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Supporting High-Quality Services at

Scale for Female Sex Workers in
Ethiopia
Tamrat Assefa
ICAP Ethiopia
Session 13c | Thursday, 12th December 2024

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Outline

• Background
• Overall program strategy
• Pilot and scale up of services for female sex workers (FSWs)
• Integration of clinical services
• Planning services for people who inject drugs (PWID)
• Lessons learned

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 National HIV Epidemic
Estimated PLHIV all ages* PLHIV who know their status*
605,238 90%

PLHIV who know their status on

HIV prevalence* ART**
0.87% 96%

New HIV infections* PLHIV on ART with VL

suppression***
96%
7,428
4,909 2,519
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa *EPHI June 2024, ** DHIS 2, *** EPHI VL Report
 Context of Key Population Program in Ethiopia

• The HIV epidemic in Ethiopia is mixed, with substantial regional

variations, concentrated in urban areas and in some geographic
hotspots driven by key and priority populations.
• FSWs are a major key population (KP) group in Ethiopia.
• In 2020, it was estimated that there were 210,000 FSWs and
they have an estimated HIV prevalence of 18.7%.
• Comprehensive, high-quality HIV programming for FSW is
therefore critical to the HIV response in Ethiopia.

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Overview of Ethiopia’s KP Program for FSW

• The KP program is led by MoH and uses a combination HIV prevention

approach (biomedical, behavioral and structural)
• The MoH provides strategic direction, sets standards, provides technical
support and coordination, evidence, mobilization of resources and supports
an enabling environment.
• The MoH ensures effective and efficient implementation of the KP program
through implementing partners and coordination at country level.
• Currently, the FSW KP program is in all 14 regions of the country, with
funding from MoH, PEPFAR, Global Fund and other donors.
• MoH has prioritized HIV prevention and treatment efforts by geography and
population to address key programmatic gaps and reach epidemic control.
• Of the 1,076 woredas (districts), 265 woredas are considered to have
a high HIV incidence ( ≥0.03%) and have been prioritized.

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Building Blocks of Ethiopia’s KP Program for FSW - 1

1. Establishing a • National KP program launched in 2018

• National Technical Working Group (TWG)
coordination structure for • National Task Force
startup of KP services • Regional TWGs

• FSW have been prioritized in the HIV National Strategic

Plan since 2018
2. Developed policy for the
• Standard operating procedures (SOPs) and guidelines
KP program developed
• HIV prevention roadmap developed

• Geographic mapping in priority towns

3. Mapping and KP • Size estimate of FSWs
population size estimate • Helped to identify “where” and “how many”, as well as
for setting targets and guidance for scale up.

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Building Blocks of Ethiopia’s KP Program for FSW - 2

• Community outreach is prioritized with Peer Navigators (PNs)

• Outreach services include information and education,
4. Community outreach distribution of condoms and HIVST kits, and referral to KP-
with Peer Navigators friendly clinics.
• Outreach plays a critical role in mobilizing FSW to access
clinical services and follow-up

• SOP developed on how to establish a DIC

5. Establishing Drop-in- • SOP describes the difference between public KP-friendly
clinics and DICs
Centers (DIC) • The DICs are intended for relaxing, socializing, and providing
a safe space.

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Building Blocks of Ethiopia’s KP Program for FSW - 3
• Established KPFCs at public health facilities (HFs)
• Different models of clinics: standalone, integrated or
6. Optimizing clinical outreach clinical services
services at public KP- • KP minimum package developed
friendly clinics (KPFCs) • Comprehensive services: HIV testing, STI, PrEP, SRH,
condoms, ART, and other special services
• PNs recruited and deployed

• Critical aspect of the KP program

• Reporting using the national DHIS system and DATIM
7. Capacity building and
• Analysis and presentation of the data
monitoring performance • Training for specific cadre
• Training of Trainers (TOTs) and certifications

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 KPFCs Establishment and Expansion

• MoH, in collaboration with CDC and ICAP, piloted KP-friendly clinical

services in 28 public HFs in 20 priority towns from 10 regions in 2018.
• Initial HF assessments were conducted to identify barriers to
implementation of KP-friendly services and the most appropriate site for KP
service implementation at the HF. Assessments evaluated accessibility,
acceptability, affordability, and appropriateness.
• The goal was to reach FSWs and their network members using a
differentiated HTS approach, with linkage to HIV prevention and treatment
services.
• At all KPFCs pilot sites MoH, ICAP, CDC and regional health authorities
participated in joint supportive supervision visits and reviewed the findings.
• In 2019, MoH evaluated the pilot results, conducted a review meeting, and
reached the consensus to scale up the KP program for FSW.
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Flow Chart for KP-Friendly Clinic Services
Clients Waiting Area ART Clinic
Medical
♦Education OPD ♦Referral & linkage to HIV care & treatment
FSWs HIV -ve ♦Group Counselling ♦Enrolment into HIV care & treatment
♦Retesting every 6 months ♦ART initiation & follow-up
♦Post-test counselling services ♦PMTCT & Mothers’ Support Group program
♦Referral & linkage to HIV -ve FSW KPFCS UNIT / VCT ♦Referral & linkage to HIV +ve FSW support groups
support groups ♦Family testing for HIV
♦Risk reduction counselling ♦Psychosocial support
♦PrEP services ♦Risk reduction counselling
FSWs FSWs ♦STI management, with partner notification
♦STI management
HIV -ve HIV +ve ♦TB screening, diagnosis & management
♦FP Services
♦GBV Services ♦Provision of TPT
♦PEP for SGBV ♦FP services
♦Peer education individual or group Laboratory Room ♦GBV services
♦Condom provision ♦Lab services ♦Peer education through PNs
♦IEC/BCC materials provision ♦Provision of male condoms
Pharmacy Room
♦Referral for support services for FSWs ♦Provision of IEC / BCC materials
♦Pharmacy services ♦Referral to support service for FSWs (CBOs, FBOs)

Outreach Services Community KP HTS Sites Referral Services

♦Peer education and counselling ♦Catchment area KP HTS sites ♦Medical Services
♦Referral services for FSWs from
♦Legal Services
outreach sites ♦Social Services
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 KP Service Scale Up in Ethiopia
• MoH supported the progressive scale
up of KPFC from the 28 pilot sites in 10
regions to 139 sites across all 14 regions
by the end of FY24
• MoH, in collaboration with ICAP,
provided training to scale-up sites and
more than 1,800 KP providers have
been trained
Scale up of KPFCs in Public HFs in Ethiopia
139

28 2018
2024
Distribution of KPFCs
# of KPFCs

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Efforts to Improve Quality: KP Quality Score Card

• The KP Quality Score Card (KP-QSC)

is a two-way and ongoing,
participatory, quality improvement
tool used for assessment, planning,
monitoring and evaluation of KP
health services program.
• It brings together the “service
user” or community member and
“service provider” to jointly
analyze issues underlying service
delivery problems and find a
common and shared way of
addressing those issues.
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Efforts to Improve Quality: KP Quality Score Card
The implementation of the KP-QSC significantly enhanced KP services
through a structured and participatory approach:
• Identified program areas for evaluation, and a comprehensive
assessment of KP services.
• Community Involvement: Engaged community members by
identifying participants from the community.
• Stakeholder Engagement: Conducted meetings and focus group KP QSC
discussions with participants, client counsels and relevant bodies, 1= 5=
Indicators Very 2 3 = 4= Very
facilitating open communication, feedback and the implementation low Low Ok Good good
of action plans. Compassionate
1 and respectful
• Service User-Facility Interface: Organized interface meetings and care
discussions between service users and facilities, promoting
Availability of
transparency and responsiveness. 2 comprehensive
• Feedback and Dialogue: Held feedback and dialogue sessions to services
present findings to all relevant bodies, leading to the development of Acceptability
targeted quality improvement plans. 3 and Quality of
KP Services
• Implementation of Community Scorecard: Rolled out in 2020 and
4 Affordability
now being conducted regularly in 63 KPFCs.
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 KPFC Results in Ethiopia
Cascade of HIV Prevention, Care, and Treatment Services for Key Populations
DATIM (FY22-FY24)
98%
115,281 5,078 4976
107,589

Prevention

1,738
Care and treatment

1829

KP Known HIV Initiated Currently on Suppressed

HIV+
reached status on ART ART viral load
Engage KPs in prevention, including access to condoms, and Earliest access and adherence to ART for KPs upon HIV
counseling support. Regular STI screening & treatment, HTS, diagnosis, in support of treatment as prevention, and
and PrEP for HIV-negative KPs. regular STI screening and treatment
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Clinical Service Integration Into KP Clinics

Key Services Integrated • Integration of services at KPFCs has been designed

TB preventive therapy (TPT) is to ensure accessible, comprehensive, holistic and
integrated into care services to stigma-free care for FSWs diagnosed with HIV.
prevent TB among FSWs living with • All national standards of care for PLHIV, including
HIV, addressing co-infection risk. TPT, CxCa, and MHI services are integrated.
• One-stop-shop services are provided at 63 KPFCs
Regular cervical cancer (CxCa)
screening is provided to detect and
In 2024, MoH with ICAP provided:
treat cervical precancer cancer early.
• Orientation on CxCa, TB and MHI to 232 healthcare
Mental health services are providers.
integrated (MHI) to address • Revised KP M&E tools to incorporate TB, CxCa, and
psychological well-being of FSWs, MHI services.
providing support for mental health • Developed separate a data collection tool (Kobo
issues. collect).
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Integrating CxCa Screening and Management Into KPFCs

FSW Living with HIV CxCa Cascade

1678
August - September 2024 (18 HFs)

14% 60% 52%

96% 2.8% 50%
235 142 74 71 2 1 1

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa Reports using KoBo tool
 TB/HIV Service Integration Into KPFCs

TB Cascade for FSW Living with HIV

40 HF in September 2024
92.8%
690
640
586

31%
2.8%
199
5.6% 100%

18 1 1

HIV+ FSW Screened for TB Presumptive TB Confirmed TB Linked to TB unit Screened Initiated TPT
cases negative for TB

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa Reports using KoBo tool
 Looking Ahead: Establishing Services for PWID

• HIV BBS among PWID in selected towns Ethiopia has started

of Ethiopia was conducted in 2024. preparatory activities to
• HIV prevalence of 3.6% among PWIDs introduce PWID services as a
pilot site demonstration
• The most common drugs used by
PWIDs in Ethiopia included heroin,
cocaine, and pethidine.
• There were co-infections with HIV,
syphilis and viral hepatitis
• Highest percentage of drug use was in
those between 18-24 years old. A team from MoH, Addis Abeba RHB, CDC, ICAP
conducted a site visit in Tanzania on the MAT services

CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Establishing Services for PWID
• Pilot implementation at a site in
Key Package of Services for PWIDs
Addis Abeba.
• Guidelines for PWID are under Targeted
HIV, TB, STI & viral
Condom hepatitis
development, including biomedical, information,
promotion and prevention,
education and
social and behavioral interventions. communication
distribution diagnosis &
treatment
• MAT guidelines
• Integrated clinical services for Prevention for
vertical
PWIDs Opioid substitution
PrEP for HIV transmission of
therapy
• There will be demand creation HIV, syphilis and
HBV
activities by community partners and
clinical services will be delivered at
the HF using the key package of Mental health
Prevention and
managing
services for PWIDs adapted from the interventions
overdose
World Health Organization.
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Lessons Learned

• The KP Community Score Card establishes a feedback mechanism between

users and providers, ensures informed decision-making and dialogue
between providers and users, tracks if services and programs are
progressing well and strengthens community empowerment
• Prioritization of high-burden areas is critical: Focusing resources on high
HIV incidence districts allowed targeted and effective interventions,
maximizing the program’s impact.
• Integrated services and offering multiple health services under one roof,
helps to ensure FSWs can access comprehensive, holistic care conveniently
and address stigma-related barriers.
• Combination approaches are key: The FSW program combined biomedical
(HIV treatment, STI management, PrEP), behavioral (counseling, prevention
education), and structural interventions (enabling environment), addressing
the multifaceted vulnerabilities of FSWs.
CQUIN 8th Annual Meeting | December 9-13, 2024 – Johannesburg, South Africa
 Acknowledgment

Clients and
providers
REGIONAL
HEALTH BUREAUS

Health facility
leadership and
their management 21
 [Link]

Thank You!