Creating a referral system for men who have sex with men in Lebanon
The International HIV/AIDS Alliance and the National AIDS Programme of Lebanon are collaborating with non-governmental organisations on an innovative programme to address the medical and psychological needs of men who have sex with men in Lebanon.
The situation
In countries with low levels of infection such as those of the Near and Middle East region, strategies for dealing with HIV are focusing more and more on targeted prevention intended for people with risky behaviour. Men who have sex with men represent an important example of key populations at higher risk. They have limited access to information and services (when available), which puts them at risk of contracting HIV and other sexually transmitted infections.
Lebanon recorded 2,900 people living with HIV in 2006 (source: UNAIDS). Studies conducted in Lebanon on the general population and vulnerable populations have demonstrated the existence of risky sexual practices, including multiple partners and inconsistent use of condoms.
In addition, a study conducted in 2002 by the organisation Soins infirmiers et développement communautaire, in collaboration with UNAIDS and the National AIDS Programme, revealed that only 47.1% to 54.5% of men who have sex with men participating in the study used condoms during their sexual relations – despite 67% of the population considering condoms affordable. Men who have sex with men were aware of HIV and AIDS, and between 82.7% and 100% knew the modes of HIV transmission and prevention. Among this population, 94.1% had consulted a health-care professional during the previous year, but only 34.4% admitted their homosexuality in the presence of this professional. 14.9% had symptoms of sexually transmitted infections and 34.7% had been tested for HIV.
During local HIV prevention efforts conducted by Soins infirmiers et développement communautaire among men who have sex with men in 2005, 874 people were reached, including 95 who described themselves as sex workers. Among these 95 people, 60% were between 16 and 31 years old. 12% reported interrupting sex if no condom was available and 30% reported having been tested for HIV. Among men who have sex with men, 37% said they needed medical attention for sexually transmitted infections. These results demonstrated the urgent need for the implementation of a referral system appropriate for men who have sex with men that would link to prevention and treatment services for HIV and other sexually transmitted infections, as well as psychological and legal support services.
At the end of 2005, a participatory community survey was coordinated by SIDC with support from the Alliance and conducted by a team of 14 peer educators. This survey took place among a sample of 40 people identifying as men who have sex with men and aged 20 to 25. The survey looked at vulnerability to HIV within the population and the limited availability of services related to HIV and other sexually transmitted infections, including:
- a lack of testing and care for HIV and other sexually transmitted infections
- a lack of medical centres receptive to men who have sex with men, people with HIV, or those with sexually transmitted infections
- the discriminatory attitudes of health-care professionals toward men who have sex with men
- a lack of appropriate voluntary counselling and testing services
- difficulty accessing existing care services, including the need to pay for testing, and issues with opening hours
- counselling and testing services not being accessible to minors without parental consent
- a lack of targeted promotion of existing health-care services.
Another problem is linked to the lack of quality services available to men who have sex with men. It is difficult to obtain free or low-cost condoms. There is also limited dependable information about sexuality and the rights of men who have sex with men, such as magazines or non-commercial films. There is a lack of friendly venues where men who have sex with men can meet without hiding their sexual identity, as well as a lack of receptiveness within organisations. In addition, information is lacking on risks in meeting places of men who have sex with men and safety measures.
The need
The studies indicated a need to create a referral system among social and medical facilities for men who have sex with men. Establishing such a system required action strategies including promoting a referral system among non-governmental organisations and health facilities. Services providers also needed training to make services such as the testing and treatment of HIV and other sexually transmitted infections more appealing. There was also a need to offer appropriate information about sexual identity, HIV and other sexually transmitted infections to men who have sex with men, to promote services available and to advocate for a telephone advice service.
Organisations
The Alliance chose SIDC to implement these strategies. SIDC has been involved in Lebanon’s HIV response since 1990 and has been carrying out fieldwork with men who have sex with men since 1992. SIDC has experience in training peer educators, training for monitoring and counselling, and outreach work. They provide anonymous HIV counselling, counselling and follow-up care for people with HIV, and advocacy work.
Helem is strategic partner for SIDC in local prevention work with men who have sex with men. Since 2004. Helem has been addressing the needs of the lesbian, gay, bisexual and transgender community. Helem offers a centre for reception, information and orientation, as well as campaigns against homophobia and discrimination in Lebanon.
Activities
The project included legal services, health-care services (including medical care, follow-up and blood tests), social services (focusing on violence, juvenile delinquents and drug users), psychological support for men who have sex with men, and free HIV counselling and testing services. Providing these services meant implementing and promoting a referral system among 15 non-governmental organisations and medical and social services in Beirut.
To ensure promotion of services, the project had to strengthen partnerships through individual or group meetings with officials, non-governmental organisations, medical and social facilities, and pharmacies by updating them about progress made. This led to the creation of a partnership with bar and movie theatre owners and the establishment of a group of peer educators (street work, advice service, hotline) to promote services.
Promotion materials developed included a referral protocol, guide and card. The project team also developed health boxes to distribute prevention materials, cards to promote the referral system, a brochure about men who have sex with men, and a brochure for the families of homosexuals.
Support
The project established selection criteria for choosing organisations and facilities to target, looking for organisations offering medical and social services as well as organisations with experience in HIV and other sexually transmitted infections. At the same time, there was a need to involve organisations with experience working with vulnerable populations (such as victims of violence, minors, delinquents, sex workers, people with HIV, and drug users) and organisations with access to men who have sex with men. Once these organisations were identified and chosen, the team sent them a letter explaining the project and inquiring about their availability and interest in the project.
At the same time, the project organised advocacy and sensitisation meetings among political and religious authorities and the public to sensitise partners to the importance and urgency of implementing prevention activities for men who have sex with men. At the same time, the meetings aimed to encourage participants to support prevention activities and motivate them to support the referral system.
The project also organised an exchange meeting with a group of representatives of health-care facilities which served to stimulate discussion about the feasibility of implementing a referral system and identify the needs for training service providers. Following this meeting, the project team developed protocols for implementing the referral system.
The next step was to train the service providers involved, with an initial emphasis on topics related to HIV and other sexually transmitted infections as well as drug use. Trainers helped the service providers to understand vulnerability, risky behaviour, strategies for reducing risk, how to encourage behaviour change, and communication with vulnerable groups. Training focused on the principles, characteristics and importance of the referral system and documenting requests. It also covered counselling and testing, motivational sessions, and developing the referral system protocol.
Challenges
The project was not without its problems. It was a pilot project with few precedents in the Arabic-speaking world. It involved collaboration in a new area with a large number of organisations and medical and social facilities. Political officials were wary of advocacy efforts, and organisations wary of the workload involved and the specificity of the population. Sensitising non-governmental organisations and social centres on the importance of their collaboration in this project was not always easy. In addition, the time allotted to preparing modules and protocols for each activity prior to project commencement was short. There was also a lack of documentation appropriate to the population and a delay in procuring preventive materials (lubricants, condoms and testing kits). Ensuring free services was difficult, as was dealing with the many needs of men who have sex with men. Another challenge was ensuring ongoing monitoring and evaluation of the system.
Lessons learnt
Several lessons came out of implementing the project, including the importance of:
- choosing an effective process for identifying problems
- integrating prior experience into local work
- implementing promotional activities targeted at services (peer education, advice service, reception service, hotline)
- motivating service providers to collaborate in the project
- creating a partnership with stakeholders for the development of a referral system
- creating a partnership with government officials to obtain their support, involve them in decision-making, and keep them up to date on activities
- diverse organisations participating in the referral system
- ensuring ongoing, responsive training
- developing and reaching agreement on the adoption of protocols for services to provide
- recognition among organisations and with government entities
- choosing peer educators involved in promoting local activities
- extending training to other areas
- monitoring peer educators
- implementing a coherent system for monitoring and evaluating project activities
- the recognition and reliability of organisations in charge of coordinating the programme and their experience dealing with HIV
- adapting activities and materials to the local context and to the needs of the population
- better understanding the needs of the population
- creating a partnership among organisations with complementary strategies
- implementing a system for collaboration and networking.
Conclusions and recommendations for the future
- It is important to develop contracts with the organisations involved in the referral system to ensure free services.
- There should be fewer organisations offering more services.
- There is a need to provide ongoing information about project results to government officials.
- A team is needed to ensure ongoing evaluation of the system.
