End Line Study: Opening doors to TG and MSM communities in the health care system in El Salvador

1. End Line Study: Opening doors to TG and MSM communities in the health care system in El Salvador Ana Cisneros Consultant amfAR – AspidhArcoiris 2013 - 2014

2. Context where the project took place The Ministry of Health has three normative bodies when providing services to LGTBI population: • Ministerial Agreement 202 of the Ministry of Health, in force since 2009 • Presidential Decree 56, which states "the prohibition of all forms of discrimination in the public service for reasons of identity / expression of gender and sexual orientation”. • “Care Protocols” mechanismscreated by the Ministry of Health in its National Health Policy 2009-2014, effective February 10, 2010.

3. The project had the following main components: • To improve knowledge and health service delivery to TG and MSM populations, in urban and rural areas. • To promote AspidhArcoiris leadership (TG organization) at the local level: community organizing, political advocacy, follow up on local/community capacity building

4. Main project’s approaches: • Sensitize and train health care professionals on sexual diversity, in order to change attitudes and discriminatory practices towards the LGTBI community, emphasis on TG and MSM. • Advocacy and follow up at different levels of the Ministry of Health for the implementation of Ministerial Agreement 202 of the Ministry of Health, in force since 2009; Presidential Decree 56, and care protocols

5. In addition,the project aimed at: • Lobbying community and municipal social networks and local movements to include in their agendas the Sexual and Reproductive Rights of the LGBTI people. • Generating empowerment for trans women leaders at the community level for the multiplication of knowledge and demands for intersectoral and interinstitutionalresponses.

6. Strategies used: • Pre-test and pos-test of medical professionals • Simulated patient • Handing out coupons to TG and MSM requiring medical attention and referral service • Train the trainer approach for medical personnel • Final assessment of learning with case studies of the medical personnel • Assessment of significant learning for AspidhArcoiris • Certification of Health Units as spaces free from stigma and discrimination • Community involvement and follow up • Public opinion follow up

7. Findings • Increased number of health professionals demanding additional training • Health professionals have started to share their knowledge with their peers, very important • Most health units and hospitals will be certified as institutions free from discrimination and stigma, which will require constant monitoring from Aspidh. The simulated patient exercise provided important insight to both, the health care system and Aspidh. • The health professionals were centered in the provision of services for the TG community, and not necessarily documenting the services provided to MSM patients.

8. Findings • There is underreporting of data for municipal and national levels, we found that the Statistics Unit of the Ministry of Health, does not record the number of cases of trans people and MSM on a disaggregated basis; all users are recorded without gender/sexual orientation distinction. • There might be a greater the number of visits from the LGBTI community, but no data was shown in official documents. • This a constant lack of planning by public institutions that greatly affect follow up and coordination with civil society organizations • Continued violation to the Health Ministry Decree 202 and Presidential Decree 56 against discrimination based on sexual orientation and gender identity and expression.

9. Findings • Hate crimes, poverty and lack of resources have limited Trans leadership to engage in further community processes. • On going training and involvement of local Trans leaders is a constant challenge to Aspidh’s programming efforts due to survival factors: poverty • Power in numbers when the LGTBI community acts together: ddespite Aspidh’s involvement in human rights struggles at the national and international level, their recognition by governmental officials and the media is still limited when acting in isolation.

10. Findings • TG population is highly vulnerable: high consumption of toxic substances; access to adequate food and permanent income; living in unsafe, high environmental risks areas. • Fundamentalist groups are continuously obstructing the sexual and reproductive rights struggles and promoting a misogynistic culture through the mainstream media, affecting both cisgender and trans women. • The municipalities where TG women do community work have been affected by a generalized context of social and hate violence, crime organizations and drug consumption, interrupting program delivery and full evaluation.

11. How this project could have been improved? • Organizational strengthening of the LGBTI movement and promotion of alliances at the municipal level are key to monitoring compliance with policies by government officials. • To enhance the access to health care, complementary projects need to be implemented, such as access to employment, education and training, access to housing, law reforms against discrimination, etc. • Projects need to take into consideration a percentage of youth involvement. Adolescent TG and LGBI populations have no access to services or prevention strategies, and seldom is not taken into consideration by civil society organizations.

12. Thank you

13. Community-basedparticipatoryresearch Eric Jovanni Castellanos Executive Director, C-NET+ Belize

14. CONTENTS • Name, target population, scope • definingresearchquestions • Implementation • Analysis • Dissemination • Results

15. INTERVENTION • HOME VISIT STRATEGY (amfAR)

16. WHAT IS IT? amfAR Home visitsstrategyfor MSM both HIV positive and negative. (local)

17. DEVELOPMENT amfAR Instrumentdeveloped and modifiedthroughconsultations with community, NGO and consultant.

18. IMPLEMENTATION amfAR Collection of data exclusively done bycommunity

19. ANALYSIS amfAR Analysiscompletely done bycommunity with guidance of consultant Knoweldgegainedbycommunity

20. DISSEMINATION amfAR Final reportsubmitted In process of presentationtocommunity, keypartners and general publicbymembers of community

21. CONCLUSIONS • COMMUNITY NEEDS TO BE INVOLVED IN ALL LEVELS FROM INCEPTION, IMPLEMENTATION, ANALYSIS AND DISSEMINATION, FAILURE TO DO SO RESULTS IN DEBATABLE RESULTS AND NON OWNERSHIP OF COMMUNITY

22. RESULTS

30. CONCLUSIONS • • During the time of the intervention, an increase in the resport of condom use in the last sexual encounter of 6% among HIV negative GMT and 10% among HIV positive GMT was achieved. • • An increase in adherence among HIV positive GMT who were in ART, of which only 3/10 reported not being adherent and at the end of the intervention they reported not missing or forgetting to take their ARVs during the last month.

31. CONCLUSIONS • • The sexual role is not conceived as a risk factor for HIV infection or re-infection, primarily for those that assume the roles of top and versatile. • • Although the reporting on the use of condoms in the last sexual encounter increased, this increase is not sustained in all the sexual encounters. • • Sexual relationships with multiple partners, increases the risk to acquire HIV (or re-infection), as well as an STI.

32. Eric Jovanni Castellanos Executive Director, C-NET+Belizecnet.belize@gmail.com+ 501 630 1900