National Consolidated Training of Key and

Priority Populations Friendly Services for

Health Care Workers

May 2023
Addis Ababa

14/05/2024 KPP friendly service training for Health Workers 1

 Introduction to Manual

Course Description
• National Consolidated Training Manual of KPP
Friendly Services is designed for health care
workers working in KP clinics and program
managers involved in KP service provision.
• This training will help HIV testing services using
different approaches (SNS, HIVST) and provide HIV
prevention based on the standard national HIV
prevention, care, and treatment guideline.
14/05/2024 KPP friendly service training for Health Workers 2
 Cont..
Course Goal
• The goal of this course is to enable health
professionals acquire knowledge on KPP and skills
to provide the service of their interests following
national HIV prevention, care, and treatment
guideline.

14/05/2024 KPP friendly service training for Health Workers 3

 Cont...
• Certification criteria
Participants need to attend all classroom sessions, 100%
attendance
For basic training, participants need to score more than
>70%and for TOT more than 80% in post course assessment.
• Training for 6 days.
• CEU-15

14/05/2024 KPP friendly service training for Health Workers 4

 Chapter 1: Introduction to KPP

Learning objectives: By the end of the Chapter the

participant will be able to:
• Define Key and priority populations.
• Identify KP and PP as per 2021-2025 national
HIV/AIDS strategic plan of Ethiopia.
• Describe the minimum service package for KP and PP.
• Describe principles and standard of KP friendly
services
14/05/2024 KPP friendly service training for Health Workers 5
 Individual Reflection (10minutes)
INDIVIDUAL REFLECTION

 What are Key Populations?

 What are Priority Populations?
 What makes them Key or Priority Populations?

14/05/2024 KPP friendly service training for Health Workers 6

 cont.…
• prevalence and incidence of HIV steadily
declined in the general population.
• magnitude of population groups who have -high-
risk behaviors remains largely with very limited
available data.
• survey data on MARPs in 2020 in 6 regional
capitals and 12 selected major towns of Ethiopia,
the prevalence of HIV among FSWs was 18.7%.
14/05/2024 KPP friendly service training for Health Workers 7
 Cont.…
• KPP identified by the National Roadmap for HIV prevention (2018-2020) and the
HIV/AIDS Strategic Plan (revised for 2021-2025) include: -
FSWs(18.7%-EPHI 2020)
prisoners(4.2%-UNODC 2014)
PWID (39.5%-OSSHD 2017)
widowed(10.9% EDHS 2016)
separated /divorced women(3,5%-EDHS 2016)
long-distance Truck drivers(4.9%-EPHI 2014)
PLHIV and their partners
workers in hotspot areas(1.5%- FHAPCO 2017)
high-risk adolescent girls and young women(0.8%-EPHIA 2018)
14/05/2024 KPP friendly service training for Health Workers 8
 Cont.…
• They are defined as Key and Priority Populations
taking into consideration local epidemiology, HIV
prevalence, high risk behaviors, increased morbidity
and mortality or higher vulnerabilities.
• Moreover, these population groups have a relatively
high risk of HIV infection, limited access to services
and some face stigma and discrimination.

14/05/2024 KPP friendly service training for Health Workers 9

 Key Populations (KPs)
• Key populations identified in National Roadmap
for HIV prevention (2018-2020) and HIV/AIDS
2021-2025 NSP are:-
female sex workers
prisoners and
People with injecting drugs.

14/05/2024 KPP friendly service training for Health Workers 10

 Female Sex Workers (FSW)
• FSWs are defined as females who regularly or occasionally
trade sex for money in drinking establishments, night clubs,
local drink houses, chat and „‟shisha‟‟ houses, “on the
street”, around military and refugee camps, construction
sites, trade routes, red light districts, and at their homes.
• This definition includes Women who identify themselves as
sex workers, and women that do not identify themselves as
sex workers, but engage in sexual relationships in exchange
for money, goods and/or favors.
14/05/2024 KPP friendly service training for Health Workers 11
 FSW cont.…
• The self-identified Female sex workers are further described
as: -
 Venue-based
 Street based
 Home based
• The non-self-identified sex workers are mostly members of
different social groups who engage in any kind of transactional
sex activities.
• As of 2020 G.C in Ethiopia, the total population size of FSWs is
estimated to be 210,967 (NSP 2021-2025).
14/05/2024 KPP friendly service training for Health Workers 12
 Prisoners
• The term “prisons” refers to all places of detention within a country.
• The terms “prisoners” and “detainees” refer to all those detained in
criminal justice and prison facilities, including adult and juvenile males
and females, during the investigation of a crime, while awaiting trial,
after conviction, before sentencing and after sentencing.
• In most countries including Ethiopia, most of the prisoners come from
poor, uneducated, and disadvantaged communities and are therefore
more likely to be at risk of infectious diseases, including HIV.
• Estimates show that there were about 85,000 prisoners in Ethiopia
incarcerated in 106 prisons in 2013.

14/05/2024 KPP friendly service training for Health Workers 13

 People with injection drug (PWID)
• PWIDs are those men and women, who, b/c of using
illegal injectable substances are at high risk of acquiring
HIV infection.
• They require special arrangements to access HIV services
and harm reduction and rehabilitation interventions.
• Notes: Discussion initiated to develop concepts,
interventions, and strategies on how to identify and
address this group (PWID) which will be included in this
training manual when revised.
14/05/2024 KPP friendly service training for Health Workers 14
 Priority Populations
Widowed and divorced Women
• Widowed woman is a woman whose spouse has died and not remarried.
• A Separated woman is a woman who lives apart from her spouse and not
remarried .
• Divorced woman is a woman who has legally dissolved or terminated a
marriage under the rule of law of the country and not remarried.
• According to the EDHS 2016 report among women 15-49 years 6.3% were
divorced or separated and 2.3% were widowed.
• In 2017 there were an estimated 1,522,702 women of reproductive age
who are divorced /separated and 555,907 women in reproductive age
were widowed.
14/05/2024 KPP friendly service training for Health Workers 15
1.2. Minimum service package for Key Populations

• Combination HIV prevention approach is that

promote a combination of
biomedical
Behavioral
structural interventions
• Designed to meet the HIV prevention needs of
key and priority populations.
14/05/2024 KPP friendly service training for Health Workers 16
 Group activity(30minutes)

Be in a small group and discuss on the Minimum Service

packages for FSW’s.
 Group I: Behavioral Intervention
 Group II: Biomedical Intervention
 Group III: Structural Intervention

14/05/2024 KPP friendly service training for Health Workers 17

 Minimum Service Package for FSWs

A. Behavioral Intervention- It includes a range of sexual

behavior change communication programs that use various
communication channels.
 Peer education session (small group and one to one)
 Communication and Promotion through community-
wide events
 Information through print (leaflets, flyers, booklets) and
social media (Facebook, telegram, Instagram, YouTube…)
 GBV screening and prevention
14/05/2024 KPP friendly service training for Health Workers 18
 Minimum Service Package for FSWs cont.…

B. Bio-Medical Intervention- is designed to prevent or reduce

new HIV infections. These interventions are the clinical aspects
of HIV services and health commodities.
• Condom with lubricant
• Gender-Based Violence care
• Pre-Exposure Prophylaxis
• Post Exposure Prophylaxis
• HIV testing services including self-test
• STI screening and treatment
14/05/2024 KPP friendly service training for Health Workers 19
 Bio-Medical Intervention- cont.…
• Family planning service provision
• Cervical cancer screening and prevention
• TB Screening and management
• ART (linkage to care and treatment, VL)
• Prevention of mother child transmission
• Voluntary Medical Male Circumcision.

14/05/2024 KPP friendly service training for Health Workers 20

 Minimum Service Package for FSWs cont.…

C. Structural Intervention- It address the critical social,

legal, political, and environmental enablers that
contribute to the spread of HIV include: -
• legal and policy reform
• Measures to reduce stigma and discrimination,
• Promotion of gender equality and Gender
mainstreaming
• Economic empowerment.
• Policy
14/05/2024 KPP friendly service training for Health Workers 21
 Minimum Service Package for Prisoners

1. Behavioral Intervention:
• Peer education (group and one to one)
• Life Skills training
• Mini media
• Information through print (information kits, leaflets,
flyers, booklets, magazines and newsletter)
• Communication and promotion through
edutainment events
14/05/2024 KPP friendly service training for Health Workers 22
 Minimum Service Package for Prisoners
cont.…
2. Bio-Medical Intervention:
• HIV testing services including linkage and referral
services for ART and PMTCT
• STI screening and treatment
• Provide safe shaving and tattooing services
• Condom for prisoners who are released or allowed
to leave the prison
• PEP, in the event of potential exposure to HIV
14/05/2024 KPP friendly service training for Health Workers 23
 Minimum Service Package for Prisoners cont.
…
3. Structural Intervention:
• Address policy, strategy, and organizational
barriers
• Prevention of gender-based violence

14/05/2024 KPP friendly service training for Health Workers 24

 1.3.Minimum
Service Package for Priority populations:

1. Behavioral Intervention
• Outreach one to one sessions
• Peer education (group and one to one)
• Information through print and (leaflets, flyers,
booklets)
• GBV screening and prevention

14/05/2024 KPP friendly service training for Health Workers 25

Minimum Service Package for PP cont...
2. Bio-Medical intervention
• Condom
• HIV testing services including self-test for eligible
based on national HIV risk screening tool.
• STI screening and treatment
• Gender-Based Violence care

14/05/2024 KPP friendly service training for Health Workers 26

Minimum Service Package for PP cont...
3. Structural Intervention
• Economic strengthening including support
through community care coalition(3C)
• Gender-Based violence mainstreaming

14/05/2024 KPP friendly service training for Health Workers 27

1.4. HIV Risk assessment Among Key Populations.

• To well explore the risk level of KPs, service

providers need to know approaches and
procedures that are important to be followed and
implemented.
• Unless we know our clients and how to approach
them, we will not be effective in knowing priority
of intervention for our clients and provide tailored
service for them based on their level of risk.
14/05/2024 KPP friendly service training for Health Workers 28
 Key Aspects of Risk Assessment

Getting to know your clients: Tips for conducting risk assessments:-

Begin by assuring confidentiality
Convey routine nature of risk assessments
Acknowledge that personal and sensitive information will be assessed
Use exploratory, open-ended questions
Go from general to specific
Use the type of words the client is using
Reinforce healthy behaviors
Remain neutral when hearing sensitive information
Focus on risk reduction
Affirm concerns
Give clear and consistent messages
14/05/2024 KPP friendly service training for Health Workers 29
 1.5. Friendly services for Key Populations (KPs)

• Making the HIV service user-friendly is important to

increase access for KP.
• It minimizes barriers to service use, makes the providers
understand and respect clients‟ different values and
characteristics and finally provide tailored service to
clients.
• This can be realized by accommodating the special needs
and peculiarities of KP and enabling service providers’ to
have positive attitude and friendly approach towards
them.
14/05/2024 KPP friendly service training for Health Workers 30
 Cont...
Principles in friendly service delivery are:-
 Accessibility: KP scan obtain the health services that are available.
 Acceptable: KP is willing to take the health services that are available.
 Effectiveness: The right health services are provided to the right client, in the right
way, and make a positive contribution to his/her health, ensuring the interventions
do no harm.
 Appropriateness: Respecting client’s human rights and accord them basic dignity
(e.g. Services are voluntary, consented, respect privacy and confidentiality and are
right health services)
 Respectful: respecting clients’ views, knowledge, and life experiences (non-
judgmental &adjusted).
 Client involvement: Recognize that clients are part of the solution (engaging them in
making decisions).
14/05/2024 KPP friendly service training for Health Workers 31
 Cont..
KP Friendly Providers’ Characteristics:
 Familiarity with clinical and psychosocial needs of KP
 Knowledge of appropriate medical care for KP according to KP minimum service
package
 Skill on Counseling, working with and serving KP
 Effective interpersonal communication skills fluently in a language of target groups
like FSW & youth:
 Ability to relate to KP in a respectful, non-judgmental manner regardless of age,
gender, sexuality, sexual orientation, marital or health status
 Skills to honor privacy and confidentiality of KP
 Skills to engage in conversation about important points like sexuality, condom use
and negotiation
 Skills to bring misconceptions/ myths prevailing among KP to the surface to discuss
and correct them
14/05/2024 KPP friendly service training for Health Workers 32
 KP-Friendly Service Delivery Point
Characteristics
 Convenient location, adequate space, comfortable surroundings
 Counseling & examination areas that provide visual and auditory privacy
 Availability of health care materials in all the languages that KP speak and
understand for various reading levels, including low literacy
 Clear and visible information about the friendly service hours and location
 When applicable, automated voice messaging on telephones and social media
providing information about location, visiting hours, and telephone number
for counseling
 Adequate and uninterrupted supply of free male and female condoms, ready
to take without harassment& discomfort
 Clear and visible information on proper utilization of condom – using posters,
brochures, demonstrations
14/05/2024 KPP friendly service training for Health Workers 33
 KP-Friendly Service Delivery Point
Characteristics cont.…
 Engaging peers
 Use of token/ number system calling instead of names in the waiting
room
 System to identify confidentiality concerns for KPs
 Flexible service hours like during lunch, evening, and weekend
appointments
 Well-established mechanism to allow client centered service provision
 Clinic staff is called by name to make the environment more informal
and welcoming
 Walk-in clients welcomed and appointments arranged rapidly
 Well-established linkages and referrals to mental health, education,
employment,
14/05/2024
and social services like IGAs or microfinance.
KPP friendly service training for Health Workers 34
 How to prepare and operationalize KP friendly
service
• To make HIV services KP friendly, it is important to
consider three intervention areas.
- service providers, health care set up and health system
management.
• Providers need to be skilled on KP friendly service
delivery.
• The health facility shall arrange the service delivery
platform, service hours and process in a way it meets KP
preferences.
14/05/2024 KPP friendly service training for Health Workers 35
 Cont.…
The following parameters can be used to assess HIV services friendliness of the KP and
improve on identified gaps:
• Convenience of Facility location and service hours for KP (accessibility),
• Service delivery env’t is attractive waiting area, recreational and edutainment facility,
• Arrangement of the service-flow shall be convenient to clients/ KP, one-stop
shopping/referral,
• Skilled service providers (appropriate knowledge, skill and attitude specific to KP)
• Non-judgmental & non-discriminatory service provision,
• Confidentiality and privacy of clients ensured with system to “red- flag”/identify concerns,
• Accommodation of service as per the clients need (waiting time, service access, list of
service posted)
• Availability of the necessary materials and supplies that make the service friendly to KP,
waiting area, recreational and edutainment facility,
• Documentation of services keeping confidentiality and reports
14/05/2024 KPP friendly service training for Health Workers 36
 Cont.…
Organizing KP in clubs/ associations and build capacity
• Once the facility starts providing KP friendly service, it is
advisory to establish peer and support groups that build
the capacity of member KP to learn and gain new
knowledge, life skills, educate, promote, support, and
protect the rights of KP.
• Volunteer peer groups from KP shall be trained/ skilled on
HIV prevention services, information dissemination,
networking, and linkage of KP to HIV service.
14/05/2024 KPP friendly service training for Health Workers 37
 Cont.…
Barriers/Challenges for Friendly Service provision
 HIV prevention program targeting KP is limited in quality and coverage, and the
available HIV services lack KP friendliness. The following are major challenges/
barriers for KP to access HIV prevention, care and treatment services:
 Service providers lack skills how to approach KP and are sometimes judgmental
 Stigma and discrimination towards KP (FSWs)
 KPs impatience for waiting too long
 Service time is inconvenient for some KP
 KP feel their needs are not understood
 Prevention package targeting KP groups were limited in kind and quality.
 Limited information on client needs and their satisfaction on available service
 Absence of standard for friendly service implementation and monitoring
14/05/2024 KPP friendly service training for Health Workers 38
 Chapter Summary
• Key Populations are:
 Female sex workers
 Prisoners
 Person Who Injecting Drugs
• Priority populations are:
 Widowed
 Separated /divorced women
 long-distance Track drivers
 PLHIV and their partners,
 Workers in hotspot areas
 High-risk adolescent girls and young women

14/05/2024 KPP friendly service training for Health Workers 39

 Chapter Summary cont.…
• Minimum Service Package for KPP is generally
categorized as behavioral Intervention, biomedical
interventions and structural interventions.
• Principles in friendly service delivery are
accessibility, acceptable, effectiveness:
appropriateness, respectful and client involvement

14/05/2024 KPP friendly service training for Health Workers 40

Chapter 2: KPP friendly service delivery settings

Learning Objectives: By the end this session, participants will be

able to
• Describe facility and community settings where KPP friendly
service clinic is provided
• Describe demand creation strategies for both key and priority
populations.
• Acquire knowledge and provide standard comprehensive HIV
prevention, care, and treatment one stop shopping in KP clinic.
• Implement collaboration activities between community and
facility settings to improve integrated KPP service of their need.
14/05/2024 KPP friendly service training for Health Workers 41
Individual Reflection (10minutes)
INDIVIDUAL REFLECTION

1. Where can Key and Priority populations receive clinical

services?
2. What is comprehensive one-stop shopping in the
context of KPP?

14/05/2024 KPP friendly service training for Health Workers 42

 Cont.…
• To reach key populations, client centered service delivery
setting will be used with strong linkages and coordination
among the different settings to match their needs or
preferences.
• The delivery settings include at community, Health facility
and facility and Community collaboration and coordination.
• At community, the service delivery settings are confidentiality
clinics and drop-in centers while, key population friendly
service clinic in public health facilities and service integration
with general OPDs are in facility settings.
14/05/2024 KPP friendly service training for Health Workers 43
 2.1. KP service delivery settings at community

 Drop-in Centers (DICs): Sustainable and low cost DICs will provide
comprehensive behavioral, bio-medical & structural interventions to KPP
especially FSWs at selected hot spot towns.
• The DICs will be implemented with gov’t ownership and in partnership with
development partners.
• DICs will be established in gov’t owned houses, where gov’t will assign staff
when appropriate and with referral linkages to KPP friendly health facilities.
• DICs will provide comprehensive HIV/SRH services (SBCC, counseling,
Condom, HIV testing, PrEP, STIs screening and Rx, FP & provision of or
referral linkage for Rx & PMTCT).
• In addition, DICs will provide or link to social services of community and
development partners.
14/05/2024 KPP friendly service training for Health Workers 44
 2.2. KP service delivery setting at health facility

 Key population friendly clinic:

• These are HIV/SRH clinics within public health facilities which provide one
stop shopping HIV/SRH services for key populations. The KP clinic will have a
trained provider who can provide friendly service to KPs.
• It will provide comprehensive services (SBCC, counseling, condom, HIV
testing, PrEP, STIs screening and Rx, FP & ART initiation and chronic care
follow up Rx and referral to PMTCT clinic for HIV positive FSWs).
• It will be open off working hrs & linked with peer service providers and
community mobilizers to create demand and mobilize KP to the friendly
clinic services.
• Bi-directional referrals between communities to facility will be strengthened.

14/05/2024 KPP friendly service training for Health Workers 45

KP service delivery setting at health facility cont.
…
 Friendly services delivered at the general HIV service delivery
outlets of health facilities:
• The HIV service delivery outlets of health facilities will be made
friendly for KPP through training of service providers and flexible
working hours to respond for needs of KPP who prefer to use the
general HIV service delivery outlets.
• At least one health facility in the 265 priority woredas as well as
across the medium incidence woredas will have friendly services
delivered through the general HIV service delivery outlets.
• Referral linkage with the peer service providers and community
level services will be strengthened.
14/05/2024 KPP friendly service training for Health Workers 46
 KP service delivery setting at health facility cont.
…
Comprehensive one stop service for KP (for FSWs)
• In Ethiopia, there are efforts to make public and private facilities KP friendly by
building the capacity of providers and arranging service delivery approach to
match their needs.
• Confidentiality clinics and drop-in centers (DICs) were established around hot spot
areas in major towns in the country that provide comprehensive HIV services to
FSW.
• The KP friendly services delivered at drop-in centers have significantly improved
HIV prevention, care, and treatment service access to FSWs.
• Therefore, enhancing the coverage & quality of HIV prevention, care & Rx services
for KP (FSWs) through initiating one stop service for KP is deemed necessary.
• From the experience of confidentiality clinics and drop-in center, there must be
one stop service at public health facilities providing KP friendly service.
14/05/2024 KPP friendly service training for Health Workers 47
 Cont.…
Below intervention activities are listed to be used as guidance for implementation:
HIV services accessibility & acceptability
• All FSWs have the right to choose receiving KP friendly service at public, private and NGO
health facilities
• All HIV prevention, testing, care & treatment services should be provided at KP friendly clinical
service clinic.
• KP one stop services should be provided by ART & KP trained health care providers.
• All HIV prevention, testing, care & treatment services to be available during off working hours
(Lunch break, Weekends, and holydays).
• All FSWs & their sexual partners should be screened and offered HIV testing & prevention
services
• All FSWs who doesn’t wish to come HFs should offer directly assisted HIVST using PNs and
unassisted HIVST for those who do not want to be assisted.
• KP friendly community outreach service will be provided by trained Peer Navigators/service
providers.
14/05/2024 KPP friendly service training for Health Workers 48
HIV testing & prevention services for HIV negative FSWs
• The HIV testing and prevention service for HIV negative female sex workers
include:-
• Conduct retesting of HIV Negative FSWs every six months
• Conduct screening, diagnosing, and managing STIs using the syndromic case
management approach
• Conduct Screening, diagnosing, and managing TB
• Promoting on and providing family planning services including male condoms
• Promoting and providing PrEP services
• Promoting and providing PEP services
• Promotion and provision of Gender Based FSWs Violence (GBV) services

14/05/2024 KPP friendly service training for Health Workers 49

 Think pair and share (15minutes)

14/05/2024 KPP friendly service training for Health Workers 50

HIV services delivery setting for Prisoners:
• Health facilities in prisons will have HIV prevention services
integrated in their general health services.
• All prisons will provide and coordinate SBCC including peer
education, HIV testing, screening, and treatment of STIs and
GBV, provision or referral of treatment services. In addition,
condoms shall be provided on release from the prisons.
• It will also be important to sensitize and build the capacity
of prison staff.
14/05/2024 KPP friendly service training for Health Workers 51
 2.3. Community service delivery settings for PP.

 Integrated HIV services at hot spot workplaces:

• All hot spot workplaces which have integrated clinic provide integrated
health and HIV services (condom, HIV testing, screening, and treatment
of STIs and GBV, referral for treatment).
• In this case, the workplace will coordinate and implement social
behavioral change communication interventions and demand creation
targeting staff.
• If the workplace has no integrated clinic, they are required to link to
nearby health facilities to get comprehensive HIV services.
• RHB/Woreda health offices and development partners will support and
build capacity of the workplaces HIV programs in hot spot workplaces.
14/05/2024 KPP friendly service training for Health Workers 52
Community service delivery settings for PP cont.
…
Targeted outreach Program: Health facilities will
have at least quarterly outreach programs to reach
PPs at nearby hotspots.
Targeted outreach HIV services will be led by a
health worker and supported by peer service
providers and community groups.
Civil society organizations and development partners
will play a significant role to mobilize PPs to attend
the outreach HIV services.
14/05/2024 KPP friendly service training for Health Workers 53
 2.4. Facility service delivery settings for PP.

• Standalone STI clinic: In the facilities where there is a STI

standalone clinic, STI patients are given the STI care in the clinic.
• Youth friendly service clinic: Health facilities will have a dedicated
youth friendly clinic in which High risk adolescent and young
women will receive the service of their need.
• Targeted outreach program: health facilities will have a regular
(quarterly) targeted outreach program. The package of the outreach
program will be social and behavioral change communication,
demand creation and targeted HIV testing for those at risk and
willing to be tested. It will also include referral to nearby facilities
for those found at risk but willing to get tested on the date.
14/05/2024 KPP friendly service training for Health Workers 54
2.5. Facility and Community collaboration and coordination.

• A fundamental need exists for improving the interface between health facilities,
community health workers, key populations, civil society organizations and networks to
address ART initiation and retention for key populations.
• KPP programs should focus on making both facility and community-based services more
KPP-friendly by strengthening the relationship between facility and community actors.
• HCWs should receive regular training on client-centered services for key and priority
populations that are co-designed and co-facilitated by key population civil society groups.
• Community-based key population outreach providers can play a critical role in this
process by ensuring an integrated KPP strategy creates a seamless clinical experience for
key population clients.
• An integrated data system and data-sharing agreement between facility and community
partners are fundamental to scaling an integrated case management approach.

14/05/2024 KPP friendly service training for Health Workers 55

 Cont..
Principles for Collaboration
 Both KPP Health Facility (HF) and Community actors need to follow and abide by the
following principles to realize a successful collaboration and coordination that meet the
needs of the clients and help achieve national and regional targets on HIV/AIDS.
 Utilization of Service mapping for KPP program happening periodically.
 Consultation and collaboration with RHBs and community partners
 Working as a team towards one goal, i.e., ending the HIV/AIDs epidemics
 Maximize complementarity
 Avoid duplication of efforts
 Client centeredness
 Ensure collaboration of facility peer navigators with community peer educators, with agreed
roles, responsibilities and geographic focus in the community
 Use of standard national KPP tools and guidelines
 Maintaining client confidentiality
14/05/2024 KPP friendly service training for Health Workers 56
 Cont.…
Areas of Coordination and collaboration
• Critical areas of coordination and collaboration for HFs and Community actors are KPP
services spanning across all the three 95 including HIV case finding among KPPs, linkage to
KPP Care and treatment services and viral load testing.
• In addition, for HIV-negative PrEP and condoms promotion and distributions. This applies for
both existing and new KPP programs and sites.
1. Avoid duplication of efforts and enhancing complementary while working in the same
catchment area.
2. Ensure that the peer educators’ recruitment for the new expansion sites should not take the
existing experienced peer navigators from facility level to DICs and vice versa by adding extra
benefit which will contribute for weak service provision at both settings.
3. Both facility and community KPP actors shall refer KPP beneficiaries for the services that
are not available at their disposal to ensure complementarities of facility and community KPP
programming, e.g., Facility KPP can refer to community sites for nutrition services and
community KPP sites can refer to facility KPP site for comprehensive ART or other clinical
services.
14/05/2024 KPP friendly service training for Health Workers 57
 Cont..
The Gov’t and implementing partners (both facility-based and community-based), develop a strong collaboration
to support the regions’ HIV program in the following areas:
• Serve Key populations in a dignified and ethical manner to ensure the optimal prevention, care and treatment
outcomes possible, and create collaborative relationships and teamwork between HF and community based
KPP service providers.
• Properly track referrals and counter referrals of HIV positive KPP identified for ART treatment and follow up.
• Collaborate to increase the number of HIV positive KPP identified and initiated on ART.
• Collaborate to share information/data to effectively track all KPP who experience treatment interruptions and
return them back to care and treatment.
• Outline a referral mechanism and collaborate to share information/data and ensure KPP access to community
level care and support services.
• Establish a regular monitoring platform to avoid duplications in data reporting especially across the clinical
cascade and continuum of care for Key Populations.
• Clearly outline KPP actors, where they are working and define the role and responsibilities of each KPP actor.
• Establish a process to facilitate access to all relevant data from each IP in the framework of their KPP
interventions to avoid duplication of efforts and unnecessary repeat testing.
• Outline regular data sharing to the coordinating body and a platform for regular joint review of KPP clinical
cascade.
14/05/2024 KPP friendly service training for Health Workers 58
 Cont..
Facility-Community KPP Program Coordination
• KPPs do have a range of needs to be addressed by facility and community package of services.
• The responsible person in the facility will send KPPs who need community service like nutrition,
etc. using referral slip.
• The responsible person in the facility will receive feedback from community/DICs and register in
the HF KPP registration book
• The responsible person in the DIC will receive KPPs through referral slip from HF and register in
the tracking register indicating source of the referral and provides feedback to HF.
• The responsible person in the DIC (from DIC as well as outreach) will send KPPs to public facilities
using referral slip or /accompanied referral for facility based clinical KPP services
• The responsible person in the facility will receive KPPs and register in the KPP register indicating
source of the referral and provides feedback to DICs and vice versa.
• Everyone has a shared goal of providing access to quality HIV services for all KPP. That should be
the unifying goal and allow for tailored services that match the individual clients’ needs
regardless of whether they access these services at the facility, community, or both.
14/05/2024 KPP friendly service training for Health Workers 59
 Cont..
• All providers and peers at facility and community
should do the following for example
 All the providers/peers need to be able to provide information about both
facility and community-based services available.
 They should allow for KPP clients to ask questions about these services and
respond in a non-judgmental manner. (Facility-based KPP providers should
not talk badly about community based KPP services and vice-versa.)
 They should respect clients’ choices about where they want to access
services, as well as make sure clients understand it’s ok if at some point,
they want to change from one site to another.
 Make sure KPP clients can determine what is best, most convenient, and
safest for them.
14/05/2024 KPP friendly service training for Health Workers 60
2.6. Demand creation strategies for KPP.

• For the KPP program to be effective a strong demand creation strategy

needs to be in place.
Demand creation approaches to be employed in order to maximize bio-
medical service uptake:
• One-to-one and small group peer session
• Community awareness creation about available service through peer
educators/navigators
• Health care providers and community health workers orientation of target
audiences
• Print media (posters, brochures and leaflets) about KP/PP programs to be
distributed among target audiences
• Targeted message through TV/Radio spots
14/05/2024 KPP friendly service training for Health Workers 61
 Chapter Summary

• KPP Service Delivery settings are at both Community and Facility.

• KP Service Delivery settings at Community includes DIC while facility service
delivery settings are KP friendly clinic and Friendly services delivered at the
general HIV service delivery outlets of health facilities:
• Community service delivery settings for Priority population are Integrated HIV
services at hot spot workplaces, Targeted outreach Program
• Priority population Facility service delivery settings are Standalone STI clinic,
Youth friendly service clinic and targeted out reach program.
• Critical areas of coordination and collaboration for HFs and Community actors are
KPP services spanning across all the three 95 including HIV case finding among
KPPs, linkage to KPP Care and treatment services and viral load testing.
• KPP program to be effective a strong demand creation strategy needs to be in
place.
14/05/2024 KPP friendly service training for Health Workers 62
 Chapter 3: HIV Testing Services

Learning Objectives: At the end of this module, participants will be able to:

• Define HTS and targeted testing

• Explain HIV Testing Service Delivery Models

• Describe the key ethical guiding principles of HIV counselors

• Demonstrate rapid HIV testing skills

• Describe qualities of a good counselor, elements of effective counseling and

demonstrate skills in counseling

14/05/2024 KPP friendly service training for Health Workers 63

 Individual reflection(15minutes)

INDIVIDUAL REFLECTION (15minutes)

 What are the approaches of HTS?
 What are the ethical principles of HIV testing
services?

14/05/2024 KPP friendly service training for Health Workers 64

 3.1. Definition and basic concept of HTS

HTS is the full range of service that should be provided to eligible clients who are
at high risk of HIV infection.

It includes :-

-Brief pre-test information and post-test counseling

-Linkage to appropriate HIV prevention, care and Rx services and other clinical &
support services

-Coordination with laboratory services to support quality assurance for HIV testing
14/05/2024 KPP friendly service training for Health Workers 65
 3.1. Definition and basic ….

 It is the critical first step in identifying and linking PLHIV to HIV care and
treatment services

 It needs to focus on high-risk individuals who remain undiagnosed and need to

be tested and linking them to treatment and care services as early as possible.

 People who are HIV-negative but with an ongoing risk also need to be re-
tested and provided appropriate prevention services or appointed for follow up
counseling
14/05/2024 KPP friendly service training for Health Workers 66
 3.1.1. Targeted HTS

• Targeted HIV testing is a process whereby high-risk individuals or specific

groups of population who are at risk of acquiring HIV are tested for HIV.
Proper utilization of HIV risk screening tool will be useful to achieve the first
95.

• The focus of targeted testing is towards identifying new individuals who are
at risk of acquiring HIV

14/05/2024 KPP friendly service training for Health Workers 67

 3.1.2. Service Delivery Models of HTS

A. Facility Based HTS

• Client Initiated or Provider Initiated (VCT/PITC) service at both public and private health
facilities

B. Community Based HTS

• Home-based testing targeting specific sub-group

• Outreach HTS - high prevalence areas (hot spots)

• Workplace HTS - Big farms, factory or construction sites including hotels and bars

14/05/2024 KPP friendly service training for Health Workers 68

 3.1.3. Approaches of HTS

Client Initiated: Voluntary Counseling and Testing (VCT)

Provider Initiated Testing and Counseling (PITC)

Index Case Testing (ICT)

Social Network Strategies (SNS)

Mandatory HIV Testing

HIV self-testing
14/05/2024 KPP friendly service training for Health Workers 69
 3.2. Ethical and policy statements in HIV testing

The WHO recommends the following guiding principles to be observed in the provision of all HIV
testing services throughout the testing procedures.

These guiding principles (also called 5Cs) to be applied in all HTS implementation sites.

1. Consent

2. Confidentiality

3. Counseling

4. Correct test result

5. Connection to care and treatment

*All health facilities and community health care workers are required to strictly follow these guiding principles
14/05/2024 KPP friendly service training for Health Workers 70
 Cont.…

Client’s Rights during testing and counseling

Clients have the right to:-

 Confidentiality

 Privacy

 Refuse testing

 Be treated with respect and

 Asking information or questions

14/05/2024 KPP friendly service training for Health Workers 71
 Group activity (30minutes)
Group activity
Be in three groups and discuss on introduction to counseling
&skills.
Group I: definition & key stages of counseling.
Group II: Basic communication skills.
Group III: Elements of good counseling & basic counseling
skills.
Time: 30 Minute

14/05/2024 KPP friendly service training for Health Workers 72

 3.3. Introduction to Counseling and skills

Definition of Counseling

• Helping people to help themselves and use their own internal

strength to live their live more effectively.

• In the context of HIV/AIDS, counseling is a confidential two-way

communication between a counselor and client (s) aimed to make
personal decisions related to HIV/AIDS.
14/05/2024 KPP friendly service training for Health Workers 73
 Cont.…

Key stages of Counseling

1. Beginning / Rapport Building stage

2. Middle / working on stage

3. Ending or key essentials summarizing stage and further immediate action

14/05/2024 KPP friendly service training for Health Workers 74

 Cont.…
Qualities of a good counselor
A good counselor must have the following qualities:

 Self-confident: certain of having the ability

 Empathetic: not disregarding nor detached

 Accepting: warm and friendly

 Genuine: not artificial e.g. behaving like he/she is perfect or knows every thing

 Trustworthy: deserving trust or able to be trusted

 Competent: having enough skill or ability to do something well

14/05/2024 KPP friendly service training for Health Workers 75
 3.3.2. Basic Communication skills

The following skills are like a bag of tools….use the manual page # 43-44

14/05/2024 KPP friendly service training for Health Workers 76

 3.3.3. Elements of Good Counseling

14/05/2024 KPP friendly service training for Health Workers 77

 Basic counseling skills

14/05/2024 KPP friendly service training for Health Workers 78

 Maintaining “SOLER” or” ROLES “

Service providers are required to develop a broad range of skills to effectively communicate with a
wide variety of people, at many different levels
S: Sit Directly
O: Open Gesture
L: Lean Forward
E: Eye Contact
R: Relax

 Providers should also adhere with ‘’WELL’’ abbreviation

W: Welcome your clients
E: Encourage your clients to talk
L: Look at your clients
L: Listen to your clients
14/05/2024 KPP friendly service training for Health Workers 79
 Common errors in counseling/Communication barriers

Jargon

Cultural Bias

Interrupting the client

Inappropriate Physical Environment. (Lack of privacy and noise and distractions)

Negative Non-Verbal Communication Includes: - Looking away frequently or not maintaining eye contact

Being judgmental

Frowning, scowling, or yawing

Speaking too quickly or too slowly, Finishing off the sentences of clients

14/05/2024 KPP friendly service training for Health Workers 80

 Communication barriers cont.…

Pressure Tactics (Imposition)- not accepting the client’s feelings

Advising before the client has had enough information to arrive at a personal solution

Interrogation, using question in accusatory “why’’ questions often sound accusatory’

 Encouraging dependence-inflating the client’s need for the counselors continuing presence; support and
guidance

Using unacceptable paraphrasing, or suggestions like “You should’’, “will tell you what to do’’ “must try “, “the
only way out is’’ “It is a must “etc.

14/05/2024 KPP friendly service training for Health Workers 81

 3.4. PITC for Adults

Pre-test information

Pre-test information should be provided by health care service providers or counselors.

The relevant information that should be provided includes but not limited to:

 Building rapport with FSW to establish a very good r/ship at household, DIC and outreach
and health facility level

 Exposure to HIV infection and implications of undiagnosed HIV infection

14/05/2024 KPP friendly service training for Health Workers 82

 3.4. PITC for Adults cont.…

Pre-test information cont.…

The clinical and prevention benefits of HIV testing individuals, sexual partners, and
eligible biological children (less than 19 years)

Benefits of early ART and the fact that people with HIV who achieve and maintain an
undetectable viral load cannot transmit HIV sexually to their partners

The meaning of an HIV-positive diagnosis and an HIV-negative diagnosis

14/05/2024 KPP friendly service training for Health Workers 83

 3.4. PITC for Adults cont.…
Pre-test information cont.…

The importance of disclosing known HIV status to the provider to minimize

repeat testing of a known case. There is a possibility for false negative results
if a person who is already on ART is tested for HIV using an antibody test.

The confidentiality of the test result and any information shared by the client

Discuss any concern through availing more time for the female sex worker.
The need to acknowledge clients’ fears and opportunity to ask the provider
questions.
14/05/2024 KPP friendly service training for Health Workers 84
 3.4. PITC for Adults cont.…

Pre-test information cont.…

The client’s right to refuse testing and that declining testing will not affect
to get access to the female sex worker minimum package services.

Verbal consent should be obtained before conducting HIV testing

14/05/2024 KPP friendly service training for Health Workers 85

 PIHTC cont.…
Offer HIV Testing:

If a client accepts HIV testing when offered, proceed to HIV testing

If a client declines HIV testing, identify the problem and proceed
to HIV testing if successful

If a client declines and our counseling is not successful, plan to

return for testing
14/05/2024 KPP friendly service training for Health Workers 86
 Reading & Role play (50minutes)
• Read Post test Counseling for HIV –Ve & +ve
result
participants manual page-48-50

Role play: PM page-51

Case scenarios for Post-Test
Counseling of HIV +ve test result

14/05/2024 KPP friendly service training for Health Workers 87

 3.5. HTS Demand creation strategy

To create awareness and increase utilization of HTS, advocacy and communication
strategies should aim to create awareness of the need for HTS, linkage for HIV prevention,
care, and treatment

Demand creation will be conducted at community platforms by the community service

providers and peer navigators

Clients must get adequate education to increase their knowledge and decision-making
ability to undergo HIV testing by the trained service providers

14/05/2024 KPP friendly service training for Health Workers 88

 Demand creation approaches

A. Advertising a unique HTS attribute (for example, workplace HTS) can improve HTS uptake but may reduce the
proportion of people diagnosed with HIV

B. Brief messaging and information (under 15 minutes) results in HTS uptake like longer or more intensive pre-test
information can be more feasible and efficient.

C. Motivational messages to increase HTS uptake.

D. One on one session: - provide information to create demand on HTS to engage clients into the HIV testing
process.

E. Small group session: - group session will be carried out at the community platform for all eligible clients for HTS.
Service providers and peer navigators will lead the group discussion and provide information on how to get and
where to get HIV testing.

14/05/2024 KPP friendly service training for Health Workers 89

 Demand creation cont.…

Initiating demand creation should emphasis on the following points:

Building rapport is very important as an entry point to start conversation with clients

Introduce and start discussion with client on how to and where to get HIV testing

Raise key issues while providing information on HIV self-testing

Summarize the discussion points

14/05/2024 KPP friendly service training for Health Workers 90

 3.6. HIV Rapid Testing

HIV rapid tests are qualitative assays that detect HIV antibodies

Most of them can detect HIV-1 and HIV-2

 HIV testing occurs in a variety of settings outside of the laboratory

The testing will likely to occur at testing and counseling centers (T&C),
antenatal care (ANC) clinics, blood banks, surveillance programs, TB clinics,
and sexually transmitted infections (STIs) clinics and KP clinics

14/05/2024 KPP friendly service training for Health Workers 91

 Rapid testing cont.…
Advantages of rapid HIV testing include:
 Increase access to prevention (VCT) and interventions (ART)
 Support increased number of testing sites (PITC)
 Same-day diagnosis and counseling
 Easy to use
 Test time under 30 minutes
 Most require no refrigeration
 None or one reagent (a substance used in a chemical reaction to detect or produce other substances)
 Minimal or no equipment required
 Minimum technical skill

14/05/2024 KPP friendly service training for Health Workers 92

 Test procedure

The national HIV testing strategy uses three test kits namely;

Test procedure 1: Job Aid for ONE STEP Anti-HIV (1&2) card test

Test procedure 2: Job Aid for First Response HIV 1-2 Card Testing

Test procedure 3: Uni Gold HIV 1.2.0 HIV Rapid Testing

* Note: make participants to read from PM#55-58 and try to demonstrate

14/05/2024 KPP friendly service training for Health Workers 93

 Test procedure
The current three test /serial algorithm Perform A1

A1+ A1­-
Report as HIV Negative

Perform A2

A1+, A2-
A1+, A2+ A1+, A2- Report HIV Inconclusive.
Plan testing after 14 days

Repeat A1 only
A1-, A2-
Report HIV Negative

Perform A3

A1+ A2+ A3+ A1+ A2+ A3-

Report HIV Positive Report HIV Inconclusive
Plan testing after 14 days

14/05/2024 KPP friendly service training for Health Workers 94

 Chapter Summary

 Targeted testing is very important implementation approach to focus on most at risk of

population
 The five C’s of WHO HIV services guidelines should be implemented to assure high
quality.
 Counseling is a two-way communication, totally different from advice, guidance, or
education
 Communication and Counseling skills should be implemented and utilized well by HIV
Counselors
 Pre-test and post information should be provided by health care service providers or
counselors
 Current Testing strategy of Ethiopia

14/05/2024 KPP friendly service training for Health Workers 95

 Chapter4: Social network strategy Implementation

Learning Objectives: At the end the session,

participants will be able to: -
• Define social network strategy, implementation
approach and describe its phases
• Interpret the M&E tools and PST for SNS.
• Conduct recruiter couching and support

14/05/2024 KPP friendly service training for Health Workers 96

 Individual reflection (10minutes)

INDIVIDUAL REFLECTION(10minutes)

 What is Social Network Strategy (SNS)?

 What is the advantage of SNS in reaching
KPPs?

14/05/2024 KPP friendly service training for Health Workers 97

4.1. Introduction and rational to social network strategy.

• Social networks approach is a recruitment strategy for HIV

undiagnosed high-risk populations whereby public health services like
HIV Counseling, Testing and Referral (HIV CTR) services are
disseminated through the community by taking advantage of the
social networks of persons who are members of the community.
• The strategy is based on the concept that individuals are linked
together to form large social networks, and that infectious diseases
often spread through these networks.
• Although similar in some ways, the social networks strategy is not
partner counseling and referral services (PCRS), partner notification,
outreach, health education, or risk education—and it is not intended
to replace these services.
14/05/2024 KPP friendly service training for Health Workers 98
 SNS cont.…
• Social network HIV testing strategy is a programmatic, peer-driven, recruitment
strategy to reach the highest risk persons who may be infected but unaware of
their status.
• This technique is accomplished by identifying newly and previously diagnosed
HIV-positive and high-risk HIV negative recruiters on an ongoing basis and
providing HIV CTR to people in their networks. Participating as a recruiter in a
social networks testing gives people living with HIV the chance to help protect
others in their community. In addition, if people in their networks are infected, it
gives them the opportunity to get medical care and treatment.
• SNS can be particularly useful in finding key populations and others who are at
risk for HIV but have not had easy access to HTS with underlying assumption of
People in the same social network share similar risk behaviors for HIV. People are
more likely to respond positively to HIV testing messages from people they know
and trust.
14/05/2024 KPP friendly service training for Health Workers 99
 4.2. SNS Implementation phases and approaches.

• SNS use a strategy to enlist HIV-positive and high-risk HIV-

negative persons (recruiters) to identify
• NOTE: Anyone presenting a coupon for testing should be
tested, but not all clients will be eligible to recruit
• SNS is a proven evidence-based HIV case finding strategy-
based experience from Performance so far in regions
implementing the strategy in Ethiopia.
• During 2021 G.C, there is a promising performance gained in
which indicates the strategy is worked to improve HIV case
finding.
14/05/2024 KPP friendly service training for Health Workers 100
 Phases of SNS
SNS is implemented in four phases.
1. Identify Initial Recruiters
2. Instruct Recruiters
3. Recruitment of Network Members
4. Testing of Network Members & Offer to
Become a Recruiter

14/05/2024 KPP friendly service training for Health Workers 101

 Criteria to be a Recruiter
Seeds (HTS clients, no limit like Respondent Recruits (recruited by KP)
Driven Sampling)

■ Member of a key population ■ Member of a key population

o FSW o FSW
■ HIV-positive or high-risk HIV-negative ■ Presentation of an SNS recruitment coupon
■ Lives or works in the focus area ■ Lives or works in {target area}
■ Able and willing to recruit network ■ Able and willing to recruit network members who have
members who have never tested or who do never tested or who do not test regularly
not test regularly ■ *Note: Does not have to be known HIV-positive.

14/05/2024 KPP friendly service training for Health Workers 102

 Recruitment Instruction Steps

Step1: Identify people in your network (friends, acquaintances, sexual partners or

relative) who may be at risk of HIV infection.
Step 2: Consider if these network members may be interested in receiving an HIV
test.
Step 3: You will receive referral coupons to give to them to direct them to a
friendly and confidential HIV testing location.
Step 4: Tell your network member that the results of his/her HIV test will never be
shared with you.
Step 5: A friendly professional can be reached by the phone number for any
questions about HIV testing location or about their test results.
Step6: Contact the HIV testing location to inquire about any referral incentives
owed to you.
14/05/2024 KPP friendly service training for Health Workers 103
 Implementation Preparations

•Health Facilities providing SNS need to have standard requirements regarding space, supplies and
equipment and personnel/staffs.
•Regarding Space, supplies and equipment, the clinic or service delivery point has to have: -
■ Secured, so that confidentiality of clients can be ensured
■ Have adequate space to conduct the program (counseling and testing, recruitment coupons and rewards
management)
■ Quiet and without interruptions (such as people entering and exiting the room or outside noise)
■ Have computers with necessary software (MS Excel, RDS)
•Personnel/Staff

1. Coupon Manager
2. Tester/Counselors
14/05/2024 KPP friendly service training for Health Workers 104
 Cont.…

Role of coupon manager Role of tester/counselor

■ Collect coupons ■ Conduct HIV/STI testing

■ Investigate previous participation ■ Conduct pre-test and post-test counseling
■ Record unique ID (next slide)
■ Offer SNS recruitment opportunity
■ Distribute coupons
■ Instruct and coach participants on SNS
■ Reinforce recruitment
recruitment

14/05/2024 KPP friendly service training for Health Workers 105

 Recruitment Tracking Tools

Coupon
• Coupon used for recruiting network members need to be Pre-printed
with:
• Sequential numbering
• Numbering format
• YYYYY XXXX
• YYYYY= 1st 2-3 Spelling of health facilities.
• XXXX= Four-digit number starting with 0001
• Consider serially printing from center (Region) and distribute to sites.
• Coupon ID = Participant ID
14/05/2024 KPP friendly service training for Health Workers 106
 Cont.…
Prepared Coupon need to have certain elements during preparation
These elements are:
 Name of site/program
 Coupon ID number
 Recruit ID
 Logo
 Facility stamp
 Message
 Sender ID, Address/phone number
 Facility Name, Address, and phone number
 Dates
14/05/2024 KPP friendly service training for Health Workers 107
 Inclusion Criteria for Coupon Distribution
Seed Non-Seed

■ Member of a key population ■ Member of a key population

o FSW (past 12 months) o FSW (past 12 months)
■ HIV-positive or high-risk HIV-negative o Other network members who are newly diagnosed
■ Lives or works in {target area} HIV positive/high risk negatives

■ Able and willing to recruit network members ■ Presentation of an SNS recruitment coupon
who have never tested or who do not test ■ Lives or works in {target area}
regularly ■ Able and willing to recruit network members who have
never tested or who do not test regularly

14/05/2024 KPP friendly service training for Health Workers 108

 Exclusion Criteria for Coupon
Distribution
Seed Non-Seed

• Not a member of a key population • Not HIV-positive or high-

• Not HIV-positive or high-risk HIV-negative risk HIV-negative

• Does not live in {target area} • Does not live in {target

area}
• Unable or not willing to recruit network
members

14/05/2024 KPP friendly service training for Health Workers 109

 Unique Identification code

• The unique identification code will be recorded in SNS for

tracking recruitment as well repeated clinic visits. To create a
unique identifier code, elements listed below are very important.
 The 1st two letters of clients Name
 The 1st two letters of Mother’s name,
 The 1st two letters of Fathers name
 The 1st two-digit number of the client’s birthday
 The 1st two-digit number of the client’s birth year
 1st two letter of living town/place.
14/05/2024 KPP friendly service training for Health Workers 110
 Individual exercise(5minutes)
Individual Exercise (5 minutes):

Write the unique identification code using given information

Client’s first name: Tigist

Client’s mother’s first name: Birtukan

Client’s father’s first name: Nigatu

Client’s date of birth: June 28, 1987

Client’s hometown: Addis Ababa

14/05/2024 KPP friendly service training for Health Workers 111
 Recruiter Coaching Guide

• The couching guides have major 4 components which

are used by service provider to couch selected
recruiters. It is a continuous of recruiter talking points.
1. Introduce the Coaching Session
2. Identify Network Members
3. Coach – Develop a Plan
4. Summarize and close your plan with the Recruiter
14/05/2024 KPP friendly service training for Health Workers 112
 Cont..
Summarize and close your plan with the Recruiter
• Let me summarize your plan for your network members.
• Does anything about this plan make you uncomfortable?

• How confident do you feel that you can carry out this
plan with your friend/relative/associate?
• I will want to follow up with you to see how things went.
Let’s talk about our plan for that follow up.
• What final questions or concerns do you have?
14/05/2024 KPP friendly service training for Health Workers 113
 Cont..
Preventing Scamming and Multiple Visits of individuals
• To identify referred network members tested every time, different
mechanisms need to be used. Based on their applicability, the followings are
mechanisms we can identify those types for clients.
• Unique identified Code
• Staff recognition
• Record identifying marks (tattoos, scars, hair (long/short and color))
• Biometric data
• Fingerprint scan
• Wrist/forearm measurement
• Good record keeping
14/05/2024 KPP friendly service training for Health Workers 114
 4.3. Monitoring and Evaluation

• The process of determining if anticipated outcomes of the program are being

met and, if not, assessing the service delivery process to identify barriers and
adjust services. The monitoring and evaluation phase consists of two main
activities.
1. Assess Program Outcomes and Processes
• Review the anticipated outcome identified in implementation plan
• If outcomes are not met, review processes to identify problem areas
2. Adjust Services as Required
• Adjust services to meet anticipated outcomes based on monitoring and
evaluating program processes
• Re-evaluate program outcome after making service adjustments in an ongoing
base.
14/05/2024 KPP friendly service training for Health Workers 115
Monitoring and Evaluation Indicators

• Indicators for monitoring and evaluation of social network testing to ensure

effective implementation of the program. To monitor the strategies, listed
indicators are used.
Number of Newly diagnosed HIV positive and high-risk HIV negative identified
Number of Newly diagnosed HIV positive and high-risk HIV negative identified
offered to be secondary recruiter
Number of Newly diagnosed HIV positive and high-risk HIV negative accepted
to be a recruiter
Number of coupon distributed
Number of coupon returned
Number of network members’ screen using risk segmentation tool.
Number of network members found high risk for HIV
14/05/2024 KPP friendly service training for Health Workers 116
Monitoring and Evaluation Indicators
cont.…
Number of network members tested for HIV
Number of network members tested HIV positive
Number of Linked to care and treatment
Number of Started ART
Number of FSWs tested HIV Negative assessed for PrEP
Number of eligible FSWs for PrEP
Number of eligible FSWs offered PrEP
Number of eligible FSWs started PrEP
14/05/2024 KPP friendly service training for Health Workers 117
 Chapter summary

• SN HIV testing strategy is a programmatic, peer-driven, recruitment strategy to reach the highest risk
persons who may be infected but unaware of their status
• One strategy for reaching and providing HIV CTR to persons with undiagnosed HIV infection is the use
of social networks
• SNS use a strategy to enlist HIV-positive and high-risk HIV-negative persons (recruiters) to identify
individuals from their social, sexual network (network members) for HIV Testing Service
• Network recruiting is facilitated using recruitment coupons.
• SNS is implemented in four phases
1. Identify Initial Recruiters
2. Instruct Recruiters
3. Recruitment of Network Members
4. Testing of Network Members & Offer to Become a Recruiter
• Health Facilities providing SNS need to have standard requirements regarding space, supplies and equipment and
personnel/staffs.
• The unique identification code will be recorded in SNS for tracking recruitment as well repeated clinic visits
14/05/2024 KPP friendly service training for Health Workers 118
Chapter 5: HIV Self-Testing (HIVST)

Learning Objectives: At the end of the session, participants will be

able to:
• Explain the rationale for the implementation of HIVST for adults and
children 2-15 years
• List the target group/eligible for HIVST
• Explain the different HIVST guiding principles
• Describe the different modalities of delivering HIV self-testing and its
implementation approaches/phases
• Demonstrate the HIVST.
• Outline the different demand creation mechanism to the target
populations
14/05/2024 KPP friendly service training for Health Workers 119
Individual Reflection (10minutes)
INDIVIDUAL REFLECTION (10minutes)

 What is HIVST mean?

 What are the approaches of HIVST?

14/05/2024 KPP friendly service training for Health Workers 120

5.1. HIV Self-test for adults
• HIVST is a process whereby an individual conduct his or her own HIV test
using a simple oral (nationally recommended) or blood-based test.
• HIVST is an emerging approach that provides an opportunity for people
to test themselves.
• Likewise in Ethiopia, different useful approaches and strategies for HIV
testing have been adopted and implemented to increase uptake of HTS
through MOH.
• As per the recommendation of WHO, unassisted and assisted HIVST has
been implemented and remarkable results drawn.
• In Ethiopia, directly assisted model of HIVST primarily using community-
based approach has been implemented in selected sites in since fiscal
year (2012 EFY).
14/05/2024 KPP friendly service training for Health Workers 121
5.1.2. Definition of HIVST

HIV self-testing (HIVST) is one of additional HTS approach, and

it can be defined as:-
• A process, in which a person collects his or her own specimen,
performs HIV test and interprets the result, often in a private
setting, either alone or with someone he or she trusts.
• It is an emerging approach that provides an opportunity for
people to test themselves discreetly and conveniently, thereby
empowering those who may not otherwise test, particularly
among key populations to know their HIV status.

14/05/2024 KPP friendly service training for Health Workers 122

APPROACHES FOR HIV SELF TESTING

1. Directly Assisted HIVST

2. Unassisted HIVST
Both directly assisted and unassisted HIVST may include
additional support tools:
Manufacturer’s instructions and brochures.
Brief in-person demonstration (one-on one) before
testing.
In-person assistance during procedure.
Hotline contacts for HIVST information.
14/05/2024 KPP friendly service training for Health Workers 123
 Target populations for HIVST

1. FSW and their partners,

2. Sexual partners and networks of index cases
3. Long distance truck drivers and their assistants
4. Daily Laborer, mobile workers
5. Index families and spouse/ discordant
6. Widowed/ divorced/ remarried
7. Partners of PMTCT/ANC clients
8. Sexual partners of STI patients
9. Prisoners
14/05/2024 KPP friendly service training for Health Workers 124
 HIVST guiding principles and its benefit

Guiding Principles
• HIVST should adhere to the following WHO 5 Cs:
 Consent
 Confidentiality
 Counseling
 Correct test results and
 Connection (linkage to prevention, care and treatment services)
• HIVST should always be voluntary, not coercive or mandatory
• Whether that coercion comes from a health-care provider or
from a partner, family member, or any other person, Coerced
or mandatory testing is never appropriate
14/05/2024 KPP friendly service training for Health Workers 125
 5.2. Demand creation strategy of HIVST

To create awareness and increase uptake of HIVST, advocacy and

communication strategies should aim to emphasize:
• correct usage of the self-test kits, and ensure correct interpretation
of results and linkage for confirmatory testing for self-test reactive
results
• It should be tailored to high-risk target populations.
• It will be conducted at health facility and community platforms.
• Clear messages are needed to ensure that users understand what to
do after a reactive self-test result, including where to go to access
conventional HTS for confirmation of results, Rx, care, and other
support.
14/05/2024 KPP friendly service training for Health Workers 126
Demand creation cont...
Demand creation messages can be delivered through:
 One to one (health care providers, health extension
professionals, peer educators, volunteers).
 Print media (banners, poster, fliers)
 Audio visual
 Networks of people living with HIV
 Community-based organizations

14/05/2024 KPP friendly service training for Health Workers 127

 HIVST Video Demonstration and practice:

• show the demonstration video on HIVST.

• Provide HIVST kits, follow the procedure you
observed from the video demonstration and
conduct the self-test
• Make them to Share his/her experience to the
group. How was it? Easy? Difficult? Why?
• Video link:
14/05/2024 KPP friendly service training for Health Workers 128
 Chapter Summary
• HIVST is a process whereby an individual conduct his or her own HIV test using a
simple oral (nationally recommended) or blood-based test.
• HIVST must be conducted using the nationally approved HIV rapid self-test kit(s). The
kit(s) will include instructions in English and local language as well as pictorial
diagrams to aid ease of use and correct interpretation of results.
• HIV self-testing (HIVST) should be highly targeted to individuals and groups not
currently being reached by existing HIV testing services (HTS).
• All HIVST kits should be distributed must also be accompanied with client education
material.
• HIVST should always be voluntary, not coercive or mandatory.
• All reactive HIVST result always need further confirmatory testing by approved
national conventional testing.

14/05/2024 KPP friendly service training for Health Workers 129

Chapter 6: Provision of Pre-Exposure Prophylaxis
in clinical settings
Learning objectives: By the end this chapter the
participants will be able to
• Define Pre-Exposure prophylaxis and describe its
benefits.
• List out PrEP target groups, eligibility criteria, exclusion
criteria and recommended ARV drugs.
• Explain the PrEP drug side effects and its management.
• Describe the importance of demand creation,
adherence and focused counseling for PrEP.
14/05/2024 KPP friendly service training for Health Workers 130
 Individual reflection(10 minutes)
INDIVIDUAL REFLECTION(10minutes)

 What is pre-exposure prophylaxis?

 Who are eligible group for PrEP initiation
according to national guideline?

14/05/2024 KPP friendly service training for Health Workers 131

 6.1. Introduction to PrEP

• PrEP of HIV is the use of ARV drugs by individuals who are not infected with
HIV but at substantial risk to block the acquisition of HIV.
• Substantial risk of HIV infection is provisionally defined as an incidence of HIV
higher than 3 per 100 person-years in the absence of PrEP and risk behavior
like inconsistence condom use.
• PrEP should be offered as an additional prevention choice for people at
substantial risk of HIV infection.
• WHO also recommended that the Dapivirine vaginal ring (DPV-VR) for women
every 28 days and injectable PrEP every two months for all eligible clients at
substantial risk of HIV infection, as part of combination prevention approaches.
• This additional PrEP option will be piloted at small scale and considered as
additional PrEP options in the future.
14/05/2024 KPP friendly service training for Health Workers 132
 Target groups for PrEP

• The target beneficiaries for PrEP service in

Ethiopia are consenting HIV Negative FSWs and
HIV negative partners of sero- discordant
couples.
• PrEP should also be offered for HIV negative
pregnant and breast-feeding women who have
HIV- positive partners for those who attend at
ANC/PMTCT clinic.
14/05/2024 KPP friendly service training for Health Workers 133
 Screening for PrEP
Screening for substantial risk for HIV infection
Clients are considered at substantial risk if they belong to Question prompts for providers:
any of the two categories below:
1)Self Identifying FSW ■ Do you trade sex for money or other material goods?
■ Have you been sexually active in the last six months?
2) If they report having a sexual partner in the last six ■ Is your partner HIV infected? Note for FSWs check if she
months who is HIV positive AND who has not been on knows the HIV status of her Baluka/Boyfriend?
effective* HIV treatment ■ Is he/she on ART?
*If partner has been on ART for less than six months, or ■ How long has your partner been on ART?
has inconsistent or unknown adherence, or has ■ Is your partner adherent to ART?
unsuppressed viral load ■ What was the last viral load result?

14/05/2024 KPP friendly service training for Health Workers 134

 Eligibility Criteria for PrEP
HIV Negative FSWs HIV Negative Partners in Sero-Discordant Couples

■ HIV negative using a rapid antibody ■ HIV negative using a rapid antibody test as per the National HIV testing
test as per the National HIV testing algorithm on the day of PrEP initiation.
algorithm on the day of PrEP
■ No suspicion of acute HIV infection.
initiation.
■ Substantial risk of HIV infection (any ONE of the following in the past six
■ No suspicion of acute HIV infection. months):
■ Self- identifying FSWs. o Has a known HIV positive sexual partner(s) who is not on ART or
■ No contraindications to PrEP
o On ART less than six months, or not yet achieved undetectable viral load
medicines (TDF/3TC)
< 50 ml/copies or

■ No contraindications to PrEP medicines (TDF/3TC)

14/05/2024 KPP friendly service training for Health Workers 135

 Exclusion Criteria of PrEP

 Finding of HIV infection (existing HIV infection should be ruled out by testing
using the national algorithm on the same day of PrEP initiation).
 Finding of Signs/symptoms of acute HIV infection, with probable recent
exposure to HIV.
 Estimated creatinine clearance of less than 60 ml/min (if known).
 Client reported allergy or there is contraindication to any medicine in the PrEP
regimen.
 Finding of Hepatitis B infection (clients with HBsAg Positive test result).
 Unwillingness or not being ready to use PrEP as prescribed and/or give detail
information required for monitoring.
 Age less than 15 (unless there is a special program that provide ART/PrEP
service for sexually active minors who are less than 15 years age)
14/05/2024 KPP friendly service training for Health Workers 136
 6.2. Recommended ARV, Adherence and Retention

Recommended ARV drugs for PrEP.

• The nationally recommended PrEP drug is a fixed dose combination that
contains Tenofovir 300mg and Lamivudine 300mg once daily for the identified
target groups with substantial risk for HIV infection.
• 3 MMDs PrEP drugs for newly and already on PrEP clients highly recommended
a mid-COVID-19 pandemic.
• If the client misses a dose of the pill, he/she should take the missed dose as
soon as remembered.
• But if it is almost time for the next dose, skip the missed dose and just take the
next dose at the regular time.
• Do not take more than one dose of the pill in a day.
• Do not take two doses at the same time to make up for a missed dose.
14/05/2024 KPP friendly service training for Health Workers 137
 Cont..
Adherence and Retention of PrEP Users
• The effectiveness of Oral PrEP is highly dependent on user’s adherence.
• After clients have initiated PrEP, the core focus of the health care
providers/case managers should be on supporting retention and
maintaining adherence among those using PrEP.
• At each follow-up visit, health care providers should assess for any
changes in adherence and evaluate the effect this may have on the
effectiveness of PrEP.
• Client centered adherence counseling should be provided and barriers
to adherence should be identified and there should be ongoing
education and counseling provided to the client during each of the PrEP
related visits.
14/05/2024 KPP friendly service training for Health Workers 138
 Cont..
Adherence can be described into types:
• Adherence to drugs: -Adherence to drug means that an
individual is taking prescribed medications correctly and
consistently. It involves taking the correct drug in the
correct dose, with consistent frequency (the same number
of times per day) and at a consistent time of day.
• Adherence with follow up: - Adherence with follow up is
that clients attend all scheduled clinic visits and observe all
required protocols, including Clinic and lab assessments,
Prescription refills.
14/05/2024 KPP friendly service training for Health Workers 139
 Approaches to PrEP Medication Adherence
Support Support Issue: Health Care Provider’s Options
Educating to create adequate and accurate knowledge on ■ Briefly explain or provide materials about:
PrEP o Indications for medication.
o The anticipated risks and benefits of taking medication.
o How to take it (one pill per day).
o What to do if one or more doses are missed.
■ Assess for misinformation.

Preparing for and managing side effects ■ Educate about what side effects to expect, for how long, and how to manage them.
■ Educate about the signs and symptoms of acute HIV infection and how to obtain prompt
evaluation and care.

Fostering self – efficacy ■ Foster discussion of personal perception of HIV risks.

■ Recommend or provide medication-adherence tools:
o Pill boxes
o Phone apps, SMS reminder services (if available)

Creating routine daily schedule ■ Discuss how to integrate daily dose with other daily events and what to do when away from
home.

14/05/2024 KPP friendly service training for Health Workers 140

 Approach to PrEP adherence support cont.
…Issue:
Support Health Care Provider’s Options
Providing support
■ Regularly assess adherence.
■ Ask for a patient self-report.
■ Complete the prescription/visit record.
■ Use new technologies (text reminders if available).
■ Offer allied clinical support services (e.g.. Pharmacist

Fostering Social Support

■ Discuss privacy issues for PrEP user.
■ Offer to meet with partners or family members if they are supportive.
Fostering Social Support
■ Consider screening for depression or substance-abuse problems.
■ Provide or refer to indicated mental health or substance-abuse treatment
and relapse-prevention services.
■ Encourage clients to take medication before / after the use of substances

Addressing population challenges

■ Consider additional medication-adherence support for:
o Adolescents.
o People with unstable housing.
o Others with specific stressors that may interfere with medication
14/05/2024 adherence.
KPP friendly service training for Health Workers 141
Investigations and Interventions at Client
Visit.
Read Table 10 from PM#93-94

14/05/2024 KPP friendly service training for Health Workers 142

Managing PrEP side effects, sero-conversion& Stigma

Managing PrEP side effects.

• The major side effects or toxicities associated with TDF /3TC are rare in PrEP
exposure to date. Minor side effects are relatively common but are usually
mild and self-limiting if they do occur (approximately 1 in 10 individuals in
the first 1-2 months), and do not require discontinuation of PrEP.
• 1 in 10 PrEP users may have side effects such as nausea, abdominal cramps,
headache; these are usually mild and resolve over the first month of taking
PrEP.
• 1 in 200 may have creatinine elevation (typically reversible, if PrEP is
stopped).
• 1 % average loss of bone mineral density; this also recovers after stopping
PrEP.
14/05/2024 KPP friendly service training for Health Workers 143
 Cont..
Creatinine level elevation (> 60 ml/min) management
• The test has to be repeated immediately / ASAP after the first result for confirmation
and discontinuation of PrEP
• Contact the client when the result for the test from the second specimen comes back
elevated.
• If no contact information, use other options like involvement of case managers, peer
navigators
• After PrEP is stopped, creatinine test can be done every month for three months, and
PrEP could be restarted after three months if eGFR returns to > 60 ml/min.
• Referrals should be made for management of additional causes and management of
creatinine elevations should be considered if:
• Creatinine elevations are more than 3x the baseline.
• Renal function or creatinine elevations do not return to normal levels within three months after stopping PrEP.
• Creatinine elevations progress at one month or more after stopping PrEP.
14/05/2024 KPP friendly service training for Health Workers 144
 Cont..
When to stop taking PrEP?
• There are several reasons when people stop taking PrEP:
 From Clinician Side
• HIV sero-conversion while on PrEP
• Sustained elevation of creatinine clearance (eCRCL) < 60ml/min.
• Clients who have side effects from the medicine that interfere with quality of life.
• Finding of Hepatitis B infection (clients with HBsAg Positive test result) while taking PrEP
• Clients with poor adherence for two consecutive months (Missing five and above pills per month) to the
prescribed dosing regimen despite efforts to improve daily adherence.
• A Partner with HIV achieves at least one undetectable viral loads result while on ART.
 From Client Side
• Acquisition of HIV infection (Positive HIV result)
• No longer at substantial risk (e.g., no longer engaged in sex work)
• Poor adherence for two consecutive months (Missing five and above pills per month) to the prescribed
dosing regimen despite providing enhanced adherence counseling to improve daily adherence.
14/05/2024 KPP friendly service training for Health Workers 145
 Cont..
How to safely discontinue PrEP
• Clients should be informed how to safely discontinue & restart PrEP. This
includes the need to contact health care provider & to continue PrEP for 28
days post-high risk behavior.
• Before discontinuing PrEP, conduct the following activities.
• Perform HIV test to confirm whether HIV infection has occurred.
• If HIV positive, establish linkage to HIV care & treatment.
• If negative, appoint the client after 12 weeks for HIV testing and ensure that
the client continues to take PrEP for 28 days after the high-risk event.
• In addition, discuss alternative methods to reduce the risk of acquiring HIV
such as correct and consistent use of condoms, behavioral change to avoid
risk etc.
14/05/2024 KPP friendly service training for Health Workers 146
 Cont..
How to safely restart PrEP
• Any person who wishes to resume taking PrEP medications
after having stopped should undergo all the same pre-
prescription evaluation as a person being newly prescribed
PrEP, including an HIV test to establish that they are still
without HIV infection.
• In addition, a frank discussion should clarify the changed
circumstances since discontinuing medication that indicate
the need to resume medication, and the commitment to
take it.
14/05/2024 KPP friendly service training for Health Workers 147
 Cont..
PrEP Seroconversion
• PrEP works when taken correctly and consistently as prescribed. In clinical
trials, the level of protection was strongly correlated with adherence.
• HIV sero – conversion after prescribing PrEP can occur if PrEP is not used
correctly or consistently, or if HIV infection was undiagnosed at the time of
PrEP initiation.
• Part of counseling should include information to help PrEP users recognize
signs/symptoms of AHI, which should prompt a clinic visit without delay.
• If a person using PrEP tests positive for HIV, PrEP should be stopped
immediately, and the person referred for prompt initiation of HIV treatment.
• Transitions from PrEP to HIV treatment without a gap avoid the risk of
resurgence in viral load, immunological injury, and secondary transmissions.
14/05/2024 KPP friendly service training for Health Workers 148
 Cont..
HIV Drug Resistance and PrEP.
• Regarding drug resistance (HIVDR) in PrEP users, there was a rare in
clinical trials.
• HIVDR occurred mostly in cases where the person had undiagnosed HIV
infection when starting PrEP.
• HIVDR will not occur when adherence to PrEP is high and HIV sero-
conversion does not occur.
• There can be risk of HIVDR if adherence is suboptimal and HIV infection
occurs while the individual is on PrEP and optimal PrEP adherence is
crucial.
• So, health providers must support and monitor adherence and teach PrEP
users to recognize signs and symptoms of AHI.
14/05/2024 KPP friendly service training for Health Workers 149
 Cont..
Possible reasons for PrEP related Stigma
• Confidentiality is essential in PrEP services.
• People may face stigma if their PrEP use becomes known.
• The main reason that leads to stigma and discrimination
on PrEP can be;
• If others mistakenly consider PrEP use to be evidence of irresponsible behavior or
mistakenly think that PrEP is HIV treatment.
• The resemblance of PrEP with ART medications.
• Such stigma will decrease PrEP uptake and adherence among people who would otherwise
benefit from it.

14/05/2024 KPP friendly service training for Health Workers 150

6.4. Demand Creation for PrEP
• PrEP service uptake and retention is generally
low due to weak PrEP demand creation activities.
• Therefore, creating demand for PrEP is important
to increase awareness about PrEP, generate
demand and improve access.
• While creating demand for PrEP will be useful to
emphasize retention/adherence for better
outcome.
14/05/2024 KPP friendly service training for Health Workers 151
 Demand creation cont..
To promote PrEP service:
• For HIV negative FSW
• Use communication materials including brochures and posters
• Use Peer educators/Peer navigators, who are oriented on PrEP will facilitate the recruitment
of eligible clients who are at high risk of acquiring HIV.
• Ensure inclusion of PrEP in SBCC sessions
• Testimony from initial PrEP users
• For HIV negative partners of sero - discordant couples:
• The selection of eligible beneficiaries will also be done through using the existing index case
register and line-listing HIV negative partners and contact through phone.
• Include PrEP importance on daily health education by health care workers and ACMs, AS and
MSGs.
• Discuss about PrEP during one-to-one counseling session by service providers or case
managers of Adherence supports and mother support groups.
14/05/2024 KPP friendly service training for Health Workers 152
 Counseling Skill

Initial counseling should focus on:

• Increasing awareness of PrEP as a choice addressing under listed
issues:
• Starting PrEP does not mean staying on PrEP for life.
• Oral PrEP should be used daily during periods of substantial risk of HIV acquisition and can be stopped
during periods of low or no risk.

• Helping the clients to decide whether PrEP is right for them.

• Preparing individuals for starting PrEP.
• Same-day PrEP initiation should be considered. If the person refuses or insist to take time to think about it, it
may be beneficial for them to be given the opportunity to return for another clinic visit after providing
counseling on its benefits.

• Explaining of how PrEP works.

• Providing basic recommendations.
14/05/2024 KPP friendly service training for Health Workers 153
 Cont..
• The importance of adherence and follow-up visits.
• Potential PrEP side effects.
• Recognizing symptoms of acute HIV infection.
• Building a specific adherence plan for PrEP.
• Young adults may benefit from more frequent appointments e.g., monthly visits, as they commonly have lower adherence rates.
• Adherence is a significant modifier of PrEP effectiveness and PrEP can be started and stopped as a person moves through
“seasons of risk”.
• Discussing sexual health and risk reduction measures.
• Assess client understanding that the protection provided by PrEP is not complete, and does not prevent other STIs or unwanted
pregnancies, and therefore PrEP should be used as part of a package of HIV combination prevention services [including
condoms, contraception, risk reduction counseling and STI management.
• Consider these points for women.
• PrEP does not affect the efficacy of hormonal contraceptives.
• PrEP does not protect against pregnancy.

• PrEP can be continued during pregnancy and breastfeeding

14/05/2024 KPP friendly service training for Health Workers 154
 6.5. Monitoring and evaluation

PrEP performance cascade monitoring Indicators.

• Number of HIV negative FSWs and SDC identified during the reporting period.
• Number of HIV negative FSWs and SDC screened for HIV substantial risk during the
reporting period.
• Number of HIV negative FSWs and SDC found at substantial risk during the
reporting period.
• Number of HIV negative FSWs and SDC who are eligible for PrEP during the
reporting period.
• Number of HIV negative FSWs and SDC offered PrEP during the reporting period.
• Number of HIV negative FSWs and SDC started PrEP during the reporting period.

14/05/2024 KPP friendly service training for Health Workers 155

 PrEP performance cascade monitoring Indicators
cont...
• Number of HIV negative FSWs and SDC declined PrEP during the reporting period.
• Number of HIV negative FSWs and SDC currently receiving PrEP during the reporting
period.
• Number of HIV negative FSWs and SDC discontinued PrEP during the reporting
period.
• Number of HIV negative FSWs and SDC LTFU from PrEP during the reporting period.
• Number of HIV negative FSWs and SDC stop PrEP by service providers due to poor
adherence during the reporting period.
• Number of HIV negative FSWs and SDC DC due out of substantial risk during the
reporting period.
• Number of HIV negative FSWs and SDC sero-converted during the reporting period.

14/05/2024 KPP friendly service training for Health Workers 156

 Chapter Summary

• PrEP can be used by HIV-negative persons to reduce the risk of

HIV acquisition.
• Daily oral PrEP with TDF-containing regimens is currently
recommended.
• PrEP should be taken as an additional prevention intervention.
• PrEP is effective if taken correctly and consistently.
• PrEP can be used by for those who have HIV substantial risk of
HIV Negative FSWs and HIV Negative Sero-discordant couples.
• PrEP is safe and has minimal side effects.
• PrEP can be safely re-started and discontinued.
14/05/2024 KPP friendly service training for Health Workers 157
Chapter 7: Post Exposure Management including
Prophylaxis
Learning Objectives: At the end of the module,
participants will be able to:
• Describe target groups for PEP.
• Demonstrate skill to manage a potentially HIV exposed
person
• Prescribe drug of choice for PEP based source code
and exposure code.
• Describe prevention of HIV transmission after sexual
assault
14/05/2024 KPP friendly service training for Health Workers 158
7.1. Management of Occupational Exposure to HIV

• Health care workers and supporting staff have a low but measurable risk of HIV
infection after accidental exposure to infected blood or body fluid.
• Compliance with infection prevention recommendations is the backbone in
prevention of occupational HIV infection. The priorities therefore must be to
train health personnel in infection prevention and provide them with necessary
materials and protective equipment.
• Risk of HIV infection after a needle stick or cut exposure to HIV-infected blood
is estimated to be 0.3% (3 in 1000). The risk of HIV infection after exposure of
mucous membranes to HIV-infected blood is estimated to be 0.1% (1 in 1000).
However, risk could vary depending on severity of injury and viral load in the
source patient.
• Antiretroviral treatment immediately after exposure to HIV can reduce risk of
infection by about 80%.
14/05/2024 KPP friendly service training for Health Workers 159
 Cont..
Support for post exposure management in health facilities
• Regular prevention education for employees (health
workers, cleaners, and other staff) involved in institutional
care for PLHIV.
• Ensure availability of control mechanisms for effective
observation of standard precaution.
• Establish system for post exposure management to ensure
urgent attention for victims who have sustained accidental
blood exposure.
14/05/2024 KPP friendly service training for Health Workers 160
 Cont..
Minimum package for PEP sites/facilities
• Assign one trained physician / Health Officer / nurse as PEP focal person for
the facility.
• The contact address of the facility PEP focal person and the facility ART nurse
or any other second person assigned to coordinate PEP activities in the
facility should be posted in all outpatient and inpatient departments within
the heath facility.
• PEP ARV drugs should be made available in designated sites inside the heath
facility which may be accessible to all staff, 24 hours, and 7 days a week.
• Provider support tools like algorithm for determination of the severity of
exposure (Exposure Code) and PEP register should be available in the facility.

14/05/2024 KPP friendly service training for Health Workers 161

 Cont..
Steps to manage potential HIV exposed person
1. Treat the exposure site /immediate measures.
• Percutaneous injury or injury to non-intact skin
• Exposed mucous membranes:
2. Report the exposure:
• To the PEP focal person or the ART physician or nurse in the facility immediately.
3. The PEP focal person who needs to do:
a) Clinical evaluation, counseling and testing of the exposed person and complete the exposure reporting form.
b) Do risk assessment and determine the exposure code (EC) and source HIV status code (HIV SC) using the PEP algorithm.
c) Using the EC and HIVSC determine whether PEP is warranted for the exposed HCW.
d) If the HCW is warranted to take PEP: Choose appropriate PEP regimen, counsel about the ARVs and prescribe according to PEP
algorithm.
e) Document properly on the PEP follow-up register.
f) Appoint the exposed person and follow.
g) Conduct follow up HIV testing at 6 weeks.

14/05/2024 KPP friendly service training for Health Workers 162

 Cont..
Assessment of exposure risk:
Low-risk exposure:
• Exposure to small volume of blood or blood contaminated fluids
• Following injury with a solid needle
• Asymptomatic source patient
High-risk exposure:
• Exposure to a large volume of blood or potentially infectious fluids.
• Exposure to blood or potentially infectious fluids from a patient with clinical AIDS or
acute HIV infection or known positive with high viral load.
• Injury with a hollow needle.
• Needle used in source patient’s artery or vein.
• Visible blood on device.
• Deep and extensive injury.
14/05/2024 KPP friendly service training for Health Workers 163
 Interpretation of exposure code (severity of
exposure).
Exposure Code Type of exposure

1 EC 1 Is a minor muco-cutaneous exposure to small volume of blood for short period (few
seconds to minutes)
2 EC 2 Is a major muco-cutaneous exposure to large volume of blood for longer duration
(several minutes), or mild percutaneous exposure (with solid needle or superficial
scratch or injury).

Severe percutaneous exposure (large bore hollow needle, deep puncture, visible
3 EC 3 blood on devise, needle used in patient artery/vein).

14/05/2024 KPP friendly service training for Health Workers 164

 Interpretation of the HIV status of the source
patient.
HIV Source Code The HIV status and severity of the illness in the source patients
(SC)

1 HIV SC 1 The source patient is HIV positive but is asymptomatic and has reasonably good
immune status.

2 HIV SC 2 The source patient is HIV positive and is symptomatic, may have AIDS or has other
evidence of advanced illness (low CD4 or high viral load).

3 HIV SC unknown The HIV status of the source patients is unknown (either the patient has refused
HIV testing or died or discharged before HIV testing) or the source patient is
unknown (e.g., unlabeled blood sample in a laboratory).

14/05/2024 KPP friendly service training for Health Workers 165

 Recommended PEP based on risk
assessment
Exposure code
Status code

EC 1 EC 2 EC 3

SC 1 Basic 2 drug PEP Basic 2 drug PEP Expanded 3 drug PEP

SC 2 Basic 2 drug PEP Expanded 3 drug PEP Expanded 3 drug PEP

SC unknown Consider basic 2-drugs PEP.

HIV negative No PEP warranted No PEP warranted No PEP warranted

14/05/2024 KPP friendly service training for Health Workers 166

 Recommended ARVs for PEP and administration
guide.
ARV drug regimen Dose Frequency Duration

2-Drug Regimen: TDF 300mg

Tenofovir (TDF) + Lamivudine(3TC) 3TC 300mg Once daily 28 days
or
Dolutegravir (DTG) + Lamivudine (3TC) DTG 50mg
3TC 150mg 12 hourly 28days

3-Drug Regimen: Triple FDC (TDF 300mg, 3TC 300mg, Once daily
Triple FDC EFV600mg)
Tenofovir (TDF) or Dolutegravir(DTG) + Lamivudine (3TC) + DTG 50mg twice daily AZT&3TC 12 hourly;
Efavirenz (EFV) 3TC 150mg twice daily EFV600 once daily
Or EFV 600mg once daily
28 days
Lopinavir/ritonavir (LPV/r)
Or
Atazanavir/ritonavir (ATV/r) LPV/r400mg /100mg 12 hourly
OR
TDF+3TC+DTG, triple FDC
ATV/r300mg/100mg Once daily
TDF300mg+3TC300mg+DTG 50mg Once daily

14/05/2024 KPP friendly service training for Health Workers 167

Timing of initiation of prophylaxis:
• To be effective, PEP should commence as soon as possible (within 1-2 hours). The maximum delay for
initiation of treatment which would prevent infection is not known in humans. Do not consider PEP
beyond 72 hours post exposure. Prophylaxis is to be given for 28 days.
Testing and monitoring after occupational exposure:
• Testing source: rapid HIV test is done after counseling and consent has been secured. If the source
patient is negative, there is no need of further assessment of the exposed health care worker. If the
result is positive the health care worker needs to be tested.
• Testing of health care worker: HIV testing should be performed immediately after exposure. If result is
positive there is no need for PEP, but if negative you should administer PEP as soon as possible as
outlined above and then repeat HIV testing at 6 weeks. Remember to initiate PEP immediately after
exposure until test result confirms the HIV status of the victim. Stop PEP if the health worker is positive
for HIV antibodies.

14/05/2024 KPP friendly service training for Health Workers 168

Recommended regimen for PEP

Dolutegravir (DTG) 50 mg daily in combination with tenofovir disoproxil Lamivudine (3TC) 300 mg daily as the preferred regimen in healthy adults and
adolescents for 28 days

Alternatively, AZT or TDF+3TC+EFV for 28 days or

Boosted Lopinavir OR boosted Atazanavir can substitute EFV.

DTG was approved in June 2020 for all children older than 4 weeks weighing more than 3kg and available with dispersible tablets that can be easily
administered for all children weighting less than 20kg. For children weighting more than 20 kg, 50 mg adult film-coated tablets can be used. (WHO 2021).

PEP is not recommended.

a) If victim presents more than 72 hours after exposure.

b) Following condom leak or tear.

14/05/2024 KPP friendly service training for Health Workers 169

7.2. Prevention of HIV Transmission after Sexual
Assault
1. Any person presenting to a health facility after potential exposure to HIV during sexual
assault should be strictly counseled and examined by trained health care worker about the
potential risk of HIV infection and ensure there is no misuse of PEP.
2. Parents/guardian of traumatized children should be counseled and informed on the risk of
HIV infection after sexual assault.
3. The following points should be covered in the counseling:
a) The exact risk of transmission is not known, but it exists.
b) It is important to know the victim’s HIV status prior to any antiretroviral treatment.
c) It is the patient’s choice to have immediate HIV testing or, if s/he prefers, this can be
delayed until 72 hours post examination visit.
d) PEP is not recommended after 72 hours following sexual assault. Patients should be
counseled about risk of infection and the possibility of transmitting infection during sero-
e) Conversion. They should be instructed to return at 6 weeks post sexual assault for
voluntary counseling and HIV testing.

14/05/2024 KPP friendly service training for Health Workers 170

PEP is not recommended.
a) If victim presents more than 72 hours after
exposure.
b) Following condom leak or tear.

14/05/2024 KPP friendly service training for Health Workers 171

 Chapter Summary

• To be effective, PEP should commence as soon

as possible (within 1-2 hours).
• Do not consider PEP beyond 72 hours post
exposure.
• Post Exposure Prophylaxis is to be given for 28
days.
• PEP is not recommended following condom
leakage.
14/05/2024 KPP friendly service training for Health Workers 172
 Chapter8: KP Quality Score Card
Learning Objectives: At the end of the session,
participants will be able to:
• Define community score card.
• Describe how community score card will improve
services.
• Describe how to design and implement score card
• Explain how to monitor the implementation of KP
quality score card.
14/05/2024 KPP friendly service training for Health Workers 173
 Individual reflection (10minutes)

INDIVIDUAL REFLECTION(10minutes)

 What is quality/community score card?

14/05/2024 KPP friendly service training for Health Workers 174

 8.1. Introduction and Rationale to KP quality score card.

• Community score card is a two-way, participatory, community- led QI tool

routinely used for assessment, planning, monitoring, and evaluation of
health services.
• It brings together the demand side (“service user”) and the supply side
(“service provider”) of a particular service or program to jointly analyze
issues underlying service delivery problems and find a common and shared
way of addressing those issues.
• A scorecard is a tool that is used by community members and health care
providers to facilitate collective agreement and action with the goal of
improving service delivery.
• It allows a community to engage with health facility providers in a formal
setting and deliberately and positively encourage service quality, efficiency,
and accountability.
14/05/2024 KPP friendly service training for Health Workers 175
 Rational of KP quality score card

• Community participation in health service have various advantages in

health care and development among which are helping communities to
develop problem solving skills, helping them to take responsibility for their
health and welfare, ensuring that the need and problems of the
community are adequately addressed.
• Community and civil society organizations can play multiple roles in the
HIV response through: -
Use of evidence to engage health care workers and policy makers to influence health policy and
uptake of HIV services
Promoting the ability of community members to identify and demand quality services by fostering
government accountability
Developing a routine platform for community and facility to both have accountability for health
outcomes
Promoting referral and adherence services
Supporting and advocate for communities affected by HIV then improve service delivery
14/05/2024 KPP friendly service training for Health Workers 176
8.2. Insight into community score card

How does a scorecard work?

• Scorecard is a four-phase process focused on continuous improvement.
1. Score the Score card
2. Interface and develop an Action plan
3. Implement Actions
4. Disseminate Data
• This methodology captures user perceptions on quality, efficiency, and transparency, such as:
 Tracking of inputs and expenditures (e.g., availability of drugs)
 Monitoring quality of services
 Monitoring benchmark performance criteria that can be used in budget decisions and investments
 Providing performance comparisons across facilities or districts
 Generating a direct feedback mechanism between health providers and users
 Building local capacity (e.g. how health care workers can better serve KP)
 Strengthening community voices in identifying health care gaps
14/05/2024 KPP friendly service training for Health Workers 177
 Cont..
How does a scorecard improve performance?
• A scorecard approach provides—
• Community members with the ability to provide feedback directly to
their catchment health facility: the scorecard acts as a vehicle for
systematically sharing feedback in a transparent and structured
manner that enables action and accountability.
• Healthcare facility service providers and administrators with a direct
link to their community.
• the scorecard collects information that can be used by service
providers to improve health care services in an informed manner
that directly responds to their constituency.
14/05/2024 KPP friendly service training for Health Workers 178
 Cont..
• Scorecards are a power lever for change as they
provide a vehicle through which communities and
providers can partner to identify and enact positive
improvements – together – at every level of the
health system.
• Service providers receive immediate feedback in a
space that allows for mutual dialogue between
community members and providers around the
indicators and scores.
14/05/2024 KPP friendly service training for Health Workers 179
 Cont..
• A scorecard approach provides communities and
health workers with data which they can use to
measure impact over time and use to advocate for
measures to improve service delivery from
governmental and nongovernmental stakeholders.
• Community members and healthcare facility
providers collaboratively develop criteria, or
indicators, for evaluating the services which are
captured in a scorecard.
14/05/2024 KPP friendly service training for Health Workers 180
 Cont..
• This re-scoring is then repeated every three
months to monitor and evaluate the action plan,
rescore the scorecard, and develop a new action
plan.
• This cyclical process of evaluation enables
ongoing improvement in access to and delivery
of quality health services.

14/05/2024 KPP friendly service training for Health Workers 181

 Strength and challenges of using community score
card.
Strength Challenges
Solicits direct engagement and feedback The process of facilitating the data collection, dialogue, and action planning
from the community members. process can be lengthy and requires a skilled facilitator to lead the dialogue.
■ Community-level data collection allows for engagement of key ■ Community-level data is sensitive in nature, particularly where it exposes
stakeholders from various groups; the consensus process for issues of stigma, discrimination, or other issues. As such, sharing various
determining the score each quarter creates a space for dialogue. reports and dashboards summarizing the data can be challenging, as
■ Flexible methodology that allows for a focus reports need to be limited to showing the data for a given district’s facility
on critical issues for a given project or location. For example, LCI scores, introducing additional work in customizing the report and
grantee scorecards ask questions about health worker behavior toward considering the sensitivity of the scorecard data.
patients and stigma toward key populations. ■ Data analysis. Data is at the crux of the scorecard. Being able to query,
■ Action planning process at the end of the scorecard data collection analyze, and visualize data is a critical set to consider when designing and
promotes the use of data for decision-making, with specific actions deploying the scorecard. A team must have someone who can competently
identified with timelines and persons responsible (which may include conduct this level of analysis to produce the kind of information needed to
escalating an issue up to the district level or above). inform change.

14/05/2024 KPP friendly service training for Health Workers 182

 How do we develop this score card?

• The scorecard concept is a dynamic process that can build robust communities of
committed change agents empowered to improve access to and delivery of
quality health services. A thoughtful and thorough design is essential to ensuring
that a scorecard is accepted and successfully implemented. Once designed, the
scorecard must be consistently deployed and used to gather data that can be used
to inform decision-making and positive change. To deploy a scorecard, it must be
designed so it reflects the needs of the community where it is being deployed.
• The design phase takes place only once and is depicted. (Change the phases to
graph)
1. Scope the scorecard concept
2. Design the scorecard
3. Design the scorecard SOP
4. Train scorecard stakeholder.
14/05/2024 KPP friendly service training for Health Workers 183
 Cont..
• Since the scorecard is designed to fuel a continuous approach to
performance improvement, it can be implemented as many times as it is
relevant and useful to the community.
1. Score the scorecard separately with the community and with the
healthcare facility service providers in Scorecard Review Meetings
2. Conduct the Scorecard Interface Meeting where both groups convene to
review their individual scorecards as identified in the Scorecard Review
Meetings, discuss their scoring and identify a joint score, and then together
develop an action plan for how they will improve scores
3. Implement the action plan and monitor actions
4. Disseminate scorecard data dashboard to stakeholders for decision-making
14/05/2024 KPP friendly service training for Health Workers 184
Score card design
• The design process is meant to be collaborative and involve all stakeholders. The foundation of the
scorecard is a set of indicators that can be scored and monitored. These indicators are used to
generate change by creating community commitment to identifying and acting on improvement-
focused action plans. This requires open dialogue about both opportunities and challenges to
access to and delivery of quality health services. As such, everyone involved must be fully aware of
and bought into the process.
• To achieve this level of buy-in and commitment, the design process must be methodical,
transparent, and collaborative. For the design process to be collaborative and representative and
result in a product with buy-in from all participants, the following groups should be represented:
• Community members who receive (or should receive) care from participating health facilities (e.g.,
members of key populations, representatives of groups from whom specific feedback is desired),
• Community leaders who have the ability to influence community members to utilize services,
• Health facility personnel whose services are being scored,
• Policymakers who have the ability to take action based on the scorecard process
14/05/2024 KPP friendly service training for Health Workers 185
Scope the score card
• A clear scope needs to be defined to set parameters for the scorecard’s implementation. Key areas to
define include:
• Areas of the health sector that the scorecard will focus on
• Overall goal of using the scorecard (e.g. access to HIV and AIDS services)
• Health facilities that will use the scorecard
• Stakeholders buy-in needed to make the scorecard data successful
• Sub-populations within the community that need to be represented as a part of the community
scorecard group
• Budget considerations, including financial support for data collection and dissemination. An analysis
should be conducted to estimate costs and inform pricing decisions for implementing the Community
Scorecard. Estimating the costs to develop and implement a scorecard activity can help ensure that an
allocated budget is adequate to cover costs, and that funding agreements are sufficient and promote
sustainability of the organization carrying out the activity. A robust tool should be built that assigns time
and material costs to each step of the scorecard process and estimates costs of different combinations of
activities. This provides decision-makers with the data needed to make an informed decision about
implementation.
14/05/2024 KPP friendly service training for Health Workers 186
 Scope of KP Scorecard
Area of focus: Comprehensive HIV/AIDS services for KP(FSWs)
Health goal: KPs on ART virally suppressed and minimized HIV
transmission
Participating Health Facilities KP friendly service providing health facilities

Community populations Key Population (FSWs)

Administrators: KP Client council and Woreda health office

14/05/2024 KPP friendly service training for Health Workers 187

 Cont..
Design the Scorecard
• Designing the actual scorecard needs to be a collaborative process that reflects the
objectives of the health system. It is the foundation of the scorecard approach and it
needs to be designed strategically so that it effectively monitors and informs
improvement in desired areas. The scorecard itself is comprised of four
components:
1. Scorecard Indicators: -Scorecard indicators are metrics that provide information “to
monitor performance, measure achievement and determine accountability”
2. Scoring Scale: - The scale is used to rate the current state of the various indicators
affecting quality service provision.
3: Action Plan Template: This template captures necessary data points to ensure that
actions are identified and enacted in response to scoring.
4. Dashboard: - The dashboard is a tool that allows stakeholders to easily access,
analyze, and report scorecard data.
14/05/2024 KPP friendly service training for Health Workers 188
 Cont..
• The following steps describe how to design a scorecard and
build each component. So long as the end result is a scorecard
that will allow a community and their healthcare facility
providers to collaboratively improve service delivery, these
steps can be adapted to their own objectives and context.
1. Convene focus group
2. Select indicator
3. Develop a scoring scale
4. Develop an action plan template
5. Develop a scorecard dashboard

14/05/2024 KPP friendly service training for Health Workers 189

 3. Design SOP

• To ensure that the scorecard is implemented in a consistent, transparent

manner, a clear process needs to be defined. Ultimately, this process is
captured in a SOP format, and it is described in detail in the annex section of
this training manual. The major activity in this section is:
1. Define a scorecard review period
2. Identify Scorecard Facilitators
3. Identify types of stakeholder groups
4. Identify individual stakeholders
5. Identify minimum stakeholder participation
6. Develop Stakeholder Scorecard Review Meeting and Scorecard Interface
Meeting Facilitator Guides
7. Develop a data management plan
14/05/2024 KPP friendly service training for Health Workers 190
 4. Train Stakeholders

• For the scorecard to be successfully

implemented, all participants must be oriented
to why it is being used as a lever for improving
performance, how it will be deployed, and the
role each participant is expected to play in the
deployment.

14/05/2024 KPP friendly service training for Health Workers 191

 Cont..
Training is focused on two groups
Focus Score card facilitator Scorecard stakeholders
Who Facilitators are those who will be leading the scoring at Stakeholders are any individuals or groups impacted by the
community and facility, Scorecard Review Meeting and scorecard process, including—
Scorecard Interface Meeting ■ Healthcare facilities whose services are being scored .
■ Community groups who are scoring health services
■ Managers or leaders within the larger health system who
have responsibility for facilities or enabling action plans

Objectives To ensure that they can effectively and consistently deploy the To ensure that they are confident in the process, scores, and
scorecard tool and are able to— action plans and have the knowledge and, as necessary, skills
1. define the community scorecard concept needed to participate in the scorecard process and can—
2. Define indicators 1. define the community scorecard concept 2. define indicators
3. deploy the scorecard tool and facilitate scoring and action 3. understand their role in using the scorecard to improve access
planning. to and delivery of key services

14/05/2024 KPP friendly service training for Health Workers 192

 8.3. Scorecard implementation and Tools

• Once the scorecard and scorecard SOP are designed, the scorecard is administered. This process is a
cyclical one and the goal of each scorecard review cycle is to facilitate incremental positive change within
the health system. From many countries experience, community score card implementation follows
these listed steps.
1. Score the scorecard with the community and with healthcare facility service providers.
2. Conduct the interface meeting and develop an action plan.
3. Implement the action plan and monitor actions.
4. Disseminate scorecard dashboard to appropriate stakeholders
• Community members meet to score service indicators, while those who provide (or administer)
healthcare services meet separately to also score the scorecard indicators. Once the scorecard is scored,
community members and service providers convene in an "interface meeting" to share their scores with
each other, identify and prioritize issues for improving services, and create an action plan for carrying out
those improvements.
• This process is repeated regularly to monitor and evaluate the action plan and to enable ongoing
improvement to the service or process. Over time, and with consistent use and commitment to
improvement, the joint efforts of both community members and service providers using the scorecard
yields change in service delivery and quality and, ultimately, positive health outcomes
14/05/2024 KPP friendly service training for Health Workers 193
 Conducting scorecard review meetings
Task Responsible Timeline Reference

1 Schedule Scorecard Review Meetings for community members and healthcare Score card Facilitator With regular Appendix__ Scorecard
facility providers interval review and interface
(e.g., every quarter) meeting at Job Aid

2 Conduct Scorecard Review Meeting with community members: Score card Facilitator With regular Score card dashboard
2.1. Verify that the necessary quorum is present interval
2.2. Administer the scorecard
2.3. Review the scorecard dashboard
2.4. Score indicators
2.5. Provide an update on any actions relevant to the present stakeholders

3 Conduct Scorecard Review Meeting with healthcare facility providers: Score card Facilitator (e.g., every quarter) Appendix__ Scorecard
3.1. Verify that the necessary quorum is present review and interface
3.2. Administer the scorecard meeting at Job Aid
3.3. Review the scorecard dashboard
3.4. Score indicators
3.5. Provide an update on any actions relevant to the present stakeholders

14/05/2024 KPP friendly service training for Health Workers 194

 Cont..
Score Scorecard facilitator
• A score card facilitator selection is a very important task to have clear and unbiased score from
both health facilities and communities. So, score card facilitator needs to have the following
quality:
1. The scorecard process requires adapt facilitation to ensure that all participants are heard and
that their input is reflected in the scoring and action plans.
2. They play the role of honest brokers— creating space for dialogue and problem solving within
the community, health facilities, and between the two groups.
3. As such, facilitators should be selected based on their knowledge of the communities,
facilities, and health system.
• Regarding KP community score card, there are recommended roles to play the facilitation as
follows.
1. Community scoring- Active FSW peer educator/Peer navigator and town/woreda multi
sectoral response officer/KP officer
2. Facility scoring-Town/Sub-city/Woreda HIV clinical officer/KP officer
3. Interface meeting- Town/Woreda/Sub-city multi sectoral response officer
14/05/2024 KPP friendly service training for Health Workers 195
 Action Plan development
Task Responsible Timeline Reference

4 Schedule the Scorecard Interface Meeting Score card facilitators Within a week -Scorecard
of the Scorecard scores
Review Meeting -Scorecard
Dashboard

5 Conduct the Scorecard Interface Meeting: Score card facilitators With regular -Scorecard
5.1 Verify that the necessary quorum is interval (e.g. scores
present every quarter) -Scorecard
5.2 Review the scores from each group and dashboard
discuss.
5.3 Agree on consolidated group scores for
each indicator.
5.4 Review the scorecard dashboard
- Review each dashboard component
- Identify trends
- Identify actions to take based on the data.
5.5 Provide an update on current action plan.
5.6 Present actions for inclusion in the action
plan.
5.7 Select actions to focus on and complete
the action plans.

14/05/2024 KPP friendly service training for Health Workers 196

 Cont..
Members interface meeting.
1. Town mayor/SC/Woreda administrator/delegate
2. Town/Sub city C/Woreda HO Head
3. Town/Sub-City/Woreda HO Deputy head
4. Woreda HIV focal person/Multi sectoral response officers
5. Town/Sub-City/Woreda KP officer
6. Town/Sub-City/Woreda Women & youth affairs
7. Town/Sub-City/WoredaWoreda Police
8. Health facility Director
9. Health facility service providers (KP)
10. FSWs representatives
11. Peer navigators
12. Hotel/bar owners/gate keepers
14/05/2024 KPP friendly service training for Health Workers 197
 Implementing the action plan
Task Responsible Timeline Reference

6 Submit scores and action plans to central focal Score card facilitator Within 1 week
point person so scores can be saved into a of Scorecard
master database and added to the dashboard. Interface Meeting

7 Aggregate scores and action plans and update Score card manager
scorecard dashboard and master action list.

8 Implement action plan. Persons as assigned During the time Action Plan
(e.g. community period between
member or Scorecard
healthcare facility Interface Meeting
provider)

9 Monitor actions. Score card facilitator As determined Action Plan

based on the
action plan

14/05/2024 KPP friendly service training for Health Workers 198

 Disseminate scorecard Dashboard
Task Responsible Timeline Reference

10 Update dashboard to reflect most recent Score card manager Within 1 week -Scorecard
scorecard scores. of Scorecard dashboard
Interface Meeting -Score Card
11 Analyze data for key findings and trends Score card manager Within 1 week -Scorecard
of Scorecard dashboard
Interface Meeting
12 Share scorecard dashboard with the Score card manager Within 1 week -Scorecard
community group and healthcare facility of Scorecard dashboard
providers Interface Meeting
13 Share scorecard dashboard with key Score card manager Time period between Scorecard -Scorecard
Stakeholders. Interface and then next Review dashboard
Meeting

14/05/2024 KPP friendly service training for Health Workers 199

 Cont..
Community score card Implementation follow up.
• In follow up of action plan implementation, client counsel will be
established to oversee, conduct bi-monthly site visit to ensure those
planned actions are implemented per the set timeline. The client councils
will be composed of various constituencies, such as women’s groups,
associations and other segments of the community based on demand
side (client of interest). For specific KP score card, there are suggested
groups but not limited as listed.
1.HIV officers (Clinical, Multi sectoral Response, KP)
2.FSWs representatives
3. Local partners working on KP
4. PLHIV association.
14/05/2024 KPP friendly service training for Health Workers 200
 Chapter Summary

• Community score card is A two-way, participatory, community- led QI tool

routinely used for assessment, planning, monitoring, and evaluation of health
services.
• Scorecards are a power lever for change as they provide a vehicle through
which communities and providers can partner to identify and enact positive
improvements – together – at every level of the health system.
• A scorecard approach provides communities and health workers with data
which they can use to measure impact over time and use to advocate for
measures to improve service delivery from governmental and nongovernmental
stakeholders
• Make all actions “S.M.A.R.T.” or Specific, Measurable, Attainable (as noted
above regarding reasonable actions), Relevant, and time bound.
• Score card process will continue every 3-6 months.
14/05/2024 KPP friendly service training for Health Workers 201
 Chapter 9: U=U (Undetectable=Un-trasmittable)
"የማይታይ መጠን = የተገታ መተላለፍ (የ=የ)"

Learning Objectives: By the end of the chapter, participants will be able to:

Explain the scientific evidences of U=U

Describe key potential U=U message points in clinical care settings

Apply counseling skills in individuals and community stigma reduction

activities

Describe benefits of U=U for clients and discuss frequently asked questions

14/05/2024 KPP friendly service training for Health Workers 202

Introduction : Clinical behavior of HIV infection
 9.1. Introduction, basic concepts and Rational of U=U

Introduction

• Twenty years of evidence demonstrates that HIV treatment is highly effective in

reducing the transmission of HIV

• PLHIV on ART who have an undetectable level of HIV in their blood have a negligible

risk of transmitting HIV sexually

14/05/2024 KPP friendly service training for Health Workers 204

 Scientific evidences behind U=U (1)

• The evidence for U=U comes from several groundbreaking

research studies and clinical trials.
• Partners of People on ART – A New Evaluation of Risks (PARTNER-1) (Rodger et al., 2016)
• Opposites Attract (Bavinton et al., 2018)
• PARTNER-2, demonstrated the effectiveness of ART for preventing the sexual transmission of HIV (Rodger et
al., 2019)

• Followed HIV-serodiscordant couples

• Previously HIV-negative partner were assessed phylogenetically
to determine genetically linked HIV transmission
 Scientific evidences behind U=U (2)

• Collectively, the studies:

• Included >1,800 HIV serodiscordant couples
• Couples in the studies engaged in >160,000 sex acts without PrEP or a condom
(Rodger et al., 2016; Bavinton et al., 2018 and Rodger et al., 2019)

• Result = No genetically linked sexual transmissions occurred among HIV-

serodiscordant couples when the HIV-positive partner achieved durable viral
suppression /un-detectable/
Correlation of viral load & sexual transmission
10
9

Rate of sexual transmission 100

8
7
6

person years
5
4
3
2
1
0
<200 cp/ml <400 400-3499 10,000-49,999 >50,000
Viral Load cp/ml

Attia et al., 2018

 9.1. Introduction, basic concepts and Rational of U=U

• The findings from these studies provided scientific proof on the

importance of working towards achieving and maintaining viral
suppression at undetectable level among PLHIV which is achieved by early
ART initiation, optimal ART adherence and retention-in-care as a viable
method for prevention of sexual transmission of HIV

14/05/2024 KPP friendly service training for Health Workers 208

 Basic Concepts of U=U

• When a person living with HIV is taking HIV drugs regularly as prescribed by HCP and their viral load
has reached undetectable levels (not enough HIV in their bloodstream for a test to measure), that
person will prevent passing of HIV to a sexual partner who is HIV-negative or the risk of sexually
transmitting HIV is negligible

• In technical terms, when viral load result is undetectable; defined as less than or equal to 50
copies/ml (based on the WHO and revised national guideline), it prevents sexual HIV transmission.

• HIV drugs cannot cure HIV.

• Achieving “durable” viral suppression means the patient’s viral load remains undetectable for at least
6 months after their first undetectable test result

14/05/2024 KPP friendly service training for Health Workers 209

Viral Load during effectively treated HIV Disease

EFFECTIVELY PREVENTS
EFFECIVELY
RISKPREVENTS
RISK

210
 Rationale of U=U

14/05/2024 KPP friendly service training for Health Workers 211

 9.2. Misunderstandings related to U=U

• Undetectable HIV viral load shouldn’t be misinterpreted as attaining cure

from HIV

• Undetectable HIV viral load is not equivalent to absence of transmission of

other STIs

• Misguided over reliance may lead to unprotected sex resulting in

unplanned pregnancy

• Providers and clients should not rely on a single viral load value
14/05/2024 KPP friendly service training for Health Workers 212
 Group discussion

Potential U=U Messages

• Instruction: Based on the U=U concept discussed above, what would be key
messages to be communicated to clients on ART at health facilities? Discuss with
your colleagues or friends about key messages related to adherence, viral
suppression and HIV prevention.

• Key U=U message points in clinical care settings include (CDC U=U strategic toolkit):

14/05/2024 KPP friendly service training for Health Workers 213

 Cont..
Messages about medication adherence

• Take your HIV medicine every day as per the prescribed dose to stay healthy, live longer, and protect your
sex partners

• When you take your medicine as per the prescribed dose/every day, the amount of HIV in your blood will
become so low that you prevent the chance to pass HIV to people you have sex with

• HIV medicine works by decreasing the amount of HIV in your blood. After several months of taking your
medicine every day, the amount of HIV in your blood will become so low that a test can’t detect it. When
that happens, HIV in your blood is “undetectable.” The only way to keep your HIV undetectable is to
continue taking your medicine every day as per the prescribed dosage

14/05/2024 KPP friendly service training for Health Workers 214

 Cont..
Messages about how U=U prevents the sexual transmission of HIV
• Taking your HIV medicine helps protect your partners.
• Taking your medicine and having a low level (undetectable level) of HIV in your blood prevents the chance of
passing HIV through sex. But, it does not prevent you from passing HIV through sharing needles.
• U=U applies only to sexual transmission of HIV. It is not applicable to the continuum of mother to child
transmission.
• Having undetectable VL does not prevent pregnancy and will not stop your or your partner from getting a
sexually transmitted infection. Consider these other prevention options:
• Use condoms correctly and every time you have sex if you want to prevent STIs and pregnancy.
• Get tested and treated for STIs.
• Talk to your HIV-negative partner about the levels of HIV in your blood and how taking your medicine and keeping your
levels low can protect both of you.
• Before the levels of HIV in your blood are low, talk to your HIV-negative partner about daily medicine they can take to
prevent HIV called pre-exposure prophylaxis (PrEP).

14/05/2024 KPP friendly service training for Health Workers 215

 Cont…
Messages about U=U and other prevention considerations

• If you take your HIV medicine every day for several months, the HIV in your blood will become very low
and you will prevent the chance of passing HIV to your partner. When this happens, your HIV is
undetectable.

• Taking your HIV medicine will help you stay healthy and will prevent the chance of giving HIV to people
you have sex with. HIV medicine won’t protect you or your partners from STIs. Get tested for STIs and
encourage the people you have sex with to get tested too. If you have an STI, get treated for it right away.

14/05/2024 KPP friendly service training for Health Workers 216

 Cont..
Messages about viral load monitoring and staying undetectable
• Don’t miss any of your health care appointments, even if you don’t feel sick. During your appointments, your
doctor or nurse will run a test to make sure the amount of HIV in your blood is still low enough to prevent
the chance of passing HIV to people you have sex with.
• Take your medicine every day and have your viral load levels checked regularly to make sure your HIV stays
undetectable.
• Having undetectable HIV does not mean your HIV has been cured. You have to take your medicine every day
if you want your HIV load to stay undetectable.
• Getting and keeping an undetectable viral load is the best thing you can do to stay healthy and protect your
partners.
• If you stop taking your HIV medicine, the amount of HIV in your blood will increase quickly and your HIV will
not be undetectable anymore. When your HIV is not undetectable, your chance to pass HIV to people you
have sex with will increase.

14/05/2024 KPP friendly service training for Health Workers 217

 Potential Messages
• ለዕርስዎ ጤናማ ህይወት እና የወሲብ አጋርዎን ከኤች አይቪ ለመከላከል የፀረ
Medication ኤች አይቪ መድሀኒትዎን ሀኪም ባዘዘው መሰረት፣ በየቀኑ በተመሳሳይ ሰዓት
adherence ይውሰዱ ፡፡

• የወሲብ አጋርዎን ከኤችአይቪ ለመጠበቅ ከመጀመሪያው የቫይረስ መጠን

Viral load ምርመራ በኋላ ቢያንስ ለ ስድስት ወራት “የማይታይ” ሆኖ መቆየቱን ያረጋግጡ
monitoring ፡፡

Prevention of • ቫይረሱ በደምዎ ውስጥ ቢኖርም የፀረ ኤች አይቪ መድሀኒትዎን በአግባቡ

sexual ከወሰዱ እና የማይታይ መጠን ላይ ከደረሰ በግብረስጋ ግንኙነት ወደሌላ ሰው

የማስተላለፍ እድልዎ የተገታ ነው ፡፡
transmission
Note :

• UU is considered as one of the combination HIV prevention

pillars
• It provides an additional prevention intervention to be used
together with existing interventions (e.g. condoms, PrEP,….)
 Group activity (15minutes)

14/05/2024 KPP friendly service training for Health Workers 220

 9.3. Frequently asked questions about U=U

Below are some of FAQs people usually asks about U=U with responses.

1. What does "undetectable" mean?

2. What does "un-transmittable" mean?

3. What does negligible risk mean?

4. Is there evidence that an undetectable viral load eliminates transmission through

breastfeeding?

5. How long do I need to be on ART and be ‘undetectable’ in order not to transmit HIV?

6. If I am undetectable and there is a "blip" in my viral load, am I still un-transmittable?

14/05/2024 KPP friendly service training for Health Workers 221

 Chapter Summary
• HIV is a chronic incurable infection with rate of transmission correlating with the level
of viral load.
• Routine viral load testing is very important for monitoring the treatment response
• Addressing adherence barriers and misconceptions contribute to stigma reduction and
promote achievement of durable undetectable viral load.
• Durable undetectable viral load refers to a viral load less than or equal to 50 copies/ml
at least 6 months after the last undetectable result
• People with HIV who take HIV medicine as prescribed and get and keep an
undetectable viral load (or stay virally suppressed) have effectively no significant risk
of transmitting HIV to their HIV-negative sexual partners.
• It is necessary to clarify misunderstandings with regard to undetectable viral status.
• The framework of U=U offers a unique opportunity to dismantle HIV stigma and
discrimination, and reemphasizes the critical importance of ART, daily adherence, and
continuous engagement in medical care for PLHIV.
14/05/2024 KPP friendly service training for Health Workers 222
Chapter 10: Prevention of Gender-based violence/sexual violence and post-
violence care

Learning Objectives: By the end of the Module,

participants will be able to:
• Define key terms in gender-based violence.
• Explain the types and consequences of gender-based
violence.
• List the types of services to be provided for gender-
based violence survivors.
• Explain the different post violence care services, first-
line support and guiding principles.
14/05/2024 KPP friendly service training for Health Workers 223
 Think pair and share (15minutes)

Think Pair and Share (15minutes)

 What is Gender?
 What is the difference between Gender and
Sex?
 What is Gender- Based Violence

14/05/2024 KPP friendly service training for Health Workers 224

 10.1. Basics of gender-based violence/ sexual violence.

Gender Concept
• Gender
-is a social construct that defines the norms, roles and relations for
males and females in the process of socialization.
-It defines how men and women; girls and boys behave and act in a
given society.
• Sex
-is the biologic difference between men and women.
- On the other hand, sex is also a biological and physiological
constitution that determines the characteristics of either male or
female.
14/05/2024 KPP friendly service training for Health Workers 225
 Individual Exercise (10 minutes):
• Read the following statements and answer whether it is “gender” or “sex” in the spaces provided. You
have 3 minutes to complete the exercise. Your facilitator will then take you through the answers.
1. Women give birth to babies; men do not. ____________
2. The majority of surgeons in Ethiopia are men. ____________
3. Cardiac infarction is less common in females than men. ____________
4. Women are more affected by esophageal cancer than males. ____________
5. In SNNP men are engaged in weaving jobs in their house. ____________
6. Women are at increased risk of acquiring HIV than men. ____________
7. Many sexually abused women do not seek medical care. ____________
8. High cure rate of TB is marked among males and high incidence among women. ____________

14/05/2024 KPP friendly service training for Health Workers 226

 Definitions of Common Terminologies

• Gender norms: refer to a set of societal “rules” or

“regulations” (a form of socio-cultural regulations)
that encourage socially desirable behavior in the
way women and men “should” look, behave or act.
• Gender roles: is a social role. It is “a set of
expectations associated with the perception of
masculinity and femininity”. Social roles are always
closely related to the value system of the society
which forms them.
14/05/2024 KPP friendly service training for Health Workers 227
 Definitions of Common Terminologies cont.…

• Gender stereotypes: a gender stereotype is a very stable element in

consciousness, i.e. psychological and social mechanisms regulating
perception and evaluating certain phenomena, subsequently
influencing opinions, judgment, attitudes and behavior.
• Gender equity: the process of e.g. allocating resources, programs,
and the power of decision making fairly to both males and females
without any discrimination on the basis of sex, while at the same
time addressing any imbalances regarding the benefits available to
males and females in accordance to their needs.
-Gender equity thus also includes recognizing that women and men
have different needs.
14/05/2024 KPP friendly service training for Health Workers 228
Definitions of Common Terminologies cont.…

• Gender equality: refers to the equal rights, responsibilities

and opportunities of women and men and girls and boys.
• Gender empowerment: empowerment is a
multidimensional social process that enables people to gain
power and control over their lives.
-It involves awareness-raising, building self-confidence,
expansion of choices, increased access to and control over
resources, and actions to transform the structures and
institutions which reinforce and perpetuate gender
discrimination and inequality.
14/05/2024 KPP friendly service training for Health Workers 229
Definitions of Common Terminologies cont.…

Gender mainstreaming:
 the process of assessing the implications for women and men for
any planned action, including legislation, policies, or programs, in
any area and at all levels.
 It is a strategy for making women’s and men’s concerns and
experiences an integral dimension in the design, implementation,
monitoring and evaluation of policies and programs in all political,
economic, and societal spheres so that women and men benefit
equally, and inequality is not perpetuated.
 The goal is to achieve gender equality.

14/05/2024 KPP friendly service training for Health Workers 230

10.1.2. GBV and Types of Violence

Gender-based Violence
-There are various but similar definitions for gender-based violence.
• Gender-based violence includes all forms of violence involving women and men
in which the female is usually the victim. The term ‘gender-based’ is used to
highlight the need to understand violence within the context of women’s and
girl’s subordinate status in society. Such violence cannot be understood,
therefore, in isolation from the norms, social structure, and gender roles within
the community, which greatly influence women’s vulnerability to violence.
• Domestic violence is a term used with many meanings. The most common
usage is with reference to violence by the spouse or intimate partner. However,
the term is also used sometimes to describe violence within the family, where
the perpetrators are usually male members, as for example violence by the
father against the daughter, son against mother and so on.
14/05/2024 KPP friendly service training for Health Workers 231
 Cont.…
• Violence against women and girls is a term often used
synonymously with gender-based violence.
-However, the term does not make it clear whether or not the
violence is derived from unequal power relationships between
women and men in society.
- According to the UN, violence against women is “any act of gender-
based violence that results in or is likely to result in physical, sexual, or
psychological harm or suffering to women, including threats of such
acts, coercion or arbitrary deprivation of liberty, whether occurring in
public or private life.” (United Nations General Assembly, Declaration
on the Elimination of Violence Against Women, 1993).
14/05/2024 KPP friendly service training for Health Workers 232
 Cont..
Key terminologies of GBV
• GBV occurs in different forms and can range from subtle to blatant actions, which can even result in death of the
victim.
Survivors/Victims:
• “Survivor” and “victim” are terms that can be used interchangeably. Both refer to the subject or target of the incident.
“Victim” is used both for those who survived or died due to the exposed incident. However, when speaking in terms
of health, it is better to use the word “survivor” as it deals with the living.
Survivors/victims can include:
 Children, especially Unaccompanied Minors (UAMs), fostered children
 Women because they are usually considered second class and inferior
 Unaccompanied females, without male protection
 Single women, female headed households
 Mentally and/or physically disabled females and males
 Economically disempowered people
 Junior staff males and females, students, less privileged community members
 Minority groups: e.g., ethnic, religious
 Asylum seekers, refugees, displaced persons Perpetrators:
14/05/2024 KPP friendly service training for Health Workers 233
• A perpetrator is the doer or committer of the action(s). The perpetrator could be a person, group,
or institution that inflicts, supports, or condones violence or other forms of abuse against a person
or group of persons. The characteristics of perpetrators include:
 Persons with real or perceived power
 Persons in decision making positions
 Persons in authority
The list of categories of people who are potential perpetrators is long but most common are:
 Intimate partners (husbands, boyfriends)
 Influential community members (teachers, leaders, politicians)
 Security forces, soldiers, peacekeepers
 Humanitarian aid workers (international, national, refugee staff)
 Strangers
 Members of the community
 Relatives (brothers, uncles, parents, aunts, sisters, etc.)
 Anyone who is in a position of power
14/05/2024 KPP friendly service training for Health Workers 234
• For any incident of GBV/SV, there is a survivor and a perpetrator. Therefore, all our
actions in prevention and response need to address both the survivor and the
perpetrator.
Human Rights:
• Human rights are universal, inalienable, indivisible, interconnected and
interdependent.
• Everyone is entitled to all the rights and freedoms, without distinction of any kind,
such as race, color, sex, language, religion, political or other opinion, national or
social origin, property, birth or other status.
• Prevention of and response to gender-based violence is directly linked to the
protection of human rights.
• Acts of gender-based violence violate a number of human rights principles enshrined
in international human rights instruments.
14/05/2024 KPP friendly service training for Health Workers 235
 Types of Gender-based Violence

1. Physical violence
2. Sexual violence/abuse
3. Psychological/emotional violence/abuse and
neglect

14/05/2024 KPP friendly service training for Health Workers 236

 Group activity(20minutes)

Group Activity

Discuss: - what are the consequences of Gender-based

violence and the clinical response that should be provided
for GBV/SV

14/05/2024 KPP friendly service training for Health Workers 237

10.2. Consequences of Gender-based
Violence
GBV has complex consequences for adult and child victims:-
 Victims/survivors of GBV often have the tendency to blame
themselves (self-blame) and feel guilt or shame.
-They are stigmatized and blamed by family, friends and the
society.
 undermines the right, autonomy, security of the victims and
reinforces gender inequality in the society.
 Has an economic impact for the society.
 Health related consequences.
-It affects physical, mental and reproductive health.
14/05/2024 KPP friendly service training for Health Workers 238
 Health consequences of GBV

14/05/2024 KPP friendly service training for Health Workers 239

 10.3.Clinical Response and Management of GBV/SV

Frist Line Support.

• is a practical, survivor-centered, empathetic counseling approach.
• is the immediate care given to an index client who has experienced
violence upon their first contact with the health or criminal justice
system.
• First-line support provides practical care and responds to a survivor’s
needs, these often being the person’s emotional, physical, safety
and support needs, without intruding on her/his privacy.
• It has helped people who have been through various upsetting or
stressful events, including women subjected to violence.
14/05/2024 KPP friendly service training for Health Workers 240
 Cont...
LISTEN Listen to the survivor closely, with empathy, and without judging
her/him.
INQUIRY ABOUT Assess and respond to her/his various needs and concerns – emotional,
NEEDS AND physical, social and practical (e.g. childcare).
CONCERNS
VALIDATE Show her/him that you understand and believe her. Assure her that
she/he is not to blame.
ENHANCE SAFETY Discuss a plan to protect her-self from further harm if violence occurs
again.
SUPPORT Support her/him by helping her get information, including on services
and social support.
14/05/2024 KPP friendly service training for Health Workers 241
A. General Considerations
I. Priorities
II. The setting
-Well before interacting with the patient ensure the setting is organized to
accommodate the optimal standards of:
• Privacy: unauthorized people should not be able to view or hear any aspects
of the consultation. Hence, the examination room(s) should have walls and a
door, not merely curtains. Assailants must be kept separate from their victims.
• Adequate lightening: to clearly see and observe the patient. Medical supplies
and equipment.
III. Timing
IV. Ethical issues
14/05/2024 KPP friendly service training for Health Workers 242
• Codes of medical ethics are based on the principles
of doing “good” and “not doing harm”.
• It is a fundamental duty of all health workers to use
their professional skills in an ethical manner and
observe the laws of the land and norms of the
community. Adherence to ethical codes of conduct is
particularly relevant when dealing with survivors of
interpersonal violence who may have suffered abuse
from a person in a position of power.
14/05/2024 KPP friendly service training for Health Workers 243
When providing services to survivors of sexual violence, the following principles are
generally considered to be fundamental:
Autonomy
Beneficence
Non-maleficence
Justice or fairness: Doing and giving what is rightfully due. These principles
have practical implications for the manner in which services are provided, namely:
Awareness of the needs and wishes of the patient.
Displaying sensitivity and compassion.
Maintaining objectivity.
14/05/2024 KPP friendly service training for Health Workers 244
Clinical Care for GBV/SV Survivors

• The overall management of survivors of GBV/SV

requires addressing of the following issues:
physical injury,
Pregnancy,
STIs, HIV and Hepatitis B,
counseling and social support and
follow-up consultations.
14/05/2024 KPP friendly service training for Health Workers 245
 Reading(20minutes)

Read table 22:Follow-up visits’ activities

corresponding to the scheduled visits: PM # 147-
149

14/05/2024 KPP friendly service training for Health Workers 246

Basic Psychosocial Support: Counseling Survivors of Sexual Violence

• The response or psychosocial services mainly include psychological

counseling, socialization, skill training and income-generating
programs.
What does psychosocial mean?
• Psycho: The mind (unique feelings, emotions, thoughts,
understandings, attitudes and beliefs which an individual acquires)
• Social: Interpersonal relationships and what goes on in the natural
environment.
• “Psychosocial” can mean the dynamic relationship between social and
psychological experiences where the effects of one continuously
influences the other.
14/05/2024 KPP friendly service training for Health Workers 247
 Cont..
Social experiences that can lead to psychological Psychological experiences that can lead to social
problems include: problems include
- Loss of loved ones - Anger
- Sickness (of oneself and/or of one’s parents) - Helplessness
- Physical disability - Frustration
- Lack of basic needs (food, shelter, love etc.) - Mental illness
- Loss of social status - Lack of peace of mind, anxiety
- Domestic violence - Worries
- Suicidal thoughts

14/05/2024 KPP friendly service training for Health Workers 248

 Cont..
Psychosocial versus Emotional Support
• Psychosocial support is defined as: “providing
compassionate and ongoing psychological assistance for
survivors to heal their emotional pain and sufferings
from sexual abuse.”
• Emotional support is a “first aid” psychological
intervention for understanding the emotional
environment of the survivor and has a healing power for
the emotional wounds of child sexual abuse survivors.
14/05/2024 KPP friendly service training for Health Workers 249
Providing Referral Services to Survivors of GBV/SV

• Referral services are important to facilitate the access to different available specialized services (in
holistic approach of survivors) with the aim of recovery and re-integration of the GBV/SV survivors.
Referral Services
• Referral is a process of linking the patient to a higher, more specialized level of care (or vice versa) to
increase the patient’s well-being and healing process. A referral system is a mechanism that links clients
to a comprehensive institutional framework of multisectoral cooperation that connects various
governmental and non-governmental organizations with the overall aim of ensuring the protection and
support of survivors.
• When referring a case of GBV, all necessary principles of rights should be ensured. This includes
respecting the client’s wishes, protecting children’s best interest, ensuring clients’ safety and
confidentiality. If the survivor agrees to the recommended referrals, it is important to request for
informed consent before referring out to other facilities. Parental consent should be obtained in cases of
children except where it might put the child in danger or otherwise be against their best If referral is not
possible for specialized qualified services, schedule follow-up appointments and provide necessary
interventions until referral is possible. Always use a referral format form for referring out.
• As health care professionals are often the first point of contact for survivors, they provide an important
entry point for referrals.
14/05/2024 KPP friendly service training for Health Workers 250
Effective referrals require health care professionals to be:
• Able to identify and facilitate the disclosure of GBV/SV.
• Able to listen to the person’s problem; and, to ask only those questions
required to clarify what service they need (no unnecessary questions);
• Able to assess the situation and needs of the individual patient as well as
the risk of further violence.
• Able to give honest and complete information about available services.
• Knowledgeable about the existing referral system and services to be able
to support the patient in identifying the best options.
• Knowledgeable about national laws on GBV/SV and on the obtaining of
the patient’s consent before sharing her or his case with other
organizations.
14/05/2024 KPP friendly service training for Health Workers 251
Prevention of Sexual Violence among Key populations.

• Female sex workers (FSWs) are an often-marginalized population further

contributing to the unequal power differentials between clients and
FSWs that influence the occurrence of GBV. Sex work can in part be
sustained through structural inequalities in a society such as gender
imbalances, patriarchy, limited employment opportunities and social
autonomy.
• The International Labor Office classifies sex workers as a high-risk group
for experience of GBV by their clients, brothel owners and other
controllers, law enforcement officials, intimate partners, families,
neighbors, and other sex workers [8].
• The illegality of sex work in many countries further inhibits sex workers
ability to report GBV and negotiate safe sex with clients.
14/05/2024 KPP friendly service training for Health Workers 252
Key recommendations for preventing and
responding to violence against KPs.
• KP members on their rights, on what violence is, on the link between violence and HIV, and on violence
response services that are available
• Explicitly discuss gender norms and rights of KPs in community, health care, educational, and religious
settings
• Integrate and co-locate HIV and violence screening and response services
• Train individuals and institutions that already work with victims of intimate partner violence, which
usually target is women in the general population, so that they can also support KP victims
• Train health care providers and psychosocial support providers to ensure they understand who KPs are,
their specific vulnerabilities to violence and HIV, how to detect and respond appropriately to violence,
including providing or referring to post-exposure prophylaxis in cases of sexual violence
• Create a mechanism to report and monitor the quality of health services
• Sensitize the police on violence, HIV, and human rights protections in national level policies so they
understand that violence against KPs increases HIV risk and they are violating the human rights of KP
members when they mistreat or refuse to help them
• Set up crisis response systems to allow for immediate on-the-ground assistance, for example, a team of
peer educators and paralegals that can mobilize trained service providers who offer health,
psychosocial, and legal services.
14/05/2024 KPP friendly service training for Health Workers 253
 10.4. Monitoring and evaluation

• Monitoring and evaluation is essential to maintain or improve the quality of health system
interventions against GBV and to understand whether these interventions have achieved the
planned targets or goals. -
• Monitoring is the continuous assessment of achievements during the implementation process.
• Evaluation is a periodic, comprehensive and systematic review of an intervention, including its
design, implementation and results.
• Indicators are numerical measures, which provide information about a complex situation or event.
They are specific, observable and measurable characteristics that can be used to show the progress a
program is making towards achieving its outcome.
• Baseline refers to the prevalence of a disease, behavior or the quality of care before an intervention
or program is initiated. It provides a comparison against which progress or change can be measured.
• Standards express the minimum acceptable level of performance. Often informed by national or
international policies or legislation or benchmarked with performances in other areas with accepted
best practices.
• Targets express the specific level of change or performance the institution hopes to achieve in a
certain period of time.
14/05/2024 KPP friendly service training for Health Workers 254
 Cont..
What should be Monitored and Evaluated in Post-Violence Care?
• Total number of survivors seen during a certain time period (further
segregated by age and sex) Post-GBV/SV care Register
• Number of survivors tested for HIV during the initial visit Post-GBV/SV
care Register Number of survivors who tested positive for HIV Post
• Number of survivors who received PEP Post
• Number of survivors who completed PEP course
• Number of survivors who initially tested HIV negative but HIV positive at
12 weeks follow-up Post
• Number of female survivors receiving Emergency Contraceptive Pill
(ECP)
14/05/2024 KPP friendly service training for Health Workers 255
 Cont..
• Number of survivors who become pregnant despite ECP
• Number of survivors who return for the first follow-up visit
• Number of survivors who receive STI treatment
• Number of survivors referred to a psychiatric clinic for
psychological/emotional counseling and support
• Number of survivors referred to police for legal support Post
• Number of survivors referred to CSO for social support

14/05/2024 KPP friendly service training for Health Workers 256

 Chapter Summary
• GBV has complex consequences on adult and child victims
• GBV has an economic impact for the society
• First-line support is a practical, survivor-centered,
empathetic counseling approach which is immediate care
given to an index client who has experienced violence upon
their first contact with the health or criminal justice system.
• Return visits are very important to examine the progress
and address additional complaints that were not addressed
adequately in the first visit
14/05/2024 KPP friendly service training for Health Workers 257
14/05/2024 KPP friendly service training for Health Workers 258