Three NGOs, Youth for Health, Together Centre and Youth Support Centre, have been working for MSM and TG to promote HIV awareness, distribute condoms and lubricants, promote and deliver HIV testing and counseling services and work on LGBT human rights advocacy since the early 2000s. The three NGOs have agreed to work together closely in order to improve outcomes of their combined/joined HIV services.
This ultimately resulted in the development and agreement of a joint HIV Outreach Strategy with a new focus on finding undiagnosed cases of HIV, promoting HIV counseling and testing (HCT), case-management for newly diagnosed MSM and TG with HIV, and performance-based outreach. It is now hard to imagine that the team that works in their common office are, in fact, formally still from three different organisations!
Testing a new quality control tool for outreach- and HIV workers
As part of a UNAIDS project (funded by USAID), I assisted in the introduction of a common examination/test tool to be used for HIV service & outreach workers. The test is based on the newly-revised HIV Outreach and Service Workers Reference Manual, with questions linking to different units in the Manual, facilitating self-study. Nearly all Ulaanbaatar-based outreach workers took the test, and they scored 66 out of 100. Based on the gaps in their answers I could easily design a tailor-made training for them. The outreach workers had excellent knowledge about STIs, condoms and HIV testing, but they lacked information about risk reduction strategies for MSM that do not involve condom use, and also needed additional knowledge about the different HIV transmission probabilities in oral, vaginal, anal (insertive and receptive) sex. They were also given additional understanding in how treatment with ARV medicines reduces HIV transmission probabilities and on the concept of syndemics, and the need for referral systems between HIV services and other health- and social services.
Mid-term evaluation of the joint NGO's MSM and HIV project
For the Global Fund on AIDS, Tuberculosis and Malaria in Mongolia, I was hired right after my UNAIDS work to conduct the mid-term evaluation of the jointly-implemented HIV project of three Mongolian NGOs based on their new Outreach Strategy, the development of which I had led in 2015. It is rare for a consultant to have the opportunity to come back a year after providing technical assistance and to have a look at what actually happened since.
Most of the elements of the new strategy are being implemented with success. The concepts of performance-based outreach based on case finding were implemented to a degree; outreach workers were paid 25% more than before and were much more motivated to do their work. Outreach workers were much more 'professional', with new shirts, caps, better reporting- and quality control mechanisms. They were more diverse (in terms of age, background) and more knowledgable than before. HIV case management had been started for MSM living with HIV, but enrolment into case management for newly diagnosed cases was still problematic, as this remains a totally new approach in Mongolia. The three NGOs are the first to have translated the HIV Outreach Manual and put it to use; 4 different types of condoms and two types of lubricant are now available (used to be only one); a YouTube-based 'soap opera' portraying two handsome gay men in a 'normal' relationship was launched, and in the third episode they will do an HIV test at the NGO Community Clinic. This was based on an idea I borrowed from Dr. Steve Wignal at FHI 360 Indonesia, which found that a similar campaign over there resulted in more than double the number of MSM showing up for testing in their clinics for several weeks. The NGOs also planned to introduced different modalities for HIV testing, including community-based testing. Protocols have been developed and outreach workers have been trained in counseling skills and finger-prick testing, however, the Mongolian Ministry of Health and Sports has yet to approve this new policy.
Overall, the joint project was performing well; a few recommendations were made to strengthen their performance, the most important being the development of a strategic communications strategy.
How many MSM with HIV are there in Ulaanbaatar?
Since the identification of its first HIV case in 1992, Mongolia has had continued low prevalence of HIV. According to MOHS sources, as of May 2016, Mongolia had a cumulative number of 212 identified cases of HIV. Mongolian men who have sex with men and transgender people bear the brunt of these cases. The 2014 IBBS research found that 12% of MSM and TG in Ulaanbaatar were living with HIV, up from 7.5% during the first IBBS in 2011.
In 2015, a size-estimation exercise was done in Ulaanbaatar by the well-known expert Dr. Tobi Saidel. She estimated that there 1,745 MSM in Ulaanbaatar (range: 1,047-3,386). Since the 2014 IBBS had found that there was 12% HIV prevalence among the MSM and TG population, it could be deducted that there should be around 210 MSM living with HIV in Ulaanbaatar. According to sources at MOH, it was known in May 2015 that 65 MSM/TG were diagnosed already in Ulaanbaatar; most of them were already on antiretroviral treatment (ART). This would mean that 145 Ulaanbaatar-based MSM/TG remain undiagnosed.
This became the ‘mantra’ of the new outreach strategy of the three NGOs: To work towards finding these 145 undiagnosed MSM and help them access life-saving HIV treatment, whereas at the same time contributing to a reduced viral load in the MSM community, slowing down and ultimately halting HIV transmission.
Since the strategy was adopted in May 2015, hundreds of Mongolian MSM have been tested for HIV. However, only 5 new positive cases were found for a sero-positivity level between 1 and 2 percent. This is much lower than could be expected if the prevalence figure of 12% were true.
Two hypotheses are put forward to explain this. Some people are now saying that the 'real' prevalence is probably much lower than 12% - possibly between 6 and 8%. The 12% prevalence figure may be flawed. The IBBS 2014 study may have had some methodological flaws, leading to bias and an over-estimation of HIV prevalence. One peculiar finding which suggests bias, for example, was that around 35% of the sample in the study had male-to-male sex for the first time with a foreigner! This indicates that the participants in the IBBS survey may have been of a higher socioeconomic standard, and they may have been in contact with foreign (higher-risk and higher-prevalence) networks of risk.
The second hypothesis is that outreach workers are currently not reaching and not referring to testing those MSM that are at the highest risk for HIV. They may simply be unable to reach them, or be unable to convince/motivate those at highest risk to get tested. Whereas over 400 MSM have been tested in the past 18 months, more than 1000 who were reached by outreach workers have not tested. Who and where are they? There is a need to design more clever and innovative outreach strategies in order to reach more MSM who may be living with HIV without knowing it. If the Ministry finally approves community-based testing, this could help--although in some countries, like Cambodia, the number of new HIV cases found after the introduction of community-based testing has been rather disappointing.
As usual when there are two hypothesis pointing to totally different explanations, the truth is probably somewhere in the middle. This means that yes, the IBBS may have estimated the HIV prevalence too high, but perhaps only by a few percentage points. There is no way to know for sure except by doing a solid, high quality new IBBS -- which I think it not in the planning. And concerning the second hypothesis: Yes, the outreach workers may need to move out of their comfort zone more, and access new networks of risk, via the internet and possibly at new locations in Ulaanbaatar.