Contributed by: Alexnadra Ataya
In 1987, the SID association (the initials come from its French name, “Service Infirmier à Domicile”) was founded in Lebanon. It started as a provider of primary health care through home-based nursing, responding to demands from all over the country. During SID’s work, commonalities in the socio-cultural and health context of the beneficiaries became evident. A needs assessment survey revealed several health problems that could be prevented by raising awareness and promoting community development. Consequently, the SID team created several health programs, which were expanded and modified to meet the needs of the various communities that they serve.
As a result, in 1992 SID became SIDC (the initials are from its French title “Soins Infirmiers et Développement Communautaire”) and its programs expanded to community development programs involving health behaviors and disease prevention. A human rights-based approach was applied to all programs, reaching out for the neediest and the most marginalized groups of the population. SIDC developed programs to reflect its principles and beliefs, and created activities addressed to youth, adult and elderly population, and vulnerable groups. Currently there are four main programs being carried out: Nursing Program, HIV/AIDS Program, Drug Program, and Youth Program. SIDC’s commitment today is to ensure quality services targeting not only the Lebanese territory but the MENA region (Middle East and North Africa) by advocating the right of the population to have access to decent health standards.
IDENTIFY THE COMMUNITY PROBLEM/GOAL TO BE ADDRESSED AND WHAT NEEDS TO BE DONE:
With a population of over 4 million, Lebanon has an estimated 3,000 persons living with HIV. Reported HIV cases indicate a 4:1 male-to-female ratio, with sexual transmission as the main mode of infection. National adult prevalence is approximately 0.1 percent. However, what appears to be a low level of HIV is not necessarily the whole picture of HIV in Lebanon. As global experience shows, such national-level data may mask the potential for smaller but more intense epidemics within certain communities or regions of the country.
Injecting drug users (IDUs), sex workers, and men who have sex with men (MSM) are identified by the U.S. President’s Emergency Plan for AIDS Relief as the most-at-risk populations (MARPs) for HIV infection. As in many parts of the world, those most vulnerable to HIV in Lebanon are likely to experience marginalization and stigma because of their sexuality, gender identity, or illegal behavior, such as drug use and sex work.
ASSESS THE LEVEL OF THE PROBLEM OR GOAL:
According to the National AIDS Control Programme (NAP), Ministry of Public Health (2008) research indicates high risk rates in these populations: 43 percent of female sex workers do not use condoms with irregular clients (clients who may only visit the sex worker once or infrequently), 43 percent of IDUs did not use a condom during their last sexual intercourse with a partner (non-sex worker), and 62 percent of MSM report having sex only with sex workers, which indicates how pervasive male sex work is among MSM. This additionally demonstrates the overlap in risk among different at-risk groups. The distinction between the groups may be blurred on many occasions.
Social and economic pressures also increase the vulnerabilities of the most-at-risk populations. For example, in one study only 15 percent of female sex workers said they would stop a sexual relationship when faced with violence, mainly because of their need for the income or their sense of disempowerment (National AIDS Control Programme, Ministry of Public Health 2008).
SIDC’s goal is to better understand these hidden communities, improve their access to services, and address social norms that render them vulnerable.
DESCRIBE THE PRIORITIZED GROUPS TO BENEFIT AND THOSE IMPLIMENTING THE INTERVENTION:
The outreach program was targeted towards sex workers, MSM and IDUs. The national HIV strategy has designated these most-at-risk populations a priority for Lebanon’s HIV programming efforts, and there is a national push to include these populations in such key processes as national strategic planning. The national HIV prevention strategy targets the most-at-risk populations in three of its four priority areas: human rights, advocacy (to review policies and legislation related to the most-at-risk populations), prevention (to promote voluntary counseling and testing [VCT], and to work on the prevention of HIV and STIs among these populations), and surveillance (to develop second-generation surveillance strategies targeting these demographics).
National government and nongovernmental partners in Lebanon recognize this situation and the subsequent increased risk of HIV infection among marginalized populations.
INDICATE HOW YOU WILL OBTAIN CLIENTS' INPUT:
A qualitative and quantitative needs assessment was conducted in the year 2000 prior to the initiation of the outreach program. In-depth interviews were conducted and surveys were filled out by individuals from the priority populations.
Most outreach workers are themselves MSM, former sex workers, or IDUs. Among the factors considered in their selection are communication, networking, and listening skills; their passion for and personal belief in the mission and principles of the program; their level of education; and their reliability. Outreach workers establish relationships with individuals in their target group and chat with them about the services they offer. They find their clients through social networks and by visiting locations known to be frequented by their target populations.
ANALYZE THE PROBLEM OR GOAL TO BE ADDRESSED BY THE INTERVENTION:
There are many personal and environmental factors that influence these populations and contribute to them not seeking proper counseling, care, and testing. The issue of HIV/AIDS is a taboo in Lebanon and highly stigmatized. At the time of the initiation of the outreach program, there was a lack of availability and accessibility to HIV/AIDS specific services for the three most-at-risk populations. As a result, the majority of people within these populations did not test for HIV/AIDS and other STIs.
In addition to the stigma, legal issues with the three populations contribute to the engagement in risky behaviors (ex: lack of condom use and sharing needles). These behaviors may put others in the community, namely partners and clients, at risk of contracting STIs.
The outreach program needed to be a multi-level program in order to deal with the different facets of this issue. There was an obvious need to address this issue on the individual, community, and policy levels.
SET GOALS AND OBJECTIVES FOR WHAT "SUCCESS" WOULD LOOK LIKE:
Goals of the program included:
- To formulate a better understanding of these communities in order to provide them with proper and specific services.
- To address social norms and issues that render these communities vulnerable
IDENTIFY AND ASSESS “BEST PRACTICES ” OR “EVIDENCE-BASED INTERVENTIONS.”
Research on international literature (via internet, brochures and best practices developed by other NGOs, site visits) was conducted. Best practices identified in the literature were selected and then modified and adapted to suit Lebanese culture.
The program was funded by different sources through the years. At the beginning of each phase, a proposal and modifications were made according to recommendations of the funders and challenges faced in the previous phase. Continuous change and improvements to the program resulted from these modifications.
HOW WAS THE ACTION PLAN FOR THE INTERVENTION DEVELOPED?
The key principles that govern program implementation include inclusiveness and partnership with the target population, peer education, harm reduction, flexibility and continuity of activities, capacity building, experience sharing, partnership development, and confidentiality.
An action plan for the outreach was developed prior to its initiation. The plan included: An advisory committee to support the outreach activities, which includes the Ministry of Interior, Interior Forces, and U.N. agencies; SIDC and the National AIDS Control Program as the main partners; two General Field Coordinators who coordinate all the outreach workers and activities; Four Thematic Focal NGOs who provide outreach workers from the at-risk communities and coordinate their own workers (Dar al Amal, Oui pour la Vie, Helem, NGO Forum Saida); and Five Hosting NGOs who are members of the referral network and host meetings.
Funding comes from different sources, starting with the United Nations in 2001; currently, the Drosos Foundation and the International HIV/AIDS Alliance provide funding. Some of the donors have provided funding for the entire program, while others support only certain program elements or only activities related to one of the at-risk populations.
Resources needed include a mobile unit, HIV, HBV and HCV rapid testing kits, condoms, syringes, mobile unit fuel, first aid kits, etc…
WAS THE INTERVENTION PILOT-TESTED ON A SMALL SCALE ?
The intervention was pilot-tested for 2 months with the 3 populations. Results were analyzed and reported back to the initial funding agency of the project. Based on the results of the pilot test some things were modified and improved for the full-scale implementation.
SPECIFY THE CORE COMPONENTS AND ELEMENTS OF THE INTERVENTION:
- Providing Information and Enhancing Skills: SIDC and its partners are conducting a legal review of the laws governing such risk behaviors as sex work and homosexuality. Continuous advocacy is conducted with officials, the media, and the public on these issues to challenge gender norms. SIDC and partner NGOs are part of an initiative to review and propose changes to laws related to homosexuality and sex work. In addition, some of the participating NGOs document and research stigma associated with gender norms. Helem, for example, produced studies on stigma associated with sexual orientation in Lebanese universities and among health care providers, and it documents human rights violations and general homophobia in the country. SIDC and Dar al Amal participated in studies documenting the status of female sex workers in Lebanon, including their experience with gender-based violence and other violations of their rights. In partnership with government partners, they completed four studies documenting the situation of sex work in Lebanon, including a legal review, a quantitative and qualitative study of clients and pimps with a sample size of 400 individuals, a situation analysis of female sex workers, and a mapping of available services for sex workers in Lebanon.
- Modifying Access, Barriers, Exposures, and Opportunities: Information is vital but not sufficient to guarantee behavior change. This program goes beyond sharing information to offer counseling and tangible services to the target population. The three most-at-risk populations receive free condoms and syringes, as well as free HIV and hepatitis testing both on the spot and through a referral network. Such tangible services are more likely to influence behavior change and strengthen the target populations’ trust in the program. Advocacy and discussions with government, the media, and community members are normalizing the debate around such sensitive issues as gender norms and sexuality. For example, when it first opened, residents in the neighborhood of one drop-in center complained it was bringing MSM to their communities. After repeated discussions with the outreach workers and witnessing how the NGO functioned, the neighborhood residents reversed course and started referring MSM to the center.
- Enhancing Services and Supports: The outreach program is linked to a well-developed referral system, including a telephone hotline. Gender-based violence is one of the key components of the program. Outreach workers are trained to detect it and offer counseling. However, some cases may require follow-up and more support. One NGO cannot address all the needs of all of the at-risk populations, so a strong partnership with other NGOs is essential to the success of the program. SIDC successfully brought together five NGOs to implement one common program in a strong partnership that supports the capacity of all involved. It created a second level of partnership among a wider group of 52 NGOs serving as referral centers to the target population for a wide range of services. These NGOs offer a range of medical, legal, psychological, and social services. These services include, but are not limited to, raising awareness, testing, diagnosis, treatment of infections, drug addiction and rehabilitation services, social and psychological counseling, legal assistance, and vocational training. Referral NGOs all abide by a unified referral protocol. SIDC produced a user-friendly referral pack listing the NGOs, the services they offer, working hours, and contact details. The outreach workers use the packs to refer their target population to the appropriate NGOs.
IDENTIFY THE MODE OF DELIVERY THROUGH WHICH EACH COMPONENT AND ELEMENT OF THE INTERVENTION WILL BE DELIVERED IN THE COMMUNITY:
Selecting outreach workers who possess the appropriate skills, attitudes, and experience plays a big role in their ability and readiness to locate and gain the trust of individuals in the target group. The outreach workers receive standardized training from SIDC. Gender norms are an important feature of the training under the topics of vulnerability to HIV infection, sexuality definitions and nuances, stigma as it relates to gender and sexuality, and gender-based violence (detection, counseling, and referral). The outreach workers also conduct exercises on condom negotiating skills and on how to empower their clients and build confidence.
The outreach workers tell their clients about HIV, other STIs, and hepatitis, and engage their clients in discussions about safer-sex behavior, such as negotiating condom use and dealing with peer pressure to share needles. The outreach workers distribute condoms, lubricants, and syringes, and inform their target group about where to access key health, legal, and social services, such as the SIDC mobile Voluntary Counseling and Testing (VCT) van. The van is equipped with rapid HIV and hepatitis C testing kits and is staffed by a VCT counselor. The outreach workers work with the counselors to coordinate a schedule of site locations and timing that suits their target population.
Outreach workers also discuss violence with their clients: how to avoid it and how to address it. In some cases, an NGO may intervene to assist a client with violence-related issues. In some cases, Dar al Amal, the NGO dealing mainly with female sex workers, provides shelter for sex workers facing physical violence from their pimps. The NGO has mediated disputes between sex workers and their pimps and, when needed, brings in the police to protect the sex worker.
If appropriate or if the client asks for it, the outreach worker also offers information and advice about vocational training and skill-building opportunities to enhance their income earnings, and may refer the client to one of the NGOs offering such training.
INDICATE HOW THE INTERVENTION OR “BEST PRACTICE ” WAS ADAPTED TO FIT THE NEEDS AND CONTEXT OF YOUR COMMUNITY:
One of the key elements of this program is that it maintains a strong link with its target population, continually updating its services based on needs. One way to do that is to ensure constant collection of data. The outreach program established a basic but comprehensive monitoring system where all collected data are disaggregated by gender and sex. This enables planners to monitor program uptake by gender and sex and, for example, determine whether a certain service is being used more by men or by women. SIDC’s outreach program has evolved several times to respond to changing needs. It began in the late 1980s, when SIDC initiated a drug use prevention program. This eventually led to establishing an HIV hotline in 1991. The outreach program began qualitative research in 2001. Since then, it has gone through many changes before it arrived at its current form. Selection criteria for outreach workers changed, the content of their training was enhanced, the services delivered were upgraded (e.g., adding the mobile van), and the referral network was strengthened over the years. However, in order to enrich its monitoring, SIDC and its partners may look towards including program outcome and program impact indicators in their data collection in order to better understand program performance.
Continuous adaptation of the initial work plan was essential throughout the program. Modifications were made according to certain situations that were presented.
Examples include:
- Adaptation of the design of coverage of the program. Initially it was a de-centralized design with coverage all over Lebanon. Training of NGOs and peer educators in each region was conducted in order to carry out the outreach work. However, after some period of time, peer educators refused to work in their regions due to high stigma and discrimination encountered in the line of work (mostly in the Bekaa, the South and the North). Fear of recognition close to home was another factor. NGOs in these regions limited their activities as well in order to keep in line with cultural values within their areas and for fear that their other services will not be accessed once they start providing these services. Therefore, the design was altered to cover a limited geographical area with outreach work conducted mostly in Beirut and Mount Lebanon by a number of NGOs from the area. These same NGOs would conduct outreach trips to the other regions (Bekaa, South and North), in limited amounts.
- Other modifications include changing plans for when to conduct outreach work (ex: original design was outreach for female sex workers during the evenings – upon their recommendation this was switched to daytime due to occupation of female sex workers with securing clients during the evenings. Ex2: restricted areas such as the Southern suburb of Lebanon were avoided following an incident with a political party regarding the provision of services in the mobile unit in a certain area – permission from the party was not granted in order to conduct the outreach work using the mobile unit).
IMPLEMENT THE INTERVENTION, AND MONITOR AND EVALUATE THE PROCESS AND OUTCOMES
Referral NGOs complete monthly reporting forms and submit them to SIDC for overall program monitoring. All outreach workers, regardless of the group they target or their NGO affiliation, use a unified monitoring system. Outreach workers complete a reporting form after each outreach session, entering standard data on their target group, discussions, and services given. The NGO coordinator transfers the forms to SIDC. SIDC analyzes the data, produces a unified report, and shares it with a wide range of partners and the National AIDS Control Program. All data are disaggregated by sex and gender, including male, female, and transgender; as well as by target population, including sex workers, injecting drug users, and men who have sex with men. The goal is to help SIDC staff understand the gender dimensions of the target groups, such as whether certain locations are better suited to reach female clientele, or if male clients are more likely than female clients to ask for condoms.
According to program data, from 2003 to the end of 2009, SIDC and its partners trained a total of 80 peer outreach workers and 70 social and health care workers, and succeeded in reaching a total of 8,946 individuals within the targeted most-at-risk populations. This includes 2,509 MSM (including male sex workers), 3,550 female sex workers, and 2,854 IDUs.
SIDC has expanded its work with IDUs by opening Lebanon’s first drop-in center offering counseling, testing, and other key services; and will soon include opioid substitution therapy, which SIDC is working with the government to introduce. SIDC also conducted an external evaluation of the outreach program covering all implementing partners and the at-risk populations to help the organization scientifically assess its work over the years. The evaluation is hoped to facilitate resource mobilization to sustain the outreach program and perhaps help it develop into an ongoing national program, rather than a time-limited project working in only a few areas. All the data that was collected from the at-risk populations during the outreach program duration is in the process of being analyzed for this purpose. Finally, SIDC is collecting all its training material into one training module on outreach to at-risk populations to support the work of partners in the region and beyond.
As an indirect effect of the outreach program, a group of outreach workers initiated a lesbian, gay, bisexual, transvestite, queer, and intersex (LGBTQI) NGO, Helem, which advocates for equality in access and rights of persons with alternative sexualities.