PEER EDUCATORS TAKE LEAD IN DEEP ENGAGEMENT GRANT (DEG) IMPLEMENTATION
The LGBT (Lesbians, Gays, Bisexual and Transgender) are among the main drivers of HIV epidemic in Uganda and yet the political and socio-cultural situation in Uganda limits accessibility and utilization of health services among this minority group. The UNAIDS’ ambitious target of stopping AIDS by 2030 can only be a dream unless the country improves the health care situation of these marginalized group. The HIV prevalence among MSM is estimated at 12.7%, doubling that of the general population (Crane Survey 2017).
The AIDS Support Organization (TASO) is one of the DEG implementing partners offering comprehensive HIV care services to the MARPS. These services did not consider LGBTI community as a specialized group. TASO was a home to only those who were HIV positive and were registered to continue accessing services. The attitude of the service providers were then negative due to the cultural orientation and this scared many from coming out openly due to fears.
SCALED-UP INTERVENTIONS UNDER THE DEEP ENGAGEMENT GRANT (DEG) PROJECT
In 2018, the TASO received funding from Elton John Foundation through Community Health Alliance Uganda under the Deep Engagement Grant (DEG) project to scale up HIV prevention and treatment services to the LGBTI community.
Currently TASO through seven centers provides services both at facility and community based. The minimum service package includes; HIV Testing Services, STI screening and management, Reproductive Health Services, TB screening, psychosocial support, home visits and Sexual gender based violence (SGBV) screening and management.
DEG project relies mainly on the peer to peer approach to reach LGBT community members with HIV prevention and treatment services. In order to achieve the progress of DEG for TASO the role played by peer educators could not be underestimated.
Peer to peer approach has been proved as a strategy of mobilizing hidden population like the LGBT community for HIV services in a stigma friendly environment “nothing for us without us”. Therefore, DEG project works with peer educators to provide a number of HIV services to their fellow peers in the community for positive behavior change.
Role of peer educators
TASO identified peer educators (2-3 peer educators per Centre) who were trained by CHAU on basic HIV prevention and treatment services, mobilization and peer navigation strategy. Their main role is to mobilize fellow peer educators for HIV services at facility and community level.
Mapping out hotspots for HIV services
Peer educators have been able to map out and identify hotspots/safe spaces where LGBT members could freely access HIV prevention and treatment services. During these outreaches self-testing for HIV was integrated.
“I organize moonlight outreaches for the LGBT community members to access HIV testing services and other LGBT friendly services are offered.” Peer educator Mbale TASO.
“I don’t know how we would have implemented DEG project without peer educators; they have done a lot of credible work in identifying hotspots where moon light outreaches are conducted. They are able to identify and refer LBGT community members for services.” Health worker Mbale TASO.
Monitor ART adherence
Peer educators monitor ART adherence for the community members with HIV positive results and those enrolled into care and support them to take medication as instructed by the health workers.
“TASO trained us on issues of confidentiality and for the period we have worked with TASO on DEG project we have never had issues of leaking members’ HIV results to the community. Some members are free to disclosure their status with us for follow-up purposes and support.” Peer educator from Mbale.
“I have been able to follow-up on HIV positive community members to access services. I am HIV positive so there is no need for them to hide when it comes to issues of health. I encourage them to come to TASO and get services.” Peer educator TASO Gulu
Provide mentorship for fellow peers to conduct self-testing, the peer educators have been empowered with the step by step information on self-testing. Therefore, some peers who come for testing are given self-testing kits for their partners after mentorship from the peer educators. After self-testing the results are shared with the health worker through phone calls and follow-up is done accordingly.
Partner testing services using Assisted Partner Notification (APN) approach
In TASO Mbale, working with the specialized staff skilled in APN, the peer educators conduct alternative reverse of APN and once a community member has been identified as HIV positive since its usually a small community the peer educators share telephone contacts of that people’s sexual partners with TASO staff. The staff then professionally follows up on the partners without disclosing the source of information. As a result, these partners are provided with HTS and if discovered HIV positive linked into ART care.
“When a community member is identified as HIV positive then I organize and have their partners to get tested too. Since we are in a small community we know who is having an affair with who, so I get the telephone contacts of all their sexual partners and share them with the TASO health workers and it has worked” Peer educator TASO Mbale
ART adherence support groups
In TASO Mbale, the peer educators manage adherence support groups. TASO Mbale established adherence support groups where LGBT people living with HIV and those on PrEP receive adherence counseling and risk reduction counseling. In these groups members are also able to get treatment buddies who follow them up to ensure that they continue to adhere to ART.
“These groups have enabled our fellow peers to adhere to medication for now we don’t have any lost clients because the group meetings happen on the same days as their ART appointment days”. Peer educator TASO Mbale
Establishment of drop-in Centre
With support from Rakai Health Sciences program, TASO Masaka has been able to establish a drop in Centre in TASO Masaka where the LGBT members are able to discuss and access HIV prevention, care and treatment. The drop in Centre is equipped with TV set, decoder and some IEC materials and it is managed by a peer educator. In the drop in Centre LGBT members are offered non-discriminatory services. The peer educators provide health education and commodities to the members.
Figure 2: BCC specialist during an interview with peer educators of Masaka at the drop-in Centre
“When members come to the Centre, I am their first contact at TASO, I make them feel comfortable and later escort them to TASO main, for services of their choices.” Peer educator from TASO Masaka
“The drop in Centre has just been established but any client who goes through it is prioritized for HIV services without queuing” Health worker TASO Masaka
Distribution of commodities and IEC materials
Commodities like condoms, la wash and lubricants have been distributed by peer educators to fellow peers to reduce the risk for HIV transmission in the community. Peer educators have been empowered with commodities and IEC materials that they distribute to community members after education to reduce to risk of HIV transmission.
“TASO has provided us with condoms, lubricants and la wash that we distribute to the community members even after outreaches. Many members have accessed information on proper condom use unlike before. We can access lubricants which were rare before, la wash is sold expensively in pharmacies but we access it freely. Some members even come home to access these commodities.” Peer educator Ntugamo
“Despite the fact that I don’t earn salary from the work I do, am motivated to work because the community hates LGBT people, so I am there to help my fellow peers access information and services on HIV and other STIs. To stay safe” Peer educator TASO Ntugamo
Figure 1 BCC specialist during an interview with peer educator Ntugamo
“Most people think that LGBT members are lazy, money-minded or sex addicts, but as I work I want to change their mind set towards Kuchus. Being a peer educator gives me an opportunity to also talk to my fellow peers about work and different training opportunities, as I link them for health services.” Peer educator TASO Masaka
“My fellow peers selected me because I was responsible to be their leader and they listen and support me.” Peer educator from Jinja
“Some community members were identified as HIV positive during outreaches and were enrolled into care; they identified transport as a barrier to pick their medicines. I spoke to the health worker of Rubale H/C and he gave me drugs to take to them. I follow them up and they are adhering that motivates me to work even harder” Ivan peer educator from TASO Mbarara
“There were two HIV positive community members; one was lesbian another bi-sexual but due to double stigma they never wanted to enroll into care. I used my life experience to get them enrolled into care; I continued talking to them even after enrollment. Last week, they called to thank me for the support. I was glad I met them at that time.” Martha peer educator TASO Gulu.
- Turnover of some peer educators, in some TASO centers it was observed in many centers that the peer educators that where trained by CHAU had stopped working.
- LGBT members only get services when TASO does conduct outreaches in some places like Ntugamo. This is due to fear of the arrests and stigma which affects HIV testing services.
- Sometimes follow-up of clients is difficult due to lack of transport and airtime facilitation.
- Sometimes peer educators are mistaken for promoters of homosexuality instead of people who mobilize others for HIV services by community members.
- Peer educators do a lot of work although some is not recorded in the data collection tools
- Establishment of adherence support groups for only LGBT HIV positive members in all TASO centers as a way to increase retention into care. The support groups will also be an avenue to discuss health and non- health issues like stigma and discrimination.
- Orientation of peer educators on the data collection tools so that they are able to collect data on information and services provided to their fellow peer educators.
- TASO to work with the peer educators to address stigma and discrimination among LGBT HIV positive members.
- Peer-to-peer support increases demand creation for services, reduces stigma and discrimination among the LGBTI and in the community improving retention in care.
- Strong Partnerships help in mobilization and leverages on resources.
- The LGBTI are comfortable accessing services in a specialized clinic other than general clinics.
- Flexible health service hours favor mobile LGBTI.
The role played by peer educators in DEG project cannot be underestimated since they can reach their fellow peers more easily. Therefore, meaningful participation of peer educators is very instrumental in the project.