strategies are difficult to implement due to financial constraint. Hence, findings from RAR will serve as evidence to advocate to the funder that such strategies are relevant and will lead into strategic interventions that are customized to relevant target population. As for Korsang, the program caters to PWUD and PWID population within Phnom Penh. Since Korsang is located in low economical area, the center also attracts families who live on the streets. The center is currently funded by several donors. 45

46 Korsang offer services to women, children and men who do use drugs or inject drugs. The center has three floor facilities; the top floor is intended for children, the second floor caters to women and the ground floor for men. Similar constraints of patronage observed in MMC were also noted in Korsang, for example; families basically prefer to stay on the ground floor where single individuals (mainly men) have express their discomfort over the noise, especially when the program caters for focus group gathering or during meal times. In addition, the ground floor is not a conducive environment for children, because the area is open for clients who smoke and linger while waiting for medical or counselling services. Findings also indicated that the center does not capture or offer friendly environment to TG or MSM clients. However, Korsang does provide outreach services to men, women, TG and MSM, but Korsang employees articulated that they have inadequate capacity to support such population needs. In addition, it was also noted that both center employees were not adequately trained or sensitized on sexual reproductive health (SRH) issues across gender. They had limited knowledge of intimate partner violence (IPV) and women rights on maternal health. Both centers team members basically adhere to cultural norms that dominate their response or required action towards such issues. In conclusion, both MMC and Korsang need to be more cognizant of their clients and employee needs; and where possible apply gender sensitivity to issues such asstaff uniforms, safe space for partners and family. Furthermore, capacity of staff to comprehend women, men, MSM, TG, girls and boys on SRH issues need to be strengthened. On the other hand, integration of IPV and maternal rights is a cultural and policy issues within Cambodia, thus strategic direction and implementation needs to be considered. Nonetheless, the management team of KHANA recognized that IPV needs to be monitored and hence evidence needs to be documented. Findings from Gender Sensitivity Checklist Both MMC and Korsang indicated a similar trend where high gender sensitivity within organization structure, moderate gender sensitivity in program development process but very low gender sensitivity in program implementation. Organization structure: Both MMC and Korsang have achieved a lot (both score 8 out of 11 points) however, sustainability of the program after AusAID funding ends is still an overarching concern. Program development: Both MMC and Korsang are moving in the right direction in this aspect of gender capacity and readiness- however, scoring needs to be improved (both score 9 out of 15 points). Program implementation: Both MMC and Korsang scored below average in this section- thus both agencies needs to strategies and ensure comprehensive approach towards program implementation is improved (10 and 11 out of 35 points respectively). 46

47 Figure 4: Scoring of MMC and Korsang using Gender Sensitivity Checklist. Findings and Analysis of Gender-sensitive Indicators based on MMC and Korsang s data Coverage of KHANA Needle and Syringes Program (NSP). Based on Report of the Commission on AIDS in Asia (2008), coverage must reach 80% to initiate the 60% behavior change that is needed to reverse the epidemic. As such, Figure 5 depicts that the coverage of Harm Reduction Program for PWUD / PWID in Phnom Penh remains inadequate (53% and 26% respectively) especially among PWID Notably, the HIV prevalence rate among PWID is six-fold of PWUD population (24% and 4% respectively) in the country. Therefore, there is an urgent need to scale-up Harm Reduction Program in order to reverse the epidemic especially among PWID. Figure 5: Coverage of KHANA NSP program versus national target, as of June

48 Number of PWUD/PWID accessed NSP. For every ten PWUD who accessed an NSP, three-four of them were female at the first half year 12 and 13. Interestingly, the data in July Dec 2012 shown a reverse trend where every ten PWUD, seven of them were female. For every ten PWID who accessed an NSP, only one female client was reached in the first half year 12 and 13. Similarly, data in July Dec 2012 shown a reverse trend where every ten PWID accessed NSP, eight of them were female clients. Therefore, an effort of integrating gender into program reach is improving but more efforts are required to attract more FWID in NSP programs. If there is an increasing trend of women participating in NSP during the period of July to December every year, more detailed data can be collected to explore the reason of why this situation has occurred. The data collected need to be disaggregated to include Transgender and MSM as well as age. Figure 6: Number of PWUD/PWID who accessed an NSP over the 18 months period, by sex. Number of PWUD/PWID reached through outreach and DIC. Most PWUD (on average 78%) were more likely reached through peers outreach work, whereas PWID were reached out through both peer outreach workers and Drop-in Center (60% and 40% respectively). However, both PWUD/PWID indicated more than half of them were reached through outreach services (78% and 60% respectively). 48

49 Figure 7: Number of PWUD/PWID reached through Outreach and DIC, January June 2013 Proportional of new clients towards the reported clients in 18 months period. On average, one out of ten PWUD (both male and female) reached through outreach and DIC is new client. For PWID (both male and female), on average every one out of five reached through outreach and DIC is a new client. Notably, a higher proportion of new PWID clients are reached by DIC compared to outreach (27% and 17% respectively). Data need to be disaggregated to include Transgender and MSM as well as age. Figure 8: Proportional of new clients towards the reported clients in 18 months period, by sex. 49

50 Number of NSP occasions of service (total contacts) in 18 months period The number of NSP reach through outreach service increased gradually for both PWUD and PWID (from 12,339 to 19,365 for PWUD and from 4,238 to 8,504 for PWID respectively). Notably, there is a decreasing trend of the number of NSP reach through DIC services especially among PWUD, from 8,888 in Jan-June 12 to 3,549 in Jan- June 13 respectively. Figure 10 indicated that the ratio of clients reached for NSP is high (ranged from 394 to 618 for PWUD and 250 to 503 for PWID through outreach; ranged from 113 to 284 for PWUD and 155 to 312 for PWID through DIC) according to the international standard (more than 70 considered high) 44, this is evident especially through outreach program. Figure 9: Number of NSP occasions of service (total contacts) in 18 months period. Figure 10: Ratio of the number of NSP occasions of service in specified reporting period per 100 PWUD/PWID. 44 The possible target Low 30 Mid 70 High, recommended under WHO, UNODC and UNAIDS Technical Guide. 50

51 Number of Needle and Syringes distributed. Even though the number of needle and syringes distributed per PWID has increased from 2 needle and syringes to 42 needle and syringes (January 2012 to June 2013), yet the number of needle and syringes distributed per PWID considered very low (20 needle and syringes distributed per PWID per 6 months) according to WHO,UNODC and UNAIDS technical guide. 45 It is recommended at least 200 needles and syringes needs to be distributed per PWID per year. Figure 11: Number of needles syringes distributed per PWID. Number of condoms distributed per PWID. Through outreach and DIC, every PWUD /PWID received 16 condoms per 6 months period. This indicates that at least 1 condom is distributed per PWUD/PWID, respectively. 45 The possible target Low 100 Mid 200 High stated in WHO, UNODC and UNAIDS technical guide. 51

52 Figure 12: Number of condom distributed per PWUD/PWID per 6 months period. Proportional of PWUD/PWID referred to other health services. There was no PWUD/PWID referred to residential rehabilitation and PMTCT during January 12 to June 13. Almost all clients (more than 80%) referred to Methadone Maintenance Therapy were male whereby all clients (98%) referred to other reproductive services were female (FWUD and FWID). On the other hand, more FWUD and MWID were referred to STI services and ARV/OI & monitoring (34% and 33% for STI services and 32% and 29% for ARV/OI & monitoring respectively). Nearly half of the clients referred to VCT and TB treatment & monitoring were male (48.5% for MWUD and 47% for MWID respectively). Notably, there was only very few FWID (4%) referred to VCT. Therefore, there should be a more specific program to encourage FWID to access VCT. Interestingly, more FWUD were referred to STI services, ARV/OI & monitoring and TB treatment & monitoring compared to other sub-groups (except referred to TB treatment and monitoring among MWID) (Table 9). Therefore, sexual partners of FWUD are at higher risk of getting infected. Data need to be disaggregated to include Transgender and MSM as well as age Figure 13: Proportional of PWUD/PWID referred to other health services, Jan 12 June

53 Table 9: Comparison table of the number of PWUD/PWID (both male and female) accessed to STI services, ARV/OI & monitoring and TB treatment & monitoring, January 12 June Referred services FWUD MWUD MWID FWID STI services ARV/OI & monitoring TB treatment & monitoring Number of PWID on Methadone Maintenance Therapy. There were a total of 82 PWID on MMT as of June 13, of which 16% (13) were female, equivalent to 5 PWID on MMT per 100 PWID. According to the data collected, high proportion of MWID left the program compare to FWID (84% male and 16% female respectively). Figure 14: Number of PWID on MMT at a specified date or over the specified reporting period (Jan 12- June 13). 53