KEY POPULATIONS MANUAL

FOR HEALTHCARE PROVIDERS

First edition
JUNE 2018
KEY POPULATIONS MANUAL
FOR HEALTHCARE PROVIDERS
First edition
JUNE 2018

ISBN: 978-0-7974-9491-6
Ministry of Health & Child Care

Kaguvi Building, 4th Street & Central Avenue, Harare

P.O. Box CY 1122, Causeway Harare

Tel: +263-24-2798 537-60 | Fax: +263-24-2729 154/ 2793 634

E-mail: [email protected]

Website: www.mohcw.gov.zw

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FOREWORD

Z
imbabwe continues to bear one of the highest global burdens of a broadly generalised
HIV epidemic, with HIV prevalence among adults aged 15–49 estimated at 14% (ZDHS
2015). While prevention of mother-to-child transmission has improved immensely over
the last few years, the impact of HIV infection on certain key populations (KP) has continued to
rise. For these populations, vulnerability and high risk converge. For the purposes of this Training
Manual, key populations are defined as: male and female sex workers (SWs); men who have sex
with men, including men in prisons and in other closed settings (MSM); people who use and/or
inject drugs, (PWUD, PWID); transgender and intersex people (TI). The extended National Multi
Sectoral Strategic Framework (2014–2018) was cognisant of the higher levels of mortality and/or
morbidity in these groups and of their low and limited access to and uptake of relevant services.

For this reason, Zimbabwe can no longer ignore the impact of negative social and cultural attitudes towards these
groups, which leave them out of HIV prevention messaging while discouraging them from accessing health services,
HIV testing, care and treatment. Much of this is a result of stigmatising attitudes among service providers, who until
now, have not been given sufficient information and awareness-raising of the needs of these key populations, which
includes: male and female sex workers (SWs); men who have sex with men, including men in prisons and in other
closed settings (MSM); people who use and/or inject drugs, (PWUD, PWID); transgender and intersex people (TI).

While globally these groups are often referred to as key populations, signalling them out in this way can also
further isolate and stigmatise. There is a strong link between marginalisation, stigmatisation and discrimination
and heightened risk of HIV, depending on the extent to which such people find themselves outside their social
context and norms. These populations are therefore key to finding solutions to each country’s epidemic, based
on their epidemiological and social context and their active engagement and involvement is key to the success
of the HIV response.

This training programme seeks to remove the barriers to engaging key populations in the continuum of care
by raising awareness among service providers of their own often unintended biases towards these groups, and
improving their understanding of the specific care and prevention needs of these populations in order to provide
better quality of care and retention within the continuum of care. Accordingly, the MoHCC, through the Zimbabwe
National AIDS Programme and in collaboration with other partners, has developed this service providers training
programme to contribute to Zimbabwe’s goal of reducing the spread of HIV and halting new HIV infections.

Equipping our service providers with appropriate knowledge and skills will not only improve access to and uptake
of services for these groups but ensure standardised levels of care and healthcare training across the country.

Major General G Gwinji, (retired)

Permanent Secretary, MoHCC.
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CONTENTS

ACKNOWLEDGMENTS............................................................................................................................................ 7

ABBREVIATIONS AND ACRONYMS..................................................................................................................... 8

OVERVIEW OF THE KP TRAINING PROGRAMME............................................................................................ 9

What are the guiding principles of this training?..........................................................................10

BEFORE YOU BEGIN TRAINING...........................................................................................................................11

Suggested Training Schedule/ Programme.....................................................................................12

MODULE ONE: Understanding Key Populations........................................................................13

MODULE TWO: Sexuality and Health............................................................................................17

MODULE THREE: Barriers to Health................................................................................................33

MODULE FOUR: Creating a Friendlier Environment................................................................35

MODULE FIVE: Interventions for Improving HIV and STI Prevention for
Zimbabwe’s Key Populations.............................................................................................................39

MODULE SIX: Promoting Mental Health.......................................................................................49

MODULE SEVEN: Taking a Sexual History....................................................................................55

MODULE EIGHT: Clinical Care for HIV and STIs...........................................................................61

MODULE NINE: Supporting the Needs of Members of Zimbabwe’s

Key Populations Who Use Drugs and Alcohol..............................................................................71

MODULE TEN: Action Planning........................................................................................................79

REFERENCES AND OTHER RESOURCES...........................................................................................................82

NOTES.........................................................................................................................................................................84

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ACKNOWLEDGMENTS

The Ministry of Health and Child Care (MoHCC) would like to thank PEPFAR, USAID, CDC and PSI as well
as I-TECH for their financial support during the production of this Trainers Guide.
The production of the training programme was greatly enhanced by the participation of Key Populations
(KP), members of the Technical Working Group including organisations and individuals, people living with
HIV (PLHIV), healthcare providers, bilateral and multilateral development partners, non-governmental
organisations, implementing partners, civil society and faith-based organisations, through a series of
national consultations led and facilitated by the MoHCC.
In addition, the Ministry acknowledges the coordinating team that provided leadership oversight
throughout the process of adaptation and finalisation of the training programme.
Getrude Ncube - National-HIV Prevention Coordinator, Taurai Bhatasara, DREAMS and Key Populations
Coordinator, MoHCC, Roy Dhlamini, PSI, Phibion Manyanga, Clinical Advisor, I-TECH.

Without their commitment, tireless efforts, valuable information and guidance, the document would
not be as technically strong as it is. We salute the support from the following KP TWG members:

Dr Albert Mulingwa MoHCC Sarah Musungwa UNDP

Samuel Matsikure GALZ Definate Nhamo PANGEA
Natalie Kruse-Levy USAID Ricardo Bako PANGEA
Samson Chidiya USAID Dr Joseph Murungu PANGEA
Funmi Adesanya PEPFAR Imelda Mahaka PANGEA
Tendayi Mharadze CESHHAR Tinashe Sande TIRZ
Stephano Gudukeya PSI Gumisayi Bhonzo Transmart
Carey Johnson PSI Wilson Box Zimbabwe Civil
Dr Ngonidzashe Madidi PSI Liberties and
Jeremiah Manyika NAC Drug Network
Tendai Mhaka NAC Norlex Chabata Hands of Hope
Victor Makaza NAC Adolf Mavheneke SAfAIDS
Masimba Nyamucheta NAC Lloyd Dembure SAfAIDS
Steady Mapfumo UNFPA Deloune Comfort Matongo AVAC Fellow
Jane Batte UNAIDS

Publications and Documentation Team was tasked with developing these materials with thanks to
Katrina Wallace-Karenga, Vivienne Kernohan and Victor Mabenge.
We thank all individuals and organisations who contributed positively in one way or the other towards
this project. The MoHCC assures everyone involved that your contribution will go a long way in
strengthening the nations efforts to achieve an AIDS-free Zimbabwe by 2030.

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ABBREVIATIONS AND ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
ART Antiretroviral therapy/ treatment
ARVs Antiretrovirals
CHTC Couples-Based HIV Testing And Counselling
DSM Diagnostic and Statistical Manual of Mental Disorders
HIV Human Immunodeficiency Virus
HPV Human Papilloma Virus
HSV Herpes Simplex Virus
HTC HIV Testing and Counselling
KPs Key Populations
LGBT Lesbian, Gay, Bisexual, And Transgender
LGBTIQ Lesbian, Gay, Bisexual, Transgender, Intersex and Queer
LGV Lymphogranuloma Venereum
MDR-TB Multi-drug Resistant TB
MSM Men Who Have Sex With Men
MSW Male Sex Worker
PEP Post-Exposure Prophylaxis
PID Pelvic Inflammatory Disease
PLHIV Person/ People Living with HIV
PrEP Pre-Exposure Prophylaxis
PWID People Who Inject Drugs
PWUD People Who Use Drugs
STI Sexually Transmitted Infection
SW Sex Worker
TasP Treatment as Prevention
UNAIDS United Nations Joint programme on HIV and AIDS
WHO World Health Organization
XDR-TB Extremely Drug Resistant TB

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OVERVIEW OF THE KP TRAINING PROGRAMME
This training programme has been developed to sensitise and train healthcare providers (including
all staff and other personnel who work at healthcare sites) on the healthcare needs of populations at
high risk of HIV in Zimbabwe. Its emphasis is particularly on how to meet those needs in a friendly,
non-judgmental and non-discriminatory way. The training has been designed to be completed in four
days, with half a day dedicated to a site visit to an already functioning KP friendly clinic setting. The
Zimbabwe Constitution Amendment (No. 20) ACT 2013 (under Chapter 2 Section 29 and Chapter 4
Section 76) guarantees the right of every Zimbabwean citizen and resident to access healthcare,
including reproductive healthcare and not to be turned away from any facility; furthermore, Chapter
4, Section 56 recognises the equality of all persons under law and their right not to be treated in an
unfairly discriminatory manner ... regardless of nationality, race, colour, tribe, place of birth, ethnic or
social origin, language, class, religious belief, political affiliation, opinion, custom, culture, sex, gender,
marital status, age, pregnancy, disability or economic or social status. This is particularly important for
those populations marginalised from mainstream society, such as male and female sex workers and men
who have sex with men, including men in prisons and other closed settings (MSM); and people who
use and/or inject drugs, (PWUD, PWID), referred to here as ‘key populations’. We should remember the
impact of our broader society and attitudes in increasing the vulnerability of key population members
to HIV infection.
Research conducted in Zimbabwe in 2017, by the MoHCC, indicated significant stigma and discrimination
experienced by sex workers and drug users (including injecting drug users) as well as people who
identify as gay, lesbian, transgender and intersex at our public health facilities. All these groups are at
elevated risk for HIV infection and other sexually transmitted infections (STIs). However, stigma and
discrimination also risk their being excluded from the continuum of HIV prevention, treatment and care.

What is the goal of the training?

The goal of this training is to educate and equip everyone working at Zimbabwe’s public health facilities
with the knowledge and skills to enable them to provide health services that support and adequately
cater for the unique healthcare needs of those at greatest risk of HIV. Leaving no-one behind is critical if
Zimbabwe is to meet its commitment to an AIDS-free society by 2030. The training programme has been
produced by the MoHCC, in partnership with PSI and I-TECH Zimbabwe. The content has been adapted
from a number of sources, building on the hard work of many individuals, groups, organisations and
government facilities. Much of the content and process of this training has already been tried and tested
at local facilities. This training programme thus provides a standardised means to ensure that lessons
from all past and ongoing efforts are mainstreamed within both our public health facilities and their
critical linkages and partners.

Who is the training for?

In addition to the medical, administrative and other staff (including full-time, part-time and voluntary
staff ) working at public health facilities who will be trained through this programme, it can also serve as
a reference for anyone who is tasked with making policies, managing programmes or in the provision of
health related services in the country.

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Healthcare providers are ethically obliged to provide services without discrimination. No consumer/
client should be seen as worthy or unworthy, and no one should be excluded from compassion and care.
De-coupling personal moral beliefs from core service provision tasks is paramount and is embedded
within the MoHCC Patients Charter. The medical and scientific imperatives are clear – for those at high
risk for HIV infection the denial of appropriate services can be literally life threatening.

What are the guiding principles of this training?

The principles guiding the training and delivery of health and related services to highly vulnerable
groups and key population members are as follows:
1. The human rights of all the people of Zimbabwe must be protected, including the right to
access quality healthcare free from discrimination.
2. Access to justice is particularly important for those individuals and key populations
who face undue discrimination in society and must be upheld by our law makers and
enforcement agents.
3. Interventions to reduce the burden of HIV and STIs among vulnerable individuals and key
population members must be respectful and acceptable to recipients as well as appropriate
and affordable.
4. Groups at high risk of HIV require accurate health and treatment information to enable their
decision-making.
5. Integrated service provision is essential to meet the multiple co-morbidities, including
mental health problems and poor social situations, experienced by those at high risk of HIV.

What are the 10 modules?

The ten modules are listed below. The introductory modules are designed to familiarise participants with
important terminology and with the legal, policy and practice environment in Zimbabwe that protects,
promotes or hinders access to health services for all; as well as providing a broad understanding of why
vulnerable individuals and key population members are at high risk of HIV and why it is important to
reduce their risk and the critical role service providers play in reducing that risk.
The remaining modules focus on critical service provision approaches and tools and wrap up with
a site visit and planning towards implementing the training at individual facilities. Each module is a
combination of knowledge sessions, presentations and videos, value exploration through activities and
discussion, as well as the critical testimony of key population members themselves.
Key Populations Training Manual: Module Titles
1. Understanding Key Populations
2. Sexuality and Health
3. Barriers to Health
4. Creating a Friendlier Environment
5. Promoting Mental Health

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6. Taking a Sexual History
7. Clinical Care for HIV and STIs
8. Supporting the Needs of Members of Zimbabwe’s Key Populations Who Use Drugs and Alcohol
9. Interventions for Improving HIV and STI Prevention for Zimbabwe’s Key Populations
10. Action Planning

Accompanying Materials
In addition to the training manual’s main content and guidance there is a power point presentation
and video links to use in the module sessions as needed.
Each participant will also receive a Participant Handbook that will be referred to throughout the
training and should thus be provided to each participant as training begins.
In addition, a reference-friendly job aid is available to support KP consultations.

BEFORE YOU BEGIN TRAINING

Working with adults

This training programme is specifically made with an audience of adult healthcare providers in mind.
The training will also include non-medical staff such as security guards, volunteers working with young
people or people living with HIV, as well as other administrative staff. As a facilitator, it is important to
act in a manner that is appropriate for your audience. Adults are autonomous, capable, and self-directed
learners and need to be treated as such. Be sure to guide their learning instead of simply lecturing.

Talking about sex and sexuality

The nature of this training expects you as the facilitator to be well prepared to talk about potentially
sensitive topics such as sexual health, non-heterosexual identities and specifically, the needs of sex
workers, drug users and other key populations such as gays, lesbians and transgender people. It is
important to provide at the minimum, a neutral tone and ideally, a culturally competent, supportive tone.

A constantly evolving learning environment

Adapt your facilitation techniques to the different needs that may arise during your workshop. If
participants are reluctant to speak out, use more small group work to encourage discussion. If plenary
discussions are dominated by only a few voices try working in pairs or in small buzz groups, or even ask
participants to write down their thoughts and share.

Know your audience

Next, you should know your audience. Is everyone a healthcare provider, or do you have a mix of
administrative and other staff in the training as well? What language suits all? Ask for a participants list
with job titles and include introductions and ice-breakers that help share who the participants are, both
at and outside of the workplace. It is important that you take these factors into consideration.

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Suggested Training Schedule/ Programme

DATE TIME SESSION TITLE

DAY 1

08.30 – 09.00 ARRIVALS & REGISTRATION

09.00 – 09.30 INTRODUCTION, ICEBREAKER, OVERVIEW OF TRAINING
09.30 – 11.00 MODULE 1: UNDERSTANDING KEY POPULATIONS
11.00 – 11.30 HEALTH BREAK – TEA
11.30 – 13.30 MODULE 2: SEXUALITY AND HEALTH
13.30 – 14.30 LUNCH
14.30 – 16.00 MODULE 3: BARRIERS TO HEALTH
16.00 – 16.30 WRAP UP
DAY 2

08.30 – 09.00 DAY 1 RECAP

09.00 – 11.00 MODULE 4: CREATING A FRIENDLIER ENVIRONMENT
11.00 – 11.30 HEALTH BREAK – TEA
11.30 – 13.00 MODULE 5: PROMOTING MENTAL HEALTH
13.00 – 14.00 LUNCH
14.00 – 16.00 MODULE 6: TAKING A SEXUAL HISTORY
16.00 – 16.30 WRAP UP
DAY 3

08.30 – 09.00 DAY 2 RECAP

09.00 – 11.00 MODULE 7: CLINICAL CARE FOR HIV AND STIs
11.00 – 11.30 HEALTH BREAK – TEA
11.30 – 13.30 MODULE 8: SUPPORTING THE NEEDS OF MEMBERS OF ZIMBABWE’S
KEY POPULATIONS WHO USE DRUGS AND ALCOHOL
13.30 – 14.30 LUNCH
14.30 – 16.00 MODULE 9: INTERVENTIONS FOR IMPROVING HIV AND STI
PREVENTION FOR ZIMBABWE’S KEY POPULATIONS
16.00 – 16.30 WRAP UP
DAY 4

08.30 – 09.00 DAY 3 RECAP

09.00 – 13.00 KP CLINIC SITE VISIT
13.00 – 14.00 LUNCH
14.00 – 16.00 MODULE 10: ACTION PLANNING
16.00 – 16.45 WAY FORWARD, EVALUATION AND CLOSE

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MODULE ONE:
Understanding Key Populations
Introduction
In nearly every country where reliable evidence exists, certain groups shoulder a
disproportionate burden of HIV and other sexually transmitted infections (STIs) when
compared to other adults. In low- and middle-income countries, key populations
are many times more likely to be living with HIV when compared with the general
population.

HIV and other STIs are not the only health issues faced by these groups. Accruing evidence indicates
that these groups also present with a host of other unique health needs, require sensitive and targeted
services to meet those needs and face significant barriers in accessing life-saving healthcare services.
These barriers occur at multiple levels and result from the widespread stigma and social discrimination
they experience in their daily lives.
Stigma and discrimination, as well as poor attitudes amongst healthcare providers are key drivers of
poor health outcomes among the most vulnerable groups in Zimbabwe. A large proportion of key
populations continue to lack basic HIV prevention knowledge and avoid seeking primary or sexual
health care altogether, due to stigmatising social and cultural norms or discomfort in talking about their
sexuality with healthcare providers.
Healthcare providers, as key actors in the health system, play a critical role in promoting the sexual
health of these groups. Knowledge among healthcare providers on key population health issues is, and
re­mains, inadequately addressed by Zimbabwe’s mainstream healthcare training and in HIV-related
training curricula.

Learning Objectives
After completing this module, participants will be able to:
1. Define the term key populations and describe sexual practices com­mon among this broad group.
2. Identify the unique challenges faced by key populations in accessing health services.
3. Discuss the provider’s role in addressing the health needs of key population members in local
settings.

Resources you will need

Time: Minimum of 1 hour and 30 minutes
Flip chart and pens, project and power point presentation, paper/ cards for writing, Participant Handbook.

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Module Activities
Knowledge Session: ±45 minutes
In sub-Saharan Africa and other parts of the world, some groups experience a disproportionate burden
of HIV, TB, STIs and other health problems. HIV prevalence is relatively higher in some groups than
others, as are mental health problems. A significant number of new HIV infections occur in those people
we call key populations or KPs. They are ‘key’ to resolving our HIV epidemic in that these people often
have the least access to health services, including to HIV prevention, treatment and care because of
marginalisation and the stigmatisation they experience when attending for health services.

Who are key populations?

In the context of this training manual, key populations in Zimbabwe are defined as: male and
female sex workers (SWs); men who have sex with men, including men in prisons and other closed
settings (MSM); people who use and/or inject drugs, (PWUD, PWID); transgender and intersex
people (TI).

l Key populations face multiple stigma, exclusion, harassment and violence because of their drug
use and sexual behaviour, orientation or identity and their HIV status.
l Discriminatory laws and policies such as the criminalisation of sex work, drug use, and some same-
sex acts contribute to and reinforce low levels of access to health services.
l These facts also increase the risk of mental health problems and mental illness among these
population groups, leading to a cycle of abuse, high morbidity and poor health outcomes.

It is a public health and human rights imperative that all persons, in particular the most at risk,
have optimal access to health services, to ensure they enjoy the right to the highest attainable
standard of health.

What does LGBTIQ mean?

l In small groups ask participants to go through the Glossary of Terms in their Training Handbook
and write down the meaning of these six terms on the papers/ cards provided.
l Write the six terms as headings on the board and ask the groups to write the meanings of each
term on the wall.
l Come back to plenary and ask the participants to volunteer a brief description of what each of
these terms means.
l Ask for any questions or clarifications on the terms or the meaning of the words used.

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Value Clarification Exercise 1: Thoughts and Feelings About Key Populations ±15 minutes
In the next 5 minutes, write down your ideas for the following sentences (Individually)
l I think key populations are…
l When I see a sex worker/ drug user/ LGBTI person (choose one or refer to all), I feel

Facilitator’s feedback:
(NB participants do not have to share their answers if they do not want to):
Ask:
l How do you feel about what you wrote?
l Do you think your thoughts and feelings about key populations are fair?
l Do these attitudes affect us as healthcare providers? How?
l Ask the group to share from their different roles as medical, security, or administrative staff as
well as outreach workers and volunteers.
Share:
During this training, we will learn that key population members are people just like us and that how we
treat them can actually increase their vulnerability.
l We cannot judge a person by the way they look, dress or talk.
l Anyone in our community can be or may become a member of a key population.
l Whether by birth or by circumstance, members of key populations are some of the most
vulnerable people in our communities.
l Stigma and discrimination make the situation worse and put everyone at risk. We need to be
careful about our use of language when dealing with all clients as we cannot tell who belongs to
a key population and we may unknowingly stigmatise them by the way we talk.

Power Point Presentation: Global Issues Around KP and Health ±40 minutes
The purpose of this presentation is to emphasise that this training reflects global and regional health
policy and learning. It discusses key populations’ enhanced risk of HIV, and the various factors that
contribute to this increased risk. Update and adapt as you need.
Conduct the presentation in an interactive and participatory way, stopping to allow questions and
discussion from the group. If there is a question you cannot answer, no problem; write it down and let
the group know you will get back to them later in the workshop.

Value Clarification Exercise 2: How Would You Feel? ±15 minutes

Describe the following scenario to the group.
Imagine this situation. Your child is very sick but you don’t know what is wrong. You rush to the
clinic but when you speak to the receptionist and show her your child, instead of helping you
she ignores you. Soon, you notice the receptionist and the nurses huddled together in a corner.
They start whispering and giggling and keep looking over at you and your child.

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 You know they are talking about you and you fear they will not give you
the help your child so desperately needs. After waiting for 30 minutes,
you decide to leave the clinic and try elsewhere.
l Ask the group to describe how this would
make them feel.
l Ask them what they think is the link
between this scenario and that
of a member of a key population
coming into your clinic.
Value Clarification Exercise 3: How Will
Clients Feel? ±15 minutes
Divide participants into their different job types or groups. If there are
participants from the same health facility, split them up across groups so the
groups are mixed.
Ask each group to share experiences they have had with the members of
different key populations during their work. First, they should take turns to
describe their experiences to each other.
Then the group should think about whether they would classify each story as a positive or a negative
experience and why. The group should address the following:
l How do we know if a client is a member of a key population?
l Do clients feel comfortable telling us that they are members of a key population?
l What are the challenges in our work related to these vulnerable groups?
Ask the groups to share a few points from their discussion in plenary.

Facilitator’s feedback:
Ask:
l Were the shared experiences positive or negative?
l Can we be an effective healthcare providers if members of key populations cannot be open and
honest with us?
l Are there any ways to try and improve the experiences of key population members?
Share:
l Ask the participants to turn again to the Training Handbook and open up at the Patients Charter
section (this is also available from MoHCC as both a booklet and a poster).
l Discuss and reflect on its guidance and bring the group back to the need to be principled in our
service provision at all times.
l Remind the group that this may mean leaving aside our personal and/or religious beliefs.
l Close the session by asking the various groups within the health facility (medical, administrative,
etc.) to share how they feel about the Patients Charter and what their role is in supporting it.

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MODULE TWO:
Sexuality and Health
Introduction
Sexuality is the way people express themselves sexually. Understanding sexuality
helps us understand how important sexual expression is in a person’s life, which in
turn influences the partners they choose, the sexual acts in which they engage and
the level of satisfaction and pleasure they experience.

l Scientific evidence confirms that same-sex behaviour is a normal expression of human sexuality.
l Like all human beings, key population members express their sexuality in a range of both
sexual and non-sexual ways that include love, intimacy, relationship, romance, dating, courting,
marriage, family, children and community.
l To better serve key population members in healthcare settings this module provides information
on sexuality, including same-sex sexuality.
l It explores the commonality of sexual practice and demystifies some of the sexual practices that
are often considered taboo and not mainstream or heterosexual practice.
l Finally, it continues to discuss the need for healthcare providers to serve all their clients in a non-
judgmental, compassionate, and respectful manner.

Learning Objectives
After completing this module, participants will be able to:
1. Define basic concepts concerning sexuality and sexual health.
2. Understand the importance of sexual health among key populations for Zimbabwe’s Health For
All targets and in the fights against HIV and AIDS.

Resources
Time: A minimum of 2 hours to complete this module.
Flip chart and pens, small pieces of paper, Participant Handbook.

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Module Activities
Knowledge, Reflection & Discussion Session: ±90 minutes
Inform participants that the purpose of this session is to orient them to issues of sexuality and gender
and how these influence sexual practice. In the process, participants will explore the diverse sexual
practices and how they can be made safe.

Using the Binaries & Boxes to Understand Sexuality1

Suggested process for facilitation for each of the four components

Inform participants that information written on the flip chart will be repeated often and will be unpacked,
step by step. This, (SEX) is the first part of the puzzle that we will unravel. By the end of this session on
Human Sexuality, the puzzle will be put together again.

Component One – Sex as a Biological Concept

Although a separate discussion from components two, three and four, this activity should not be seen
as a separate entity. The four components together make up the puzzle of human sexuality.
Divide a flip chart paper into four quadrants. This specific activity starts in the top left corner, the first
quadrant. Only the word ‘SEX’ is written on the top of the first quadrant (for now). Place the flipchart
where everyone can see it.

1. 1. SEX
Male
Female
2.

Intersex

3. 4.

The first section is ‘SEX’ as a biological concept. Start the discussion by asking: “When I say the word
‘SEX’, what comes to mind?”
Allow the group to give their take on what the word means to them. Most will answer that it is something
that happens between the sheets, some might give the correct answer.
When a participant mentions ‘MALE’ or ‘FEMALE’, write it down, with one below the other.

Now ask: “How do you know what sex somebody is?”

Look in the pants – male has penis, female has vagina. Biological sex is about what’s in the pants, as well as the
hormonal and genetic makeup which indicates a person as being biologically male or biologically female.
Ask if the group knows of any other biological sex? Probe by asking what they have heard from the
media. Write down the word ‘INTERSEX’.

1 Adapted from Van Dyk, D. & Matlou, J. Binaries & Boxes, Understanding Human Sexuality. OUT Wellbeing (unpublished), (2010)

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Explain the word Intersex.
l We don’t exactly know what an intersex person has in their pants, but that is not important.
However, it is important to know that they exist.
l Intersex people used to be called hermaphrodite but this is an offensive and inappropriate,
politically incorrect term and should not be used.
l In some cases the genitals are not clear at birth;
l In others individuals discover much later in life that they are intersex.
l Intersex can manifest in many ways.
Refer (with respect) to the well known South African athlete, Caster Semenya who has (according
to media reports) a vagina and internal testes. Testes produce the male hormone, testosterone,
resulting in masculine features. Another example is that of the case of a woman who wanted to
have a baby in her late 20s and found that she did not have a uterus – another type of intersex.
l Many years ago, even maybe today, when a baby was born intersex, doctors urged parents to
choose the sex of their baby. The genitals would then be surgically modified to fit the chosen sex
binary. Cases were reported where the choice was that of a boy but, later in life at about puberty,
the ‘boy’ developed breasts.
l These days, parents are referred to endocrinologists. A choice is not made immediately and the
child is allowed to grow up without any ‘corrective’ surgery and supported to make their own
choice in terms of sex and gender identity.
l Having an intersex child can be very traumatic for parents. According to Intersex SA, one in 500
babies in Africa is born intersex today. This is a very sensitive issue and clients should be referred
to the correct healthcare providers for help with the various challenges.
l Because of stereotypes, we look for a penis or a vagina.
Penis Vagina *Intersex

* Born with ambiguous genitalia, or sex organs that are not clearly distinguishable as female or male.

l Explain to the group that this information is just the tip of the iceberg and that they should read
more on the topic.
l End this session with a statement, for example something along the lines of “Intersexuality
challenges the notion that there are only two sexes. But who knows, there may be even more
than just male, female and intersex.”
l Check with the group if all the information is understood so far.

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Component Two: Gender as a Social Construct
Although a separate discussion from components one, three and four, this activity should not be seen
as a separate entity. All four components make up the puzzle of human sexuality.

The word ‘GENDER’ is written on the top of the second quadrant e.g...

1. 1. SEX
Male
Female
2. GENDER

Intersex

3. 4.

GENDER - Ask what this word means. If sex is male, female and intersex, what is gender?
Most people express confusion between the terms sex and gender. Sex is a biological concept; gender
is a social construct.
l A construct is something that is put together by society, – in the case of gender – where meaning
is placed on what it means to be male or female.
l Encourage a discussion about ‘who’ is society?
l Who decided what a man or woman should or should not do? It would also be useful to have a
discussion on why society decided how men and women should be.
Write the following two terms on the flip chart:
ll Masculine
ll Feminine

2. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex

3. 4.

l Continue with a discussion on gender expectations. Use an example of what is represented in

the media, e.g. the well known beer advertisement, of “Real men don’t drink pink drinks, Dave”.
This advertisement reinforces the stereotypical masculine male model in a very subtle way. So
who only drinks pink drinks? Stereotypically, women. What about those women who prefer to
drink a strong beer? Are men not real men when they drink pink drinks? Encourage a discussion
around these notions.
l Ask: “What are some of the social expectations for men and women respectively?” “What is
the impact of these social expectations for men and women’s health, intimate relationships,
relationships with your children?”
l Some behaviour/roles are perceived to be masculine – like drinking too much – and are accepted
by society, even if they are pathological in nature. If a woman portrays masculine behaviour, e.g.
being dynamic, what is the perception of that woman? That she is a bitch? That she wants to be
a man? As soon as a person is boxed or stereotyped, there is a danger of discrimination.
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 Use examples you feel comfortable with. Further examples: Female jobs: administration, teachers,
nurses, housewives, counsellors. Male jobs: engineers, directors, doctors, preachers.
l Masculine – is tough, hard, driven, while femininity represents soft and caring.
Another example: Women wearing denims or pants. Thirty years ago only cowboys wore jeans. One
hundred years ago women were not allowed to wear pants at all. Now most women wear denims or
pants because they are comfortable or for various other reasons. What if a man wears a dress? What
is the perception of such a man? Maybe in another 50 or 100 years men will wear dresses.
Another example: What happens at a baby shower? Girls get pink, and boys get blue. Who
decided that blue was a ‘boy colour’ and pink a ‘girl colour’?
l Human beings are (usually) born with a sex, not with a gender. Gender is what human beings are
‘taught’, what is expected of male bodied people and female bodied people.
l The irony is that for a human being to be whole, they need both masculine and feminine
characteristics.
A man has to be in touch with his feminine side and a woman with her masculine side;
our masculine and feminine characteristics should be in balance in the self.
When there is no balance, the power imbalance may lead to different forms of abuse of the self,
or of a partner.

Repeat what has already been covered: Sex, Gender.

l Next, introduce the word, transgender
l Write it somewhere between the blocks for ‘sex’ and ‘gender’.
l Transgender is an umbrella term that encompasses two terms.
l Ask if anyone knows what transgender means.
l Probe the participants with the word ‘trans’ – think of transport, to move from one to the other.

l Transgender covers two elements: write down the words transsexual and transvestite under
a picture of an umbrella:

2. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex
Transgender

Transsexual
(MTF & FTM)
Transvestite

• Ask the participants if they know the difference between the two words.
A transvestite is a cross dresser, in most cases, a male who has the need, for various reasons,
to wear female clothes, underwear, make up etc. It is not related to who they are attracted to.
Although women can wear men’s clothing, (and some men in Africa wear dresses), men as cross
dressers are, sadly, not accepted by society.
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 Transvestites are generally heterosexual. Often, cross-dressing men – those who like to wear
women’s underwear or wear women’s clothes – wonder if they are actually gay.

Transgender has nothing to do with sexual orientation. It is because of the myth that gay men want
to be women that even heterosexual transvestites will question their own sexual orientation, although
they are well aware of to whom they feel sexually attracted. Some gay men will wear women’s clothes
too and are commonly known as drag queens.
l Transsexuals, on the other hand, are people who transition, or are in the process of transitioning,
to bring their body and gender identity closer together.
Example: A child is born; there is, or appears to be a penis, and there is the assumption that he is a boy.
When brought up, the person follows a masculine gender role but feels uncomfortable with the self
as a man, and feels more comfortable with a feminine role, and being a woman. She feels trapped
in the wrong body.
Remember to use the correct pronoun.

VERY IMPORTANT! Again, it is important that participants understand that gender identity and
sexual orientation are not the same, although they share the same experiences of prejudice and
discrimination. It is about the relation of the person with themselves – their gender identity – not
whom they love or feel attracted to.

l Gender identity: refers to how someone feels about themselves in the world as a woman or a
man, i.e. a person’s sense of themselves as male or female. While most people’s gender matches
their biological sex, this is not always the case. For instance, someone may be born biologically
male, yet have a female gender identity.
l Continue by further explaining the complexity of transgenderism, where people who feel they
cannot identify with their sex organs (for instance someone feels like a woman inside but has a
man’s body or the other way around). Some will try to change their bodies through hormones
and/or sex change operations (gender reassignment surgery). Not all transsexual people are the
same. A transsexual person can be of any sexual orientation.
For example a man, married to a woman, felt trapped in the wrong body, had a sex change
operation to become a woman but remained married to the same woman. This has an impact on
their sexual orientation; a lesbian woman trapped in a man’s body. This will be discussed after this
component.
In Samoa, fa’afafine are biological males who have a strong feminine gender orientation, which
Samoan parents recognise quite early in childhood. They then raise them as female children or
rather ‘third gender’ children. They grow up as fa’afafines, which is a gender category/identity
altogether different from men or women and so they have their distinct gender roles specific
to them, different from both men and women. It is something which is not discouraged in
traditional fa’asamoa (Samoan society).

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 l Terms used to describe transsexual people: MTF (male to female) or FTM (female to male), with
or without gender reassignment surgery.

2. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex
Transgender

Transsexual
(MTF & FTM)
Transvestite

l Check that everyone understands so far and answer any questions. Mention that we are now
moving to the third part of the puzzle.

Component Three: Sexual Orientation

Although a separate discussion from components one, two and four, this is not a separate entity. All four
components make up the puzzle of human sexuality.
This activity starts in the lower left corner, in the third quadrant. Only the word ‘SEXUAL ORIENTATION’
is written on the top of the third quadrant e.g.

3. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex
Transgender

Transsexual

(MTF & FTM)

Transvestite
3. SEXUAL 4.
ORIENTATION

l Do not give the answer immediately. Allow people to think a bit.

Ask what the ‘term ‘sexual orientation’ means. Participants can either write it down as part of an individual
reflective process by pairing with the person next to them, or in group work.
Suggested questions: Ask “What do you think it is? Do you have a sexual orientation? Do all people have
a sexual orientation? What are the different sexual orientations?”
l Ask the group if there is anyone who does not have a sexual orientation. Often, there is a mis-
perception that only homosexuals have a sexual orientation. Everybody has a sexual orientation.
It is unclear what determines a person’s sexual orientation.
l Often people ask; “Where does homosexuality come from?” Well, The answer is, the same place as
other sexual orientations. The question is often asked because homosexuality and bisexuality are
wrongly seen as different, or an illness. This is because people do not understand human sexuality due
to the limited information available and all the shame that used to be connected to homosexuality
because of heterosexism and homoprejudice (we’ll talk about these terms a bit later).
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Definition of sexual orientation: it is about attraction and feelings. Attraction has many levels – sexual,
physical, intellectual, emotional and spiritual. Thus, it is not only about sex!
l Now ask the group to call out the different sexual orientations and write them in box 3.

3. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex
Transgender

Transsexual

(MTF & FTM)

Transvestite
3. SEXUAL 4.
ORIENTATION
Heterosexual
Homosexual
Bisexual

Heterosexual (straight). ‘Hetero’ means opposite, therefore heterosexual people are attracted to the
opposite sex; a man attracted to women, or woman attracted to men. This attraction is sexual, emotional,
intellectual, physical and spiritual.

Homosexual. ‘Homo’ means same, therefore attracted to the same sex; a man who is attracted to a man,
a woman who is attracted to a woman on ALL the different levels of attraction, not just sexually (this is a
very important concept for participants to understand. Repeat the definition of a sexual orientation
several times if necessary).
l Write these down next to the term homosexual:
Ask if they understand what the words gay and lesbian mean and what the difference is.

3. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex
Transgender

Transsexual

(MTF & FTM)

Transvestite
3. SEXUAL 4.
ORIENTATION
Heterosexual
Homosexual

Gay Lesbian
Bisexual

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 l Although being gay or lesbian is an identity, there are some women who prefer to be called a gay
woman. While the term ‘gay’ was originally used to refer to feelings of being ‘carefree’, ‘happy’, or
‘bright and showy’, it had acquired connotations of ‘immorality’ as early as 1637.
l Today it usually refers to a homosexual man (http://www.etymonline.com/index.php?term=gay.)
The ‘label’ is not important, what is important is that the person feels comfortable within their
own identity.

Bisexual. ‘Bi’ means two and therefore refers attraction to both sexes; a person attracted to people of
both sexes on ALL the different levels of attraction, not just sexually (as mentioned above). It is a sexual
orientation in its own right. However, it is often misjudged and stereotyped as those who have multiple
concurrent partnerships or people who ‘can’t choose’. This could be the case for some, but for most
bisexual individuals this is a slap in the face.

Very important to remember: People of all sexual orientations can have multiple partners (preferably
do not use the term ‘promiscuous’ – it is judgmental).

l For many years, people thought that homosexuality could be cured or fixed but the reality is that
homosexuality cannot be cured or fixed. It is not a disease or an illness but a natural expression
of human sexualities; there is nothing to fix or cure.
Give an example by choosing a heterosexual person in the group (always ask permission first!)
by saying: “Change your sexual orientation now; choose to be a homosexual person”. Ask the
person if they would feel comfortable with a change/to be cured/to be fixed?
l In 1973, homosexuality was removed as a mental illness from the Diagnostic and Statistical
Manual of Mental Disorders (DSM). Yet almost 40 years later, some professionals and lay people
still look for a cause as if there is a ‘cause’ of hetero or homo orientation. Statistically, one in every
ten people is lesbian or gay, according to the Kinsey study from the 1950s.
l Sexual orientation is not a choice. Usually participants want to talk about the ‘Nature versus
Nurture’ debate. Unfortunately, there is no clear answer, maybe because there is nothing wrong
with the homosexual person. It is natural to look for the cause to a problem or illness, but if
nothing is the matter, why look for a cause?
Discuss an example of what happens in life: A child is born with a penis; society teaches the
baby to be masculine and have relationships with the opposite sex. Society assumes he must be
straight. Another assumption: If you are female, you must be feminine, and therefore straight.
Or another assumption: If a boy is gay, then as a male he must be feminine – that is how a
homosexual man should be. These are just gross stereotypes; if lesbian, you are female and
therefore you must be masculine, another gross stereotype.
It does not always work like that. You can get a male who is very masculine, who is homosexual.
Or a female, who is very feminine, and homosexual.
l Behaviour (masculine or feminine) does not determine a person’s sexual orientation. There are
males with feminine characteristics who are straight and females with masculine characteristics
who are straight.
l Sex does not inform gender, nor does it inform sexual orientation.

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 l Start to make the links on the flipchart, by using examples of different people in terms of sex,
gender and sexual orientation. Use a pen. You can use yourself as an example, or with their
permission, a participant or two.
l Mention that the pieces of the puzzle are coming together.

3. 1. SEX

Male
2. GENDER

Masculine

Female Feminine

Intersex

3. SEXUAL 4.
ORIENTATION

Heterosexual

Homosexual

Gay Lesbian

Bisexual

l How do you know what a person’s sexual orientation is? You will only know if they tell you. Never
assume. If you don’t know, ask. Don’t ask to intrude but if you need to know, ask, with a professional
attitude (as a professional needing information from your client). Again, never ever assume.

The world (or most of the people in it!), assumes that everybody is heterosexual.
l Relate this discussion back to the work the group does. For instance, if they are counsellors, give
the following example:

A woman comes in. She tells you her problems. You automatically assume that person is
straight and ask “How is your boyfriend or husband doing”. You are assuming. Maybe she has
a girlfriend, or a boyfriend AND a girlfriend. Maybe she is married, to a man, but has sex with a
woman. Surely, you would have lost your client!

Another example: A man, a dad, sits next to you. He has problems. You assume he is married,
maybe he is but he also confides in you that he also has sex with men on the side. You cringe
–client lost! Do not let your own judgment and belief systems interfere with your job.

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l If you let a person, your client, tell you more about their intimate lives and if you respond in a
non-judgmental manner, you will be surprised at how much you learn.
l Discuss the importance of understanding some discriminatory concepts. Lets have a look at the
terms heterosexism or homoprejudice: Look at the -ism, think of racism – when one race acts as
if it is better than all the other races and discrimination follows.
What was the impact of racism in Zimbabwe, or of and apartheid in South Africa? How did racism
play out in practice? Were proper health services availed to black people? People were abused.
Gross humans rights violations and even murder were perpetrated on people. Remember those
times?

l Heteronormativity is a cultural bias that only heterosexuality is ‘normal’ or accepted. Because

most people, including homosexuals, look at the world through a heteronormative lens, they
assume and even expect same-sex partners in relationships to have male/female roles. They
expect one to be more masculine and the other to be more feminine. This comes from the
cultural assumption that a family consists of a mother, father and children (heteronormative
model). Even most gay and lesbian individuals and couples try to fit within the stereotyped
gender expectations. Remember the discussion on how stereotypes are internalised in the last
session?
Example: two masculine gay men in a relationship confuses people, they want to know who is
the ‘wife’ and who is the ‘husband’ in a homosexual relationship. Some gay men refer to their
partner as ‘my wife’, because the other partner is more effeminate. Even though people joke
about it, such statements validate the acceptance of negative stereotypes about gender roles
and homosexual people.
l In many societies, including most in Africa, men are considered superior to women and their
roles are dominant. In these so-called patriarchal, heteronormative, heterosexist societies:
males, ‘masculine’ characteristics (such as rationality and competitiveness) and roles assigned to
men are considered superior and valued above those of females; those characteristics considered
‘feminine’ (such as emotion and nurturing) and roles assigned to women.
Gender and gender roles are, however, not fixed as society and culture are forever changing.
l Now we’re ready to move on the final piece of the puzzle.

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Component Four: Sexual Practices
Although a separate discussion from components one, two and three, this activity is not a separate
entity. All four components make up the puzzle of human sexuality.

In the lower right corner, the fourth quadrant write only the word ‘SEXUAL PRACTICES’:

4. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex
Transgender

Transsexual

(MTF & FTM)

Transvestite
3. SEXUAL 4. SEXUAL
ORIENTATION PRACTICES
Heterosexual
Homosexual

Gay Lesbian
Bisexual

l Ask the group to name the different body parts that people use to experience sexual pleasure
and reach orgasm. Write them down in the fourth quadrant:
Examples:
l Penis
l Vagina or vulva
l Anus
l Fingers
l Mouths

4. 1. SEX
Male
Female
2. GENDER
Masculine
Feminine
Intersex
Transgender

Transsexual

(MTF & FTM)

Transvestite
3. SEXUAL 4. SEXUAL
ORIENTATION PRACTICES
Heterosexual Penis
Homosexual Vagina
Anus
Gay Lesbian Finger
Bisexual Mouth

l Ask the group if a penis and a vagina can go together? Connect the body parts on the flip chart
with different colour pens.
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 l Can a penis and an anus go together? Can a penis and mouth go together? Can a finger and
vagina go together? Can a finger and anus go together? Can a mouth and vagina go together?

4. 1. SEX

3. SEXUAL
2. GENDER

4. SEXUAL
ORIENTATION PRACTICES
Penis
Vagina

Anus

Finger
Mouth

l Now, ask them if you mentioned who the body parts belonged to? What the sex of the two (or
three or more) people was? The answer is NO! Thus it is all possible. And it is all seen as sex. Ask
the group if they agree. Why is it important to know how people view sex? Because for many
years sex was only seen as penetration of the vagina by the penis. Remind the group of the
heteronormative view of relationships and sex. The primary risk linked to that kind of practice
was limited to pregnancy.
l Nowadays we know the risk is also in contracting a STI (including HIV), but still many people
think that because there is no vagina in the sex act there is no chance of contracting an infection,
because they link risk, consciously or unconsciously, with pregnancy. Therefore, any sex practices
that do not involve the vagina and the penis are perceived by many as not being sex and are
considered non-risky. As a matter of fact, we know that unprotected anal sex with an infected
partner is the sexual practice that carries the highest HIV transmission risk.

l Let’s talk about MSM (men who have sex with men) and WSW (women who have sex with
women); people who have sex with those of the same sex do so for a variety of reasons other
than as an expression of their sexual orientation or identity.
l Some may regularly have sex with others of the same sex without seeing themselves as lesbian
or gay (whether due to cultural, religious or personal reasons).
l Others may do so due to circumstances, such as being confined to a facility (e.g. a prison, mines)
or a period of separation from the opposite sex (such as during military training or operations).

VERY IMPORTANT! People have sex for different reasons. Men have sex with men for different
reasons, but they could still identify as heterosexual. An MSM can have any sexual orientation.

l How people perceive anal sex differs. You may refer to the Durex Sexual Health and Wellbeing
Study.
l The inside of the anus is a very sensitive place, like the inside of the mouth. Because it can be
easily damaged, it is highly susceptible to a sexually transmitted infection.

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 l Inside the male anus is a gland called the prostrate. For most men the prostrate is a very
pleasurable spot when stimulated, no matter what their sexual orientation.
l However, if you look at the Durex study results, some homosexual men do not prefer anal sex.
Some lesbian women prefer anal sex.
Below are the reported percentages of how men and women experience anal sex according to the
results of the Durex study.
l Anal sex – giving (8% hetero female, 19% hetero male, 72% homo male, 10% homo female)
l Anal sex – receiving (18% hetero female, 11% hetero male, 67% homo male, 15% homo female)
11% of heterosexual men reported that they like receiving penetrative anal sex from their female
partners
l Oral sex– giving (56% hetero female, 58% hetero male, 83% homo male, 77% homo female)
l Oral sex – receiving (55% hetero female, 56% hetero male, 81% homo male, 74% homo female)
l Discuss the issue of guilt and shame associated with certain sexual practices, e.g. the ‘anal taboo’.
Because of that, some people take part in hidden and risky sexual activities.
A heterosexual man might feel too shy to ask his wife or girlfriend to perform anal sex on him; he
might try to find the sexual satisfaction he needs elsewhere, often putting himself and his male
and female partner(s) at risk.
l Originally anal sex was seen as a gay sexual practice. We are now aware of more and more women
who include anal sex, both giving and receiving, in their sexual repertoire.

l A challenge arises when trying to identify an MSM. You cannot say an MSM is 1.8 m tall, has a
beard, and wears only blue shirts. From experience we know that MSM are not easily identified
and would not necessarily disclose to service providers, so may end up not receiving services
appropriate to their needs.

Not all MSM see the sexual practices they have with other men as sex, for example, anal
penetration without a condom and water-based lubrication. They might assume that, since there
is no vagina and no chance of pregnancy, what they are doing is not sex, but rather ‘just playing
around with the boys’! The reality is that they are engaging in high risk sex and are vulnerable to
HIV transmission without even being aware of it.

VERY IMPORTANT: Men who engage in anal intercourse, irrespective of whether this is insertive
(TOP), receptive (BOTTOM) or both (VERSATILE) and whether it is with men or with women,
or both, must be informed that HIV can pass through the delicate mucosal membrane of the
rectum. For this reason, receptive anal intercourse poses a particularly high risk of HIV infection.

Don’t assume people know what sex is all about. Again, never ever assume.

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 l When talking about responsible and safer sex strategies with a client, never assume the sexual
practices they may be indulging in. The message must be all encompassing.
For example, when giving safer sex messaging to lesbian women, say something like, ‘Here is a
safer sex pack, use condoms on toys or when you have sex with men etc.’, act as if it is the most
natural thing in the world for you to talk about. When speaking to men, try something along the
lines of “Here is a condom.
Use it when you have sex with a male or female partner, anal or otherwise.”

Close the binaries and boxes session by saying: “Who we have sex with is not important for
healthcare providers. How safely we have sex with others – that is what is important to ensure
good community health!”
Value Clarification Exercise 4: How We Have Sex ±30 minutes
l Begin by assuring everyone that this process is anonymous; no one will need to reveal the
answers they write.
l Encourage participants to be open and honest to promote learning and understanding.
l Now give each participant a small piece of paper and ask them to write which parts of their
bodies they enjoy bringing together for sex.

l Collect the completed papers in a black cloth or bag so that no one can see whose note is where.

Facilitator’s feedback:
Ensure that no one sees the papers or feels worried about what is being read out. Read out the written
papers ignoring any repeats, once they have all been collected. This excercise aims to demonstrate and
acknowledge that sexual practices are diverse and to normalise the not so common practices. Reinforce
that the discussion is not to focus on the identities of the people but on their sexual practices and how they
can be made safe. You can never assume another person’s sexual orientation or their preferred sexual
practices.

Ask the group:

l Why would a man have anal sex with a woman?
l If everyone has the potential to have sexual pleasure in these many different ways, how would
we ensure everyone gets the best support when they come to the clinic, whether they are a key
population member or not.

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Share:
l Some people may regularly have sex with others of the same sex without seeing themselves as
lesbian or gay (whether due to cultural, religious or personal reasons).
l Gender presentation has nothing to do with being lesbian or gay. Most lesbian women consider
themselves as women and similarly, most gay men consider themselves to be men.
l Being transsexual has nothing to do with being lesbian or gay. Transsexual people can be
heterosexual, lesbian, gay or bisexual.
l Being transvestite has nothing to do with sexual orientation. Transvestites can be heterosexual,
gay or bisexual.
l Intersex is a biological variant and NOT a sexual orientation nor does it refer to sexual behaviour.
l Having a penis does not make you a man; having breasts does not make you a mother; being
heterosexual does not make you ‘normal’.
l Our language is too limited to fully describe a human being’s sexuality and sexual expression.
Round up by informing the group that how to take a sexual history will be covered in a later module so
that important tools and communication skills can be learned to ensure that this is done in a way that
is both respectful and in line with professional etiquette. Not all those in the training will do this but the
section activities will give everyone a role to play.

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MODULE THREE:
Barriers to Health
Introduction
Members of key populations experience social discrimination in many ways,
precluding them from accessing necessary healthcare services. While some of
these barriers and experiences are within the health system, other factors, such as
laws concerning sex work, drug use and homosexuality, or the lack of proper legal
recourse in the case of human rights abuses, impede the ability of key population
members to talk about their sexuality or health issues with healthcare providers.

l It is important for everyone at a healthcare facility (including the people clients meet right
at the entrance) to be equipped with knowledge concerning the social context in which key
population members navigate their healthcare needs; this ensures that they can create a safe
and welcoming environment within their respective healthcare settings and includes the need
to ensure that all staff – even groundsmen and security guards – are educated about treating
ALL clients in a friendly nonjudgmental manner. Structural barriers have the potential to
exacerbate vulnerability and increase high-risk behaviours and HIV and STI transmission among
key population members.

Another way of ensuring your facility is key population friendly is to consider engaging peer educator
‘patient champions’ and also to EMPLOY members of KP groups in the healthcare system to be based
at your clinic, even if only on certain days. This will help encourage members of key populations to
understand that the facility will treat them with respect.

This module is designed to increase provider understanding of the well-known barriers faced by key
population members in Zimbabwe and how these may negatively affect health outcomes.

Learning Objectives
After completing this module participants will be able to:

1. Identify barriers, facilitators, and critical enablers that impact access to and utilisation of
healthcare services.
2. Describe how stigma undermines the health of key populations.
3. Identify the advocacy role of providers in mitigating barriers to healthcare access.

Resources
Time: This session requires a minimum of 1 hour and 30 minutes to complete.
Flip chart and pens, project and power point presentation, Participant Handbook.
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Module Activities
Power Point Presentation: Title ‘Barriers to Health’. ±45 minutes
l Begin with a brainstorm, asking the group to share and list all the barriers that a key population
member might face in accessing the healthcare they need.
l Make sure you get different perspectives from administrative staff, volunteers, medical
staff and guards etc.
l Once you have filled a flip chat (or two), introduce the PowerPoint section entitled ‘Barriers to
Health’ and take the group through each slide. Adapt and update this as you need.
Value Clarification Exercise 5: Which Barriers are Real? ±45 minutes
This exercise can be conducted as a ‘snowball’ exercise, whereby the three questions below are asked one
at a time and participants discuss in pairs for a very short time, then snowball (or enlarge) to a group of 4,
then to a group of 8, before giving feedback on each question. Do not start a new question until feedback
on the first is complete. The last question can be presented on flip charts by each group.
1. Are there instances or examples that you can think of where government law and policy may render
harm to key population members such as sex workers or gay men in Zimbabwe?
2. What are some of the guiding principles that help healthcare providers deliver competent and high
quality care regardless of a client’s sexual identity and behaviour or gender expression?
3. Of the barriers listed in the brainstorm exercise, group them under the following headings:
l Structural (includes how things are done, availability of services, social justice and human rights)
l Behavioural (what people do to put them at risk of HIV infection or other poor health outcomes)
l Medical (co-infections, science and technologies).

Facilitator’s Feedback:
l Understanding barriers to care is a very important factor in being able to support the most
vulnerable people in our community. Without this understanding, healthcare providers are
much less able to support and treat those at highest risk of HIV.
l Consider engaging peer educator ‘patient champions’ to be based at your clinic, even if only on
certain days to reassure members of key populations that the facility will treat them with respect.
And don’t forget the support staff in your educational awareness campaigns.
l Everyone entering your premises should feel respected and not judged. However, even the greatest
knowledge of barriers will fall short if the service provider has a negative and judgmental attitude.
l There may be need to remind participants of Zimbabwe’s protective Constitution, excerpts of which
can be found in the Training Handbook under the section ‘Key populations, health and the law”.

“There is a thin line between our lack of knowledge and a

poor attitude for some of us in the healthcare sector.”
Taurai, MoHCC, Stakeholder Consultation Process, May 2018
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MODULE FOUR:
Creating a Friendlier Environment
Introduction
Key populations experience a variety of barriers to receiving appropriate health
services. Many delay seeking care or receive inappropriate care because of stigma
or discrimination by healthcare providers and other staff. One important way to
help overcome these barriers is to ensure that the healthcare service environment
is respectful and welcoming to all. A welcoming and enabling environment helps
clients feel safe and encourages them to build trusting relationships with healthcare
providers. It alleviates concerns about discrimination and can lead to better quality
healthcare. Healthcare providers can take positive steps to promote the health of
key populations by examining their practices and policies and by providing staff
training. There are simple ways to make any clinical setting more welcoming.

l This module asks us to reflect on why members of key populations might avoid seeking healthcare
or disclosure about their sexual practices. It provides powerful testimony from key population
members themselves, in the belief that stigma and discrimination is often born of ignorance that
can be overcome by sharing experiences and simply getting to know one another.
l This module should also discuss how to involve ALL staff at a health facility, from security guards,
to administrative staff, volunteers and outreach workers connected to the facility. Medical staff
alone do not make an enabling environment and the health teams must ensure everyone on
their site is sensitised and trained.

Learning Objectives
After completing this module, participants will be able to:

1. Understand why key population members may avoid seeking care.

2. Identify strategies for creating safer and friendlier environments for key population members to
access care.
3. Understand the importance of communication and confidentiality while engaging with key
population members.

Resources
Time: This module requires a minimum of 2 hours to complete.
Flip chart and pens, videos and KP volunteers to give testimony (work with partners ahead of training to
ensure their participation), Participant Handbook.

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Module Activities
Value Clarification Exercise 6 ( ±60 minutes): How Friendly is my Facility?
This works best if participants are grouped by facility or local area network. Make sure everyone
participates, this is not just about medical staff. All staff need to get involved.
Which services does your health facility, or the facilities you work with support or offer? Make a list
and share with others in the group. Now refer the participants to the list of ideal services in the
Participant Handbook.
l Identify gaps in your service provision.
l How can you cover those gaps?
l Discuss the following examples:
ü Imagine a sex worker has come to your facility because she was forced to have unprotected
sex by one of her clients. She has an itchy discharge and is worried. Where would she go in
your clinic? What would her experience be? What do you think she would say? How would
the provider most likely respond?
ü Imagine a married man (you may know him from the community or surrounding area) who has
a boyfriend he sees from time to time outside of his marriage, visits your clinic with a suspected
anal STI. You see from his records he has been here several times before with the same problem.
His wife has also attended and been seen. You sense there is something he is not telling you (you
may not know about the boyfriend). How would the healthcare provider most likely respond?
ü How can everyone at the facility be more involved in supporting members of key populations
access the services they need?

Facilitator’s Feedback
l Go through each question with the plenary group and ask for suggested responses. In particular,
go through the examples given.
l Discuss how comfortable the sex worker or the MSM might feel telling the truth of what has
happened and whether they might make something up instead.
l Discuss how the person might even reach the medical staff after talking to other staff at the
facility first.

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Movie Screenings! ±30 minutes
There follows a series of short videos that highlight the very real difficulties many key population
members face on visiting a healthcare service. They are presented to show healthcare providers that
these are ‘real people’ like anyone else. They have volunteered to be part of these short films to help
increase understanding and empathy. It is important to respect their confidentiality, as many have taken
a personal risk to participate in the films to help educate others about their lives. A short summary of
each video can be found below.
https://www.facebook.com/safaids/videos/1381625501875770/ SEX WORK
https://www.facebook.com/PositiveTalkTv/videos/856266097774654/

Positive Talk TV – Life of a Sex Worker

The story of how Tendai became a sex worker. Her’s is not a straightforward journey but begins at her
birth and the challenges she faced finding a job and a husband. When her husband died she was unable
to get a regular income, despite her seven O-level passes. The bars offered some support and she found
herself having to sell sex to pay her children’s school fees. Both children are very clever, driving her to
keep in sex work to ensure they do well. She is now living with HIV as a result of the challenges of sex
work. Her dream is to leave sex work and become a nurse.
Positive Talk TV – Young People and Drugs
This short interview is about young people in South Africa addicted to a drug called nyaope. It is a
mixture of ARVs, dagga and heroin. Drugs also make them too brave to ask for help. Sometimes, the
drugs drive them to aggressive and dangerous acts. They are driven to take drugs to chase away hunger.
Watch their plea for help. Many young Zimbabweans are in the same situation.
Before you show and discuss each film, ask everyone to take notes while they watch and to reflect on
the following areas:
1. How did you feel when watching the film?
2. What did you find surprising or unexpected? Do these stories change your perception of key
population members in any way? If so, how?
3. How can you involve everyone at your health facility? What do you need to do?
Testimonials! ±30 minutes
This is a very important part of the training. Interaction between these vulnerable groups and healthcare
providers is designed to help break down barriers and mistrust, dispel stereotypes and give healthcare
providers a more in-depth understanding of how stigma and discrimination affect these individuals,
as well as giving an opportunity for the voices of key population members to be heard and their
experiences validated.
l This session needs to be mobilised in advance and be given plenty of time. Each testimonial
should have the space to be given freely without interruptions and followed by a question and
answer session.
l The people giving the testimony should be invited to stay, participate and mingle with the
training group for tea or lunch. However, this is voluntary and should not be forced.
l Ask the group to read the article on protecting transgender people from HIV in the Participant
Handbook.
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38
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MODULE FIVE:
Interventions for Improving HIV and STI
Prevention for Zimbabwe’s Key Populations
Introduction
Promoting the health of members of key populations requires a positive and
respectful approach to sexuality and sexual relationships. It requires the possibility
of having pleasurable and safe sexual experiences free of coercion, discrimination,
and violence. Many organisations embrace a positive sexual health approach in
their HIV services to key populations. This approach takes the whole person into
account, including the importance of pleasure and intimacy, mental and physical
health, shame and guilt concerning sex, stigma, discrimination, and other social
and structural factors.
This module presents established interventions for HIV and STI prevention (sometimes called a Minimum
Service Package). It discusses combination HIV prevention and World Health Organization (WHO)
recommendations for HIV prevention, care, and treatment for key population members. This includes:
l Correct and consistent condom use with condom-compatible lubricant.
l Newer biomedical approaches to risk reduction: pre-exposure prophylaxis (PrEP), post-
exposure prophylaxis (PEP), and voluntary medical male circumcision.
l The risks of sex without a condom.
l Possible risk reduction strategies for those who practice sex without a condom.
l An in-depth discussion of HIV testing and counselling for both individuals and couples.
l Triple site assessment, and
l The importance of HIV prevention for people living with HIV.

Learning Objectives
After completing this module, participants will be able to:
1. Understand more about combination HIV prevention and why it is important for key population
members to have service options.
2. Understand the WHO consolidated guidelines for reducing HIV in key populations and adapt them
to support Zimbabwe’s clinical setting and health for all targets.

Resources
Time: This module needs a minimum of 1 hour and 30 minutes to complete.
Flip chart and pens, Participant Handbook, a hard or soft copy of WHO Consolidated Guidelines on HIV
prevention, diagnosis, treatment and care for key populations (2016 update).
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Module Activities
Knowledge & Discussion Session: ±45 minutes
About Combination HIV Prevention
Currently, most HIV researchers and practitioners agree that to effectively address HIV prevalence and
incidence among key population members a comprehensive approach sustained over time and tailored
to local needs, is necessary.
l A combination approach involves combining and integrating biomedical, behavioural,
community-level and structural approaches to address HIV epidemics. One example is delivering
behavioural interventions like risk reduction counselling, together with biomedical interventions
like HIV treatment, while also addressing barriers to access, thereby addressing numerous issues
at once.
l Focusing only on one factor, whether it be prevention, treatment and care, or psychosocial
support, does not sufficiently address HIV incidence at the population level. Similarly, addressing
HIV with only one type of intervention is unlikely to result in significant long-term gains. This is
why a combination approach is recommended.
With biomedical approaches such as PrEP, for example, there are inequities in access to basic
health care. Key populations cannot benefit from biomedical interventions if their access to
these interventions is reduced because of cost, stigma, discrimination, or criminalisation. Having
a combination of the following interventions available directly (ideally) or by close and reliable
referral is critical in supporting key populations for HIV prevention.
WHO intervention recommendations for HIV prevention, care and treatment for key populations
WHO CRITICAL ENABLERS: WHO acknowledges that a number of conditions will allow recommended
health interventions for HIV prevention, care and treatment to be more effective in treating key
population members. These are listed below and call all service providers towards advocacy on these
issues that create barriers to good health for all:
l Laws, policies and practices must be brought into line to support access to health by all, together
with meaningful engagement of stakeholders from key population groups to ensure up to date
information, implementation and scale-up of services to key populations.
l Anti-discrimination and protective laws must be present and enforced. These are derived from
human rights standards and aimed at eliminating stigma and discrimination and violence against
members of key populations.
l Health services must make available services that are affordable, accessible and acceptable to
key population members, based on the principles of medical ethics, avoidance of stigma, non-
discrimination and the RIGHT to health.
l Programmes that enhance community empowerment amongst key populations (demand
creation and targeted outreach).
l Specific laws preventing violence against key population members, with such violence monitored,
reported, and redress mechanisms in place to provide justice.

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Below is an ideal set of services that would be provided at all sexually active clients at any health centre.
This can also be found in the Participant Handbook. Page 72 has a recommended minimum service
package for HIV prevention for KPs in Zimbabwe that should also be shared and discussed.
Reflection and discussion exercise in groups:
l Which of the services in the suggested interventions below, is currently offered by your facility?
l Which of these services is offered by a partner or a nearby facility that could be used for referral?
l Which of these services would be a problem for your healthcare facility to offer? Explain why.
WHO INTERVENTIONS: WHO recommends the following specific health sector interventions be made
available to key population members.

1. Condoms together with condom-compatible 2. Oral pre-exposure prophylaxis (PrEP) [new

lubricants recommendation]

3. Post-exposure prophylaxis (PEP) 4. Voluntary Male Medical Circumcision (VMMC) and

Male Sexual Health Education

5. Needle and syringe programme for PWID 6. Opioid substitution therapy for people who use
access to sterile injecting equipment as a drug/dependent on opioids
minimum.

7. Assessment, feedback and advice on alcohol 8. Access to naxalone for emergency opioid
and other substance abuse overdose management [new recommendation]

9. Provider Initiated testing (PITC) & Voluntary 10. ART and ART management for those presenting
HIV testing and counseling (HTC) offered in or testing HIV positive
both clinic and community settings

11. Prevention of mother-to-child 12. TB prevention, screening and treatment

transmission (PMTCT) in line with pregnant support, including for HIV positive (isoniazid)
women from other populations

13. Hepatitis B & C prevention, screening and 14. Routine mental health disorder screening and
treatment support, including for HIV positive management (esp. depression)

15. Screening, diagnosis & treatment of STIs, 16. Reproductive options and contraception,
including extra-genital, or triple site for sex including for those living with HIV, including female
workers and MSM sexual health education

17. Abortion services available as appropriate to 18. Cervical cancer screening for all women from
the law and as for women from all populations key populations, anal & prostate cancer screening
for men from key populations

19. Conception & pregnancy care (referral to 20. HPV vaccinations for sex workers, young women
specialist services, ante & post natal care (ANC selling sex and MSM
and PNC) as for women from other groups

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Know More Session: Critical Services ±30 minutes

1. Correct and Consistent Condom Use

Male and female condoms are sheaths of latex or another material used during anal, vaginal, or oral
sexual intercourse.

Condoms create a physical barrier between the genitals and sexual fluids of the partners engaging in
sexual intercourse. When used correctly for all sex acts, condoms are 80–95% effective at preventing the
transmission of HIV and other STIs.

However, many people do not and/or cannot use condoms correctly or consistently, increasing potential
exposure to HIV and other STIs.

2. Provision of Lubricants (and other barrier methods)

Promoting condom use must be accompanied by emphasis on the use of appropriate lubricants. This is
especially important for key population members and especially for anal intercourse, because the anus
does not produce its own lubrication.
Gay men, other MSM and sex workers should be educated on the benefits of and need to use condom-
compatible lubricants to ensure that condoms do not break. Key population members often report
difficulty accessing condom-compatible lubricants.
Providers should be prepared to advise their clients on what is and what is not appropriate to use as
lubricant with latex condoms. Water-based lubricants are the most commonly available. Silicon-based
lubricants are also suitable for use with condoms but are less readily available. Saliva is not recommended
as a lubricant because it dries quickly and therefore increases risk of damage to the rectal mucosal lining.

3. Pre-Exposure Prophylaxis
Pre-exposure prophylaxis (PrEP) is an HIV prevention intervention whereby an HIV-negative individual
takes antiretroviral medications (ARVs) regularly in order to reduce their risk of contracting HIV.
An example medication for PrEP is Truvada, an ARV containing tenofovir disoproxil fumarate and
emtricitabine (TDF/FTC). Clinical trials have shown that PrEP is effective at preventing HIV infection in
both men and women.
PrEP is beginning to be more widely rolled out in Zimbabwe and it is important that healthcare providers
are aware of this and seek to provide it to clients who may benefit. However, while PrEP is effective, it is
not a ‘silver bullet’ and depends on strict adherence. Clients should be counselled on the need to take
their treatment in the correct way. Research shows that few key populations know about the existence
or availability of PrEP in Zimbabwe, meaning additional awareness-raising is necessary.

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4. Post-Exposure Prophylaxis
Post-exposure prophylaxis (PEP) is a biomedical HIV prevention inter­vention whereby an HIV negative
individual takes ARVs follow­ing a potential exposure to HIV. PEP involves taking ARVs immediately
after exposure – usually within 72 hours – and continuing for 28 days. PEP does not reduce risk of HIV
acquisition to zero, but is highly effective. It has been used to reduce transmission through several
exposure routes, including:
l Occupational exposures (needle sticks, scalpel cuts, etc.)
l Sexual exposures (sex without a condom, condom failure, sexual assault, etc.)
l Percutaneous exposure from injection drug use
l Neonates exposed to HIV through breast milk or during birth.

To best support their needs, clients who are receiving PEP should:
l Receive HIV prevention counselling to reduce risk of future exposure.
l Be monitored to ensure medication adherence.
l Be monitored with laboratory safety evaluations such (liver enzymes, creatinine levels, etc.).
l Be tested for HIV and other STIs, including hepatitis B and C.
As with PrEP, additional awareness-raising is necessary for PEP.

5. Voluntary Medical Male Circumcision

Male circumcision has been shown to reduce the odds that a man will acquire HIV from a female partner
who has HIV by more than 60%.
l WHO guidelines recommend sexually active men who have sex with women access voluntary
medical male circumcision.
l However, there is no strong evidence showing that male circumcision offers the same benefits
during male-male intercourse. This is because most MSM are versatile, engaging in both receptive
and insertive sex and circumcision does not protect the receptive partner.
l But it must be noted that there are gay men or MSM who do have insertive sex with women and who
would therefore benefit from circumcision as a protective measure against HIV, herpes and HPV.

6. HIV Testing and Counselling

HIV testing and counselling (HTC) refers to a public health intervention whereby an individual, a couple,
or a family receives HIV testing and counselling on HIV prevention, treatment, care, and support. The
approach may vary in a number of ways, but the core components generally consist of:
1. Pre-test counselling that outlines the testing process
2. A behavioural risk assessment
3. Informed consent of the participant
4. Administration of the HIV test
5. Post-test counselling, which varies depending on the results of the test.

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HTC is a key entry point to care, treatment, and support for people living with HIV. Early detection
enables linkage to care and support services that not only prolong the life of the individual. It also
improves their quality of life and prevents the spread of HIV through risk reduction and behaviour
change. SInce HTC is a key entry point to care, it should be offered in an accessible and affordable
manner. There are several HTC modalities ranging from facility-based to community-based, client and
provider-initiated and mobile clinics to door-to-door. Regardless of the modality, several factors must
be taken into consideration for HTC with key population members:
l HIV stigma, homophobia, and hostile attitudes create environments in which key population
members are unable to safely access services.
l Many key population members believe that health services are primarily geared toward
heterosexual people or ‘not them’.
l Injecting drug users should be encouraged to test regularly for HIV due to their heightened risk.
l HIV self testing kits are now being rolled out in Zimbabwe and may be a useful option of members
of key populations who are reluctant to attend testing centres and clinics. However, it should be
remembered these groups may already have mental health issues and without the counselling
provided during a normal HIV testing procedure may suffer greater mental health challenges in
coping with a positive result from a home test.

7. Couples HIV Testing and Counselling

One important modality of HTC is couples-based HIV testing and counselling (CHTC). CHTC has been
tested primarily in heterosexual couples but is a strong intervention for members of key populations,
despite the fact that their relationship structures and networks may be very different. CHTC differs from
standard HTC in that a couple receives pre- and post-test counselling – including the results of HIV tests
– at the same time in the same room. It is a way to interrupt HIV transmission in serodiscordant couples,
help seronegative couples negotiate plans to remain negative, and link seropositive couples to care; it
also facilitates communication and partner support. Advantages to testing couples together include:
l CHTC provides a safe environment for couples to discuss risk concerns.
l Partners hear information together, enhancing likelihood of a shared understanding.
l The counsellor can ease tension and diffuse blame.
l Counselling messages are based on the test results of both individuals rather than only one.
l An individual who receives a positive test result is not burdened with the need to disclose the
result to their partner or persuade their partner to be tested.
l Counselling facilitates the communication and cooperation required for risk reduction.
l Treatment and care decisions can be made together.
l Couples can engage in decision-making for the future.
l CHTC is a voluntary, confidential interaction that respects the right of each client to make
decisions. Each client must consent to the counsellor sharing HIV test results with their partner
or they will revert to individual HTC. Once consent is given, CHTC will assist couples to establish
goals that fit their particular situation.

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Minimum Services Package for HIV Prevention For Key Populations in Zimbabwe.
Definition of KPs in Zimbabwe:
Male and female sex workers (SWs); men who have sex with men, including men in prisons and other
closed settings (MSM); People who Use and Inject Drugs, transgender and intersex people.

Treatment and Psychosocial

Prevention
Care Support

ll Male and female condoms & water-based ll Diagnosis and ll Mental health
lubricants. treatment of services,
opportunistic counselling &
ll HTC and ART initiation infection/TB care
ll TB Screening (Including for PLHIV) (Including PLHIV)
ll Legal advice &
ll Presumptive STI screening (triple site ll Vaccination, support
screening) diagnosis and
treatment of viral ll Establishment
ll Targeted IEC (through peers, mobile phones, of KP peer
hepatitis
internet, etc.) support groups
Antiretroviral
ll PEP and PrEP therapy (ART) and networks at
clinic sites and in
ll Cervical cancer screening & female sexual ll STI treatment communities
health education
ll Cryotherapy for
ll Family planning (all methods expect genital warts
permanent, which can be done through
referral)
ll Voluntary medical male circumcision & male
sexual health education
ll Anal & prostate cancer screening
ll HPV vaccinations (SW and MSM)

By referral (to partners or larger public facility):

ll Management of severe ART failure.
ll Harm reduction services, including sterile needles/syringes.
ll Overdose management, medically assisted treatment.
ll Drug detoxification & drug dependence treatment.
ll Relapse prevention including socio-economic and related reintegration services.
ll Services for the sexual partners of MSM (female, transgender, male) including family planning.

Cross Cutting Elements:

ll Key population-friendly outreach and ll Life skills training
decentralised drop-in centres and clinics ll IEC
ll Case management ll Crisis response and management
ll Peer education ll Peer counselling and individual and small
ll Prevention of violence group interventions

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Value Clarification Exercise 8: Risk Reduction Role Plays ±30 minutes
This activity contains several role plays designed to make participants think about which risk reduction
strategies they would suggest for their key population clients in a variety of situations.
l Divide the participants into pairs or small groups and assign each pair or group one of the case
studies below.
l Instruct each pair or group to role play the case study with one participant act­ing as the counsellor
and one participant acting as the client.
l Instruct the participants to use risk-reduction counselling to find an appropriate risk reduction
plan for the client in each case study. (Alternatively, the case studies can be used as case studies
for the larger group spread throughout the module.)
Give participants some time to work through each case study. For each case study, address the following
questions:
l What are the key risk behaviours of the client?
l What strategies would you create to help each client reduce their risk?
l How would you prevent the client from feeling judged?
l What types of language would you use when speaking with the client?
Discussion: Ask each group to present their strategy for their case study. Allow other groups to pose
questions. As the facilitator, you may also point out strategies you feel are particularly appropriate.
Summarise key findings: After all the groups have presented, highlight important aspects of the strategies,
especially highlighting that no single strategy is appropriate for all clients.

Case study 1
Luke is a 24-year-old gay male from Bulawayo. He is in a relationship with his boyfriend Temba.
When they have sex, Luke only enjoys being the receptive part­ner, but Temba enjoys both the
insertive and receptive roles. They do not use condoms when they have sex with each other.
Because Luke does not enjoy tak­ing the insertive role, the two have agreed that Temba may find
partners outside of their relationship to have sex with when he wants to bottom. Temba does
not have an emotional attachment to these third parties. He reports that he almost always uses
condoms with his casual partners.

Case study 2
Rosaria is an eighteen year-old girl who is unemployed. Recently she has been hanging out at
the local football field with a group of boys who smoke mbanje and occasionally other drugs
when they can afford them. She had never tried drugs and didn’t like to smoke but when a new
dealer arrived one day, he encouraged her to try some cocaine. The drug made her forget all her
problems and made her feel really self-confident. She ended up having unprotected sex with the
dealer, for which he paid her with some more cocaine. She is afraid she will get HIV but she doesn’t
want to stop having sex with the dealer as she wants more cocaine.

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Case study 3
Adam is an 45-year-old gay male who lives in Chitungwiza. Adam is also living with HIV. He has
been in a long-term relationship with his HIV-negative partner, Tonderai, for many years. When they
have sex, they often take turns being the penetrative and receptive partner. Because they know
that Adam is living with HIV, they have always used condoms every time they have sex. Recently
however, Tonderai has been pressuring Adam to forego condom use because he likes the added
sense of intimacy asso­ciated with having sex without a condom. Adam continues to insist on using
condoms when they have sex, but the issue has begun to cause problems in their relationship.

Case study 4
Tinashe is 27 years old and identifies as gay. He has come into your clinic for an HIV test, which
he gets every six months. During the pre-counselling session, he tells you that he recently ended
a serious relation­ship with his boyfriend. Following the break up, he fell into a deep depression
and often visited bars and drank heavily. Many times, he found a man to have sex with. He tells
you that he usually uses condoms, but that sometimes there were no condoms available, so he
had unprotected sex. He also has difficulty finding lubricants to use. Other times, he has been too
intox­icated to remember.

Case study 5
Adolfo is 25 years old and was thrown out of home by his parents, who are strong born-again
Christians, when he was 15. He stayed with the parents of a friend for a while but eventually ended
up living on the streets When he was begging at the shops one day, a man offered him food and
when they went to his house, they had sex. The man paid him and offered to put Adolfo in touch
with other men who would pay him for sex. Since then, Adolfo earns a good living as a sex worker
and has his own place, but often his clients don’t want to use condoms.

Case study 6
Tatiana is 24 years old and is a transwoman in the process of social transitioning. She is not
on hormone treatment. She has come into your clinic because of a rectal tear. During the pre-
counselling session, she tells you that she recently lost her job because she decided to wear a dress
to work and asked to be called Tatiana (she had previously been called Titan). As a result, she found
herself with no way of earning a living except sex work. On examination, you find significant scarring
and damage to the anus. Tatiana admits that a client had raped her without using a condom, when
he discovered she was a trans woman.

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48
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MODULE SIX:
Promoting Mental Health
Introduction
Key population members can experience chronic high levels of mental distress and
related challenges as a result of rejection, isolation and marginalisation. Research
suggests that key population members, especially gay men and other MSM and
transgender people, are at increased risk for major depression, bipolar disorder,
and generalised anxiety disorder, likely as a result of the stigma, discrimination
and homophobia they commonly experience. Sustained stress can also lead to key
population members turning to drugs and alcohol to cope with their problems
and even to contemplate suicide, while use of drugs themselves can lead to or
aggravate mental illness.

This module provides a review of common challenges key population members face from a mental
health perspective and the factors that drive those challenges. It also provides basic guidance for how
healthcare providers can better support their clients to care for their mental health.

Learning Objectives
After completing this module participants will be able to:
1. Understand the factors that fuel negative mental health outcomes among key population
groups.
2. Describe common mental health issues faced by key populations.
3. Describe basic strategies for approaching mental health with key population groups.

Resources
Time: This module needs a minimum of 1 hour and 30 minutes to complete.
Flip chart and pens, Participant Handbook.

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Module Activities
Knowledge Session: ±50 minutes
Part A: Factors Leading to Poor Mental Health Outcomes among Key Population Members
l Many key population members demonstrate resilience – the ability to end up healthy human
beings despite facing severe discrimination and marginalisation; but others present with mental
health challenges.
l Social discrimination is a key factor leading to poor mental health outcomes across all key
population groups. This discrimination is well documented in settings all around the world,
regardless of the cultural, social, political, economic, or legal environment.
l Discrimination manifests in many ways, including personal hardships like harassment, ridicule,
rejection, or violence, and also higher-level structural factors like discriminatory policies or
straight forward human rights violations.
1. Criminalisation
Beyond violating basic rights, criminalisation has made key population members more vulnerable to
poor health outcomes, reduced their access to health services and created inequities in access to and
affordability of essentials like housing and work. Repealing laws that criminalise sex work, drug use
and same-sex behaviour is an important step towards combating prejudice against key populations.
However, it must also be accompanied by work at the grassroots level to address societal attitudes.
Other consequences of criminalisation of sex work, drug use and same-sex sexual behaviour include:
l Under representation of key population members in the development and implementation of
policies and programmes.
l Lowered client participation in and discouragement of staff from working in programmes for key
populations.
l Lack of research and resources concerning key populations.
l Discuss some of the following statistics. HIV prevalence is taking root in three ‘key’ groups. It is:

§§ 28 times higher among people who inject drugs.

§§ 12 times higher among sex workers.

§§ 49 times higher among transgender women than in the rest of the adult population.

l Ask the group to read the article on Stigma and Discrimination in their Participant Handbooks.

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2. Reparative Therapies
Reparative therapies, also known as conversion therapies, are a group of harmful and ineffective
interventions that aim to change an individual’s sexual orientation from homosexual to heterosexual.
Such attempts to reform or ‘cure’ someone’s sexual orientation using these ‘therapies’ will not only
fail, but are likely to cause harm including depression, anxiety, suicide and, in some cases, a loss of
sexual feeling altogether. Should clients themselves express the desire to change sexual orientation the
most effective and appropriate therapeutic response that results in maximum mental health benefit is
provider-initiated support, acceptance, and validation of same-sex sexual orientation.

3. Family Rejection
Research correlates family rejection with negative health outcomes among lesbian, gay, bisexual,
and transgender (LGBT) people. Young LGBT adults who experience high levels of family
rejection during adolescence are eight times more likely to attempt
suicide, six times more likely to report high levels of depression,
three times more likely to use drugs and report unprotected sexual
intercourse, than peers who report no or low levels of family rejection.
It is important that healthcare providers are aware of these issues and
probe to better understand an individual’s circumstances.
In situations where a family member has difficulty accepting
someone’s sexual orientation, healthcare providers should
refer them to an appropriate support organisation for help.
And provide positive sexuality education (see the glossary in
the Participant Handbook for an understanding of this term). If possible,
connect the family member experiencing the difficulty to local resources that can help them accept
their family member without feeling guilt, shame, prejudice or judgment.
Sex workers face a similar taboo and the strain of hiding their source of income, while lying to family and
loved ones can also take a physical and mental toll.

Part B: Common Mental Health Issues for Key Population Members

Due in no small part to experiences of marginalisation and discrimination, key population members
are vulnerable to a variety of mental health issues. The harassment and discrimination experienced
contribute significantly to anxiety and are linked to depression and other mental health disorders. The
following section is intended to give healthcare providers a broad overview of the mental health issues
common in many key population groups.

NB: This module does not provide guidance on how to make a clinical diagnosis around
any mental health illness. However the Ultra Quick Screening Tool and the Shona Symptom
Tool in the Participant Handbook may help.

It is hoped that the resources mentioned will help healthcare providers increase their knowledge and
sensitivity to mental health problems in order to make referrals when necessary.
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Anxiety
Anxiety is a normal emotion and is closely related to fear. However, when anxiety becomes excessive, is
difficult to control, and affects an individual’s everyday life, it becomes a disorder and must be adequately
managed. Some symptoms of anxiety disorders include:
l Fear, uneasiness, and worry
l Sweating
l Shaking
l Racing heart
l Nausea
l Dizziness
l Shortness of breath
l Chills or hot flushes.

Depression
It is normal for most people to have ‘ups and downs’. Depression, however, is far more than simply a
bad mood. It is a prolonged mood disorder that can drastically affect an individual’s daily life. Some
symptoms of depression include:
l Feeling sad, hopeless, worthless, guilty, or bad about oneself
l Being unable to enjoy things that would usually be pleasurable
l Feeling apathetic and lacking motivation to act
l Feeling tired and having no energy
l Feeling lonely and cut off from other people
l Difficulty in concentrating
l Sleeping badly – either sleeping too much or too little
l A change in eating habits – either eating too much or too little
l Contemplating suicide.

Suicide
Research suggests that LGBT adolescents attempt suicide at higher rates when compared with their
heterosexual peers. The strongest risk factor for suicide is a history of previous attempts. As previously
noted, LGBT individuals who experienced family rejection were eight times more likely to attempt
suicide. Family connectedness, caring adults, and school safety all serve as protective factors from
suicide for LGBT individuals.

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Current suicide risk assessment tools do not provide the necessary guidance for mental healthcare
professionals to tailor assessments for key population members due to the unique and very aggressive
stressors in their environments. However, healthcare providers must take the possibility of sui­cide
seriously and should be familiar with local and national resources available in their own community
or country context. They should have a list of mental health professionals who are trained to handle
suicide-related mental health concerns. In addition to what may be locally available, additional resources
are included at the end of this module.

HIV-related Stress Disorder

While key populations living with HIV often experience dual stigma associated both with HIV and with
social and cultural marginalisation, those living with HIV may also experience specific instances over the
course of the illness that cause physical harm or additional psycho­logical stress. Life-threatening illness
is recognised as a stressor that can lead to a post traumatic stress response. However, rather than shame,
humiliation, or guilt, this response is primarily as­sociated with a sense of fear and helplessness. Some
instances associated with HIV that can cause this response are:
l Trauma associated with receiving an HIV diagnosis
l Beginning HIV treatment
l Lack of access to treatment
l Fear of disclosing HIV status to partner, family, or friends
l Treatment-related side effects
l Distress caused by life-long treatment
l HIV-related discrimination and marginalisation.

Sexual Problems
Sexual problems may be common. These may include issues related to:
l Desire
l Sexual aversion
l Excitement and arousal
l Orgasm
l Sexual pain disorders
l Sexual compulsivity.
Additional sexual problems for some key populations are related to anal sex, HIV and sexually transmitted
infections, erectile dysfunction, difficulty in ejaculation and lack of sex drive or interest in sex.
Though not always the case, these problems may arise or persist longer in the presence of mental
health issues like depression or psychological stress. Sexual dysfunction, in turn, can impact overall
psychological well-being and lead to significant stress within relationships. Where available, referral
to psychological or specialised services may be nec­essary. If psychological distress is the cause of the
sexual problem, then addressing the distress will likely solve the sexual problem.

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Eating Disorders
The connection between physical health and body image is fundamental. How we feel about our bodies
affects how we treat them, particularly with regard to what we choose to eat. Studies have found a
relationship between body image dissatisfaction and dietary lifestyle – overeating, over-exercising –
and the development of eating disorders. With few exceptions, studies have found that many vulnerbale
population members are significantly more likely to develop eating disorders and have higher rates of
dissatisfaction with their bodies as compared with others.

Physical and Sexual Violence

Physical and sexual violence against vulnerable population members remains a neglected area in clinical
science research and practice around the world. The following are a few points about sexual violence
targeted against vulnerable population members:
l Sex workers and men CAN be raped or sexually coerced; at home, the workplace, school, on the
streets, in the military, in prisons, and in police custody.
l Rates of domestic violence amongst vulnerable populations are similar to general domestic
violence rates; many have suffered traumatic or abusive sexual experiences in childhood.
l Key population members who have suffered violence may be unwilling to speak openly about
it because of shame, fear, or guilt. These crimes may also not be reported because of the
negative attitudes and indifference of law enforcement officials.
l Local resources to support key population members who experience sexual violence are scarce.
Exercise (±40 minutes): Using the Ultra Quick Screening Tool (by facility or network, if referral partners are
also present):
Ask participants to review the tool in Module 5 of their Training Handbooks. Then ask the group to think
how they could use this in their health facility. Let them discuss and consider the following questions:
l How do we really feel about mental health issues generally? Do we feel different when it is the
mental health of a client who is a member of a key population? If so, say why.
l How do we currently deal with clients with mental health issues? Is this adequate?
l What changes would be needed for our facility to use this tool?
l Is it only medical staff who can use these tools or can others at the facility help? If yes, how?

Participants should also be made aware of The Friendship Bench programme, which runs at several
clinics within Harare and makes use of the Shona Symptoms Questionnaire to assess mental health
issues. A copy of this questionnaire is included in the Participant Handbook.

Facilitator’s Feedback.
Encourage the group to reflect and share experiences amongst themselves. Before closing, share the
following points if they have not already been made:
l Homosexuality is NOT a mental disorder; any information to this effect in current training
curricula is wrong!
l Experiencing stigma and discrimination, including from healthcare providers, puts members of
vulnerable populations at higher risk of developing a mental disorder; in a healthcare setting
the attitude and behaviour of the most senior people at the facility is key.

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MODULE SEVEN:
Taking a Sexual History
Introduction
Healthcare providers play a central role in the prevention and treatment of health
conditions that affect members of key populations, particularly HIV. Experts
recognise that health promotion occurs largely at the individual level and is
effectively facilitated by meaningful health assessments and behaviour modification
techniques. However, members of key populations are less likely than others to
receive adequate assessment, treatment, and prevention of health problems.

Health facilities that are able to effectively assess the risks their clients face are better able to promote
their overall health, including HIV prevention and supporting adherence to treatment.
This module provides an in-depth discussion of how to take a comprehensive sexual history for all
clients in light of what we have learned in Module Two about sexual practices. It stresses the importance
of confidentiality when taking a sexual history, presents the barriers to sexual history taking, as well as
how to overcome them. It then discusses key communication issues when taking the sexual history,
giving specific questions to ask during the course of the sexual history interview.

Learning Objectives
After completing this module, participants will be able to:

1. Take a comprehensive sexual history sensitively.

2. Describe the various steps of health assessment.
3. Assess the health status of sexual partners.

Resources
Time: This module needs a minimum of 2 hours to complete.
Flip chart and pens, Participant Handbook.

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An Important Note on Confidentiality Before You Start!

Confidentiality is critical to all provider-client relationships. This is true

not only for key population members, but for ALL clients. However,
confidentiality gains special significance when working with vulnerable
key population members. Many KPs do not disclose their sexuality or
sexual behaviour to their healthcare provider because doing so could
result in harassment, blackmail, violence, or even imprisonment.
Providers should discuss confidentiality and its limits with their clients.
Assuring them that any information provided during a session will not
be shared without their express permission may help alleviate any fears
or concerns they may have.
Clients who fear the negative consequences of disclosure are less
likely to engage productively in counselling and less likely to receive
the full benefits of the session. Assuring clients that their privacy and
confidentiality will be respected should be a priority of each session.
Everyone at a health facility needs to respect confidentiality; not just the
medical staff.

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Knowledge Session: ±45 minutes
Barriers to Sexual History Taking
Taking a complete and accurate sexual history is critical to providing appropriate care but key population
members are often reluctant to volunteer their true sexual history to a provider whom they perceive to
be judgmental. There are many barriers to taking a sexual history.
Provider barriers
l Lack of experience or discomfort with asking relevant questions.
l Discomfort, or inability to respond to issues that arise.
l Homophobia and anger towards sex workers and drug users.
l Inability to understand consensual same-sex sexual behaviour between adults as a normal
expression of sexuality.
l Inability to understand sex work or drug use
l Makingfalseassumptionsregardingsexual behaviour and the level of risk of key population members.
l Uncertainty on how to help a client feel comfortable, particularly with regard to key population
members and sexual orientation or practices.
l Lack of time.
Client Barriers
l Embarrassment or shame.
l Perceived stigma from a healthcare provider.
l Lack of awareness on sexual health issues.
l Differences between doctor and client:
age, gender, skin colour, appearance, ethnicity,
national origin, sexuality, culture, wealth, social
class, sexual orientation.
Steps to Address These Barriers
Most of the barriers presented above can be overcome by
planning ahead and becoming educated about clients and how to take their sexual history. Though it
is common to feel uncomfortable discussing matters of sexuality with clients, most service providers
already possess the skills necessary to do so. Over time and with practice, providers will feel more
comfortable and discussing sexuality will become easier. Though each individual will develop their own
personal style, here are a few tips relating to sexual history taking and communication.
l Develop a policy that shows when to initiate a sexual risk assessment.
l Determine how sexual risk assessments will be integrated into the clients’ overall care.
l An important issue is the extra time needed. You may want to have set times for KP groups (at
the start or end of each day or specific days in a week, or at times when you know the facility is
not as busy).
l Identify specific questions to ask.

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 l Develop a plan for how to respond to information that might surface.
l Train staff on how to perform a sexual risk assessment.

Key Communication Issues

Providers might feel that clients will be surprised by questions about sexual health but most clients
actually welcome them. Providers should simply begin by preparing the client so they are aware that
these types of questions are to come. Providers should also:
l Develop rapport with the client while being sensitive to concerns about confidentiality and
assuring the client that they can speak freely without fear of judgment.
l Explain the importance of taking a sexual history. Providers should advise the client to be open
during the interview because these questions will help the provider give optimal care, even
though the questions may be sensitive.
l Never assume the client is either heterosexual or homosexual, a sex worker or drug user.
l Use terms like they or them, partner, rather than husband or wife, to avoid assuming the sex of
clients’ sexual or emotional partners.
Underscore that the interview is part of routine care, emphasising confi­dentiality and the desire to
provide quality care. A few key issues are:
l Avoid making assumptions: Assumptions based on gender, age, marital status, disability or
other characteristics are not necessarily correct. For example, a male client who is married to a
woman may not be sexually monogamous with their spouse and does not necessarily have sex
with only women.
l Be nonjudgmental, direct, and specific: Doing so with questions about sexual behaviour
is a good way to normalise the behaviour and make the client comfortable. Providers should
cultivate self-awareness of their own judgments and how these affect their work so that they can
leave their judgments at the door. They should also be aware of their non-verbal communication
to avoid coming across as judgmental.
l Ask open-ended questions: Questions that require more than a yes or no answer help to open
the dialogue between the provider and client, encouraging a more complete history.
Examples of statements to introduce the sexual history and reinforce confidentiality include:

“As I do with all of my clients, in order to provide you with the best possible care, I am going
to ask you several straight forward questions related to your current and past sexual activity.
I will also ask questions about drug and alcohol use.”

“Everything we discuss is strictly confidential and will stay between you and me.”

“I take a sexual and alcohol/ drug use history with all of my clients as part of their health
assessment. This is important in order to provide optimal care. I know that these subjects are
very personal. Please be confident that I will not divulge this information to anyone.”

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1. Ask about experience with condom use and other prevention modalities
As appropriate, providers should ask clients about the frequency and consistency with which they use
condoms and the circumstances surrounding their condom use. Some clients may never use condoms
or may use them differently with casual partners than with regular partners. They may use condoms only
for certain types of sexual act, such as anal intercourse but not oral sex. It may be best to ask an open-
ended question since clients may provide more information this way. One way to ask for information
about condom use is:
“Tell me about your experience with condom use”

2. Ask about known HIV and STI status of the client and of their sexual partners
Providers should ask about the client’s HIV and other STI status and that of their sexual partners. Example
questions to ask for information about HIV or other STI status include:
“Have you ever been tested for HIV?”

“What about your sexual partners?”

If yes, “When were you last tested for HIV? What was your last result?” If No “What are the
reasons you have not been tested for HIV? Do you have any concerns regarding HIV testing?”
“Have you been tested for STIs?”

If yes, “When were you last tested for STIs. What was the result?” If No “What are the reasons
you haven’t been tested for STIs?” “ Do you have any concerns about STI testing?”

3. Ask about drug and alcohol use

Key population members, like others, use drugs and alcohol for any number of reasons. Literature
suggests that key population members use drugs and alcohol as a mechanism for coping with stigma
and homophobia. In the context of sexual history taking, providers should ask about drug use in a
nonjudgmental and non-stigmatising manner. Providers should not assume that reported drug use
automatically means sexual risk behaviour or dependence.
Example questions to ask for information about drug and alcohol use include:
“Tell me about your alcohol use?”
“What has your experience with drugs been?”

4. Summarise the client’s response to questions. This assures the client that the provider is listening
and helps clarify any misunderstandings.
5. Ending the interview: By the end of the interview, the client may have questions or concerns that they
were not ready to discuss earlier. Providers should give the client an opportunity to voice these concerns.

“What other things about your sexual health and sexual practices would you like to
discuss today?”

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Exercise: Taking a Sexual History (±75 minutes)
l This activity helps participants practice and feel more comfortable asking questions relating to
sex and sexuality to their clients. Participants should refer to their Training Handbook for this
exercise.
l Ask participants to form pairs or groups. Medical and other staff who will be taking the sexual
history can be paired with other staff who would not, such as administrative staff, maintenance
or security staff, who can act as the clients.
l Then, either using an existing sexual history taking tool or one that the participants create, ask
them to role play the questions they would ask to elicit information from their clients when taking
a sexual history.
l Have participants go through each of the parts in the above section. Take turns being the
provider and the patient.
l Try changing the personalities of the patient. Try one who is reluctant to divulge information versus
one who provides a lot of detail of sexual exploits. Compare participants’ questions to the examples
given earlier.
Facilitator’s Feedback
l Afterwards, facilitate a brief discussion about any difficulties participants encountered and how
they felt while taking the sexual history. Discuss any specific aspects to follow up specifically
when taking the sexual history of a vulnerable population member.
l Summarise the key points elicited during the discussion for the group.

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MODULE EIGHT:
Clinical Care for HIV and STIs
Introduction
Clinical care for HIV and STIs need not take a different form from that of any other
client attending our clinics. However, members of key populations have been
under-served or ignored in the delivery of health information and care for quite
some time and it is therefore worth making sure that they are provided with
inclusive and non-judgmental care. Though gaps remain, the HIV epidemic has led
to epidemiological data on this group becoming increasingly available. For HIV-
negative patients, an STI diagnosis is both a marker for possible high-risk activity
and a potential co-factor for HIV acquisition. Members of key populations have
been shown to be, on average, more likely to be infected with HIV or certain STIs
than their peers, in nearly every nation where data is available

This module covers generally recommended steps for STI testing and treatment. It also focuses on HIV,
before discussing HIV testing and treatment. It covers the benefits of early treatment, considerations
for initiating antiretroviral therapy (ART), and treatment as prevention (TasP). The module closes with a
discussion of HIV co-infection with two other serious infections: tuberculosis and hepatitis.

Learning Objectives
After completing this module, participants will:
1. List signs and symptoms of well-known STIs and corresponding treatment recommendations
as they are relevant to key population groups.
2. Understand the relationship between STIs and HIV infection, including HIV-related co-infection
with tuberculosis (TB) and hepatitis.
3. Describe the main steps involved and reasons for carrying out a triple site physical assessment.

Resources
Time: This module needs a minimum of 2 hours to complete.
Flip chart and pens, Training Handbook

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Module Activities
Knowledge session: ±60 minutes
Sexually transmitted infections: When a pathogen infects a sex organ or the reproductive system and
the infection is transmitted from one person to another (usually through sexual methods) it is termed a
sexually transmitted infection.
l Most STIs spread though bodily fluids such as semen, pre-ejaculate fluid, or blood, or through
direct contact such as touching skin to a sore.
l STIs vary widely and include viruses, bacteria, parasites, protozoa and fungi; they may present
with or without symptoms.
l Because STIs are often asymptomatic, healthcare providers should test clients for STIs regularly.
l Clients should also test when entering into new sexual partnerships, both to ensure the client’s
health and to avoid transmitting an infection to their partner.
l The table starting on page 55 provides an overview of common STIs across key population groups.

Recommended Steps for STI Testing for Key Populations

This is a fairly technical session but all staff can benefit from it so make sure everyone is involved. Have
non medical staff sit with medical staff so that they can explain difficult or medical terms.
l Healthcare providers should assess the STI risk of all sexually active clients, and especially those
identified as members of vulnerable populations following the sexual history taking.
l A triple site assessment of all sexually active clients is also recommended (refer to the Training
Handbook).
The following is suggested:
1. Interview the client and conduct a culturally sensitive sexual history (as per module 6).
2. Identify risk of STI exposure.
3. Assess alcohol use history and drug use and assess if it is relevant to client’s sexual health
(as per module 8).
4. Assess underlying social and psychological challenges (as per module 4).
5. Ask the client if they are experiencing any STI symptoms and ask about specific symptoms
consistent with the presence of an STI. Keep in mind that the client may be asymptomatic.
Common symptoms include dysuria, urethral discharge, pain, skin rash, and ano-rectal pruritis.
l In addition to HIV, STIs pose a serious public health concern for the whole community, key
population members and their partners and clients. This is in part because the presence of an
STI increases an individual’s susceptibility to HIV acquisition. For example, in MSM, a history of
two rectal STI infections has been associated with an 8-fold increased risk of acquiring HIV.
Recent research has shown that in this region, transgender women are more likely than
heterosexual MSM to test positive for HIV, as well as to report experiences of stigma, depressive
symptoms, and condomless sex2.

2 http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002422

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 Compounding this, STIs are difficult to detect, diagnose, and treat, especially in resource-limited
settings. This module provides an in-depth discussion of HIV and other STIs.
l It discusses STIs common in key populations and the importance of testing for STIs.
l Service providers should always emphasise to clients the need to have their sex partners tested
and treated, should an STI be identified.
l On completing the sexual history, it is strongly recommended that ALL sexually active clients
receive a triple site assessment, with the aim of establishing a less stigmatising approach towards
members of key populations.
l Triple site examination involves a visual inspection of the mouth and throat, the vagina/ penile
areas and the rectum.
l Depending on the sexual history/ risk assessment and the results of the visual inspection, specific
diagnostic tests can then be carried out. Refer to the Training Handbook for a detailed list of
what a full triple site assessment entails.

6. Consistently provide the following recommended clinical STI prevention services:

Testing (at least annually) for:
l STI signs (visual inspection of the skin, mouth, genital, and anal area).
l HIV infection if HIV negative or not tested within the previous year.
l Syphilis, with a confirmatory test to establish whether it is recent untreated syphilis, partially treated
syphilis, or whether the client is manifesting a slow serologic response to appropriate prior therapy.
l Urethral N. gonorrhoeae (GC) and C. trachomatis (CT) in men who have had insertive intercourse.
l Rectal N. gonorrhoeae and C. trachomatis in men and women who have had receptive anal
intercourse.
l Pharyngeal N. gonorrhoeae and C. trachomatis in men who have had receptive oral sex.
l Vaccinate against HAV and HBV for all sex workers, transgender people, gay men and other MSM
in whom a previous infection or vaccination cannot be documented.
l Consider screening for other STIs: Lymphogranuloma venereum (LGV): consider LGV in diagnosis
of compatible syndromes (proctitis and proctocolitis) and perform tests to diagnose chlamydia.
l Check for Herpes simplex virus (HSV)
l Check for Human papillomavirus (HPV).
Screen all sexually active members of vulnerable populations annually. Clients at higher risk (such as
those with multiple partners or those who engage in anal intercourse without a condom with anonymous
partners) should be screened every three to six months.

Excercise: Triple Site Screening For Sexually Active Clients (oral/ genital and rectal, and for
pharyngeal gonorrhoea) ±60 minutes

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Diagnostic Tests
Throat Swabs (if indicated)
l Gonorrhea (GC) and culture and sensitivity (C&S) throat swabs are indicated for: men who have
sex with men (MSM) who have had receptive oral sex (with or without symptoms) clients who
have had receptive oral sex with a partner who has ano-genital gonorrhoea, others determined
to be at potential higher risk (e.g. clients who are involved in sex work, transgender persons) and
at the discretion of the nurse
l GC/CT nucleic acid amplification test (NAAT) is indicated for clients determined to be at potential
higher risk (e.g. clients who are involved in sex work, MSM) and at the discretion of the nurse.
Vaginal Specimens
Vaginal specimens are indicated when any of the following are identified:
l abnormal odour: identified by the client or during physical assessment
l abnormal vaginal discharge: identified by the client or during physical assessment
l vaginal irritation and/or inflammation pH ≥ 4.5 • symptoms of pelvic inflammatory disease (PID)
l clients determined to be at potential higher risk (e.g. involved in sex work, street involved or
residing in correctional facility)
l pre-upper genital tract instrumentation (e.g. intra uterine device/IUD insertion)

Cervical Specimens
l GC C&S swab if client is symptomatic or a contact to gonorrhoea or others determined to be at
potential higher risk (e.g. clients who are involved in sex-work or drug use) and at the discretion of
the nurse
l Pap smear if indicated
l HSV PCR swab, if lesion present.
Rectal Swabs, if indicated
l GC C&S for men who have sex with men (MSM) who have had receptive anal sex (with or
without symptoms), clients who have had receptive anal sex with a partner who has ano-genital
gonorrhoea, others determined to be at potential higher risk (e.g. clients who are involved in sex
work or are street involved) at the discretion of the nurse
l NAAT for GC/CT for clients experiencing rectal symptoms
l NAAT for GC/CT for clients determined to be at potential higher risk (e.g. clients who are involved
in sex work, MSM) and at the discretion of the nurse. Check with your local lab for availability of
this test.
Genital Ulcers or Lesions (peri-anal swab)
l HSV PCR, if lesion present
l Syphilis

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Venepuncture:
l Syphilis
l Human Immunodeficiency Virus (HIV)
l Hepatitis A Virus (HAV): consider HAV testing in clients who are not immune AND have at least
one of the following: HCV positive, HBV positive (carrier or acute, needle or drug paraphernalia
sharing, sex work, MSM, residence in correctional facility (past or present)
l Hepatitis B Virus (HBV) consider HBV testing in clients who are not immune, have not been
previously immunised AND have at least one of the following: residence in correctional facility
(past or present), HCV reactive active or resolved, HIV positive, needle or drug paraphernalia
sharing, sex work, multiple sex partners, sex partner of a person who tests positive for HBV, MSM.
l Hepatitis C Virus (HCV)
Consider HCV testing for clients with the following: needle or drug paraphernalia sharing, sex work;
residence in correctional facility (past or present), HBV positive − chronic or acute; HIV positive − co-
infection with other STIs where sores and lesions are present, such as Lymphogranuloma Venereum
(LGV) and Syphilis (moderate to low risk), longer term partner who tests positive for HCV (low risk).
Also recommended:
l Yearly screening for C. trachomatis and N. gonorrhea for all sexually active females aged ≤25
years.
l Asymptomatic non-genital Chlamydia/ Gonorrhoea infections contribute to a high burden of
infection.
l Screening of sexually active young men should be considered in high prevalence settings (e.g.
adolescent clinics, correctional facilities, and STI clinics).
l MSM with relevant exposures should be screened for urethral and rectal CT/ GC, and for
pharyngeal gonorrhea, at least annually. Consider every 3 to 6 months for men at highest risk.
Adapted from the College of Registered Nurses of British Columbia, Canada.

https://www.crnbc.ca/Standards/CertifiedPractice/Documents/ReproductiveHealth/719STIAssessmentDST.pdf

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The following table gives guidance on treatment of critical STIs.

INFECTION CAUSATIVE SYMPTOMS Recommended treatment

AGENT
Chlamydia Chlamydia Often no symptoms, can be a Azithromycin 1 g orally in a single
trachomatis discharge from the penis, painful dose
urine, swelling of testes. In women
OR
this can spread to the fallopian
tubes causing pelvic inflammatory Doxycycline 100 mg orally twice
disease (PID) daily for 7 days
Can also infect the rectum of MSM
(proctitis) and may include a discharge
with bleeding, pain and swelling.
Gonorrhea Niesseria Often no symptoms, whitish, Ceftriaxone 250 mg in a single
gonorrhoeae yellowish or greenish discharge intramuscular (IM) dose
from penis or vagina, painful and
PLUS
frequent urination (sometimes
burning sensation in women, Azithromycin 1 g orally in a single
sometimes PID or vaginal bleeding dose or doxycycline 100 mg orally
between periods). twice daily for 7 days
Rectal infection in both men and If ceftriaxone is unavailable
women may include discharge, (urethral, rectal, cervical infection):
anal itching, soreness, bleeding Cefixime 400 mg in a single oral dose
or painful bowel movements.
Pharyngeal infections from PLUS
unprotected oral sex can cause sore Azithromycin 1 g orally in a single
throats. dose or doxycycline 100 mg orally
twice daily for 7 days
PLUS
Test-of-cure in one week

Syphilis Trepomema A single sore (chancre) first appears (Primary) Benzathine penicillin G
palladium and can become multiple sores 2.4 million units IM in a single dose
usually on the outside of the
genitals, inside the vagina or anus
and even on the lips of the mouth. (Secondary) Benzathine
Secondary phase leads to skin penicillin G 7.2 million units total,
rashes in the mouth vagina and administered as 3 doses of 2.4
anus and comes with fever, swollen million units IM each at one-week
lymph glands, sore throat, hair loss, intervals.
headaches, weight loss, muscle
aches and fatigue. In the latent
phase can last for 10 to 30 years. (Latent) Early latent syphilis:
Untreated it can lead to blindness, Benzathine penicillin G 2.4 million
dementia and death. units IM in a single dose.
Late latent syphilis or latent
syphilis of unknown duration:
Benzathine penicillin G 7.2 million
units total, administered as 3 doses
of 2.4 million units IM each at
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INFECTION CAUSATIVE SYMPTOMS Recommended treatment
AGENT
Hepatitis A Hepatitis A Loss of appetite, malaise, fatigue, Usually requires only supportive
virus (HAV) nausea and vomiting, abdominal care with rest, abstaining from
pain, enlarged liver, dark urine, alcohol, and coping with nausea
jaundice rash and arthritis until the body eliminates the
symptoms. virus. Hospitalisation might be
necessary for clients who become
dehydrated because of nausea and
vomiting and is critical for clients
with signs or symptoms of acute
liver failure.
Medications that might cause liver
damage or are metabolised by the
liver should be used with caution
among persons with HAV.
Hepatitis B Hepatitis B Loss of appetite, malaise, fatigue, No specific therapy is available for
virus (HBV) nausea and vomiting, abdominal persons with acute HBV; treatment
pain, dark urine, jaundice rash and is supportive. Persons with chronic
arthritis and may result liver cancer. HBV infection should be referred
for evaluation to a physician
experienced in the management
of chronic liver disease. Certain
therapeutic agents for the
treatment of chronic hepatitis B,
including some ARVs, can achieve
sustained suppression of HBV
replication and remission of liver
disease in some persons.

Hepatitis C Hepatitis C Often no symptoms, but can be loss Persons found to have HCV
virus (HCV) of appetite, malaise, fatigue, nausea should be evaluated for the
and vomiting, abdominal pain, presence of active infection,
enlarged liver, dark urine, jaundice presence or development of
rash and arthritis and if chronic, chronic liver disease, and possible
cirrhosis, liver disease and possibly treatment. Combination therapy
death. with pegylated interferon and
ribavirin is the treatment of choice
for people with chronic HCV.
However, those newly infected
may be cured with relatively short
course treatment with specific
antiretroviral medicines.

Healthcare providers should

consult with specialists
knowledgeable about manage­
ment of HCV infection.

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INFECTION CAUSATIVE SYMPTOMS Recommended treatment
AGENT
Herpes Herpes simplex Tingling, itching, pimples or blisters Acyclovir 400 mg orally three times
virus (HSV-1 that crust over and scab like a cut. daily for 7-10 days
(usually oral Symptoms recur every few weeks, OR
herpes) and months or years. Aggravated by Acyclovir 200 mg orally five times
HSV-2 (usually stress. daily for 7-10 days
genital herpes) OR
Famcyclovir 250 mg orally three
times daily for 7-10 days
OR
Valacyclovir 1 g orally twice daily
for 7-10 days
Human Human Often no symptoms, genital or Treatment is directed at the
Papilloma virus Papilloma anal warts in males and females. macroscopic or pathologic lesions
infection virus (HPV) Rare but may be warts in the throat caused by infection. Subclinical
(knows as recurrent respiratory genital HPV infection typically
papillomatosis) clears spontaneously and antiviral
therapy is not recommended. In
the absence of lesions, treatment is
not recommended for subclinical
genital HPV.
Human Human Symptoms of acute infection See National Treatment Guidelines
immune- immune- are often flu-like and include:
deficiency virus deficiency virus headaches, swollen glands, sore
infections (HIV) throat, rash, fatigue, muscle and
joint aches and pains, diarrhoea, dry
cough, rapid weight loss, recurring
fever, night sweats and untreated,
opportunistic infections such as
pneumonia, even NCDs and cancers.
Lympho- Chlamydia This is often a painless sore on Doxycycline 100 mg orally twice
granuloma trachomatis, the male genitals or in the female daily for 21 days
Venereum serovar L2 genital tract, there can be blood Alternative recommendation:
(LGV) or pus from the rectum, painful Erythromycin base 500 mg orally
bowel movements, groin swelling four times daily for 21 days.
and redness as well as drainage
from inguinal lymph nodes (rarely
there is also diarrhoea and lower
abdominal pain)

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Tuberculosis and Co-infection with HIV
Co-infection with TB occurs when an individual is living with both HIV and has either a latent or active
TB infection at the same time.

l Globally, TB is the leading cause of death in this population.

l Latent TB infection can usually be treated with one type of medication, whereas an active TB
infection might require several concurrently.
l Common first-line TB treatment medications include Isoniazid, Rifampin, Ethambutol, and
Pyrazinamide.
l In the case of multi-drug resistant TB (MDR-TB) or extremely drug resistant TB (XDR-TB), second-
line medications such as Streptomycin, Kanamycin, Clarithromycin, Amikacin, Capreomycin, or
other antibiotics are necessary. These drugs are more expensive, more toxic, less effective, and
require a longer course of treatment than first-line drugs.
The WHO has established guidelines for the treatment of TB in people living with HIV. These include:

Antiretroviral Therapy: ART can restore some immune system function, which can mitigate the impact of TB
and HIV. All people living with HIV with an active TB infection should be placed on ART immediately.
Intensified TB Case Finding: All people living with HIV should be screened regularly for TB. Research on
TB case finding shows that the presence of one or more of the following three symptoms – persistent
cough, fever, or night sweats – detects the vast majority of active TB cases.
Isoniazid Preventive Therapy: People living with HIV who test positive for a latent TB infection should be
put on Isoniazid preventive therapy (IPT) for up to 36 months.
Infection Control for TB: This includes rapid detection of people who are infectious, precau­tions to reduce
airborne transmission in healthcare settings and treat­ment of those either suspected or confirmed to
have active TB.
There are two key challenges for TB treatment in people living with HIV.
l The first is MDR-TB. The likelihood of dying from MDR-TB is high, especially for people living with
HIV, unless treatment with appropriately tailored therapy can begin very quickly after infection.
Ensuring that clients complete TB treatment with methods such as directly observed therapy
short course (DOTS) is, to date, the most effective way to avoid the spread of MDR-TB.
l Second, clinical management of HIV/TB co-infection is difficult because of the many
treatment interactions between medications for HIV and TB. These interactions can cause
many negative health effects such as liver-related illnesses.
l Because key populations are disproportionately affected by HIV and experience greater difficultly
in accessing the health system, it is particularly important that efforts be made to integrate TB
screening and case finding into the minimum service package for this population. Refer to the
Participant Handbook.

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25
MODULE NINE:
Supporting the Needs of Members of
Zimbabwe’s Key Populations Who Use
Drugs and Alcohol
Introduction
Research has shown that people who inject or use drugs are at higher risk of HIV due
to reduced capacity and inhibitions and when using drugs. This is why people who
inject drugs and people who use drugs are classified as key population groups in
Zimbabwe. Research also suggests that other key populations such as sex workers,
MSM and transgender people, are more likely to use drugs and alcohol than adults
in the general population.

In this training programme, ‘drugs’ includes both prescription drugs such as Tramodol and Bronchclear,
as well as non-prescription drugs that are considered illegal or otherwise ‘recreational’ in most countries.
These higher rates of use can be a reaction to the poverty, homophobia, discrimination, mental health
issues or violence that key population members experience because of their lifestyles or sexuality.

In the clinical setting, candid discussions between healthcare providers and clients about the use of
drugs and alcohol can be challenging and present various barriers in nearly every context and when
serving any given population. This is aggravated because drug use and possession is not only highly
stigmatised but also criminalised, with harsh punishments for those caught.

l This module aims to increase healthcare providers’ knowledge of alcohol and drugs that are
commonly abused. It also discusses the contexts in which drug or alcohol use occurs.
l It aims to increase healthcare providers’ sense of comfort in discussing drug- and alcohol-related
issues with clients in the clinical setting.
l This module does not aim to provide clinical guidance and training on how to implement specific
harm reduction interventions like needle exchange programmes, which are not commonly
catered for in Zimbabwe. However it is important that healthcare providers understand their role
in advocating for needle exchange programmes, as they play an important role in reducing the
spread of HIV and hepatitis, as well as in encouraging injecting drug users to come into the open.
l It is beyond the scope of this module to include information on how to diagnose or treat drug or
alcohol dependence. Clients seeking or needing such higher-level interventions are best counselled
according to nationally recognised guidelines around drug- and alcohol-related healthcare or
referred to qualified allied health professionals.
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Learning Objectives
After completing this module, participants will be able to:

1. Describe the reasons for drug and alcohol use among members of key populations.
2. Describe the known patterns of drug and alcohol use among members of key populations.
3. Name the common drugs used by members of vulnerable populations in Zimbabwe.
4. Discuss drug and alcohol use within the clinical setting with members of key populations
more comfortably and effectively.

Resources
Time: This module needs a minimum of 2 hours to complete.
Flip chart and pens, Participant Handbook, you may want to show again or for the first time video link/
podcast on drug abuse listed in Module 4.

It is important to recognise that an unknown proportion of people, regardless of socio-economic

status or education level, use drugs and alcohol globally and do so for any number of reasons.
Many of these individuals go through life using drugs and alcohol either regularly or occasionally
without any disruption or negative impact on their social, professional, or physical lives. A
proportion of them may even report positive benefits from their use of drugs or alcohol. It is also
important to recognise that for others, drug and alcohol use might be problematic every time
they use drugs and alcohol, or only under specific circumstances.
For instance, drug and alcohol use may be problematic only when they use a particular drug or
type of alcohol, or only when they use an excessive amount. In these cases, they may report that
their drug and alcohol use interferes, either at all times or under specific circumstances, with their
personal health goals and/or with their goals for security, job, relationships, and family.

Module Activities
Value Clarification Exercise 7: Getting Comfortable Talking About Drugs and Alcohol ±45 minutes
This activity is designed to allow participants to explore their beliefs and attitudes toward sub­stance use.
Participants will choose their placement along a continuum of true and false for a variety of statements
relating to drug and alcohol use.
l Write or use a computer to print ‘True’ on a large sheet of paper and tape it to a wall on one end of
the training room. Write or print ‘False’ on a second large sheet of paper and tape it to the opposite
wall. Tell the group that you will be stand­ing in the middle of a line that runs across the room.
l One end of the room is the ‘True’ area and the opposite end of the room the ‘False’ area.
l In between represents a continuum of responses any­where between ‘True’ and ‘False’.

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Next, read the following statements aloud and ask the participants to move to the point on the line that
best represents their views or beliefs. All of the statements are ambiguous. After everyone has moved,
ask volunteers from the True, False and Middle groups to support their points of view.
Statements:
l I use drugs.
l It’s okay for young people to drink under their parents’ guidance.
l It is important for people to be held responsible for things they do when they drink or get high.
l It’s okay if my friends drink alcohol.
l It’s okay if a friend uses illegal drugs.
l A drug user who works for your organisation should be fired.
l Manufacturers of alcohol should be allowed to advertise their products on TV.

Questions for discussion: After you have completed the above statements, ask each of the questions
below for discussion.
1. What did you learn as you participated in this activity?
2. Did anything surprise you? What?
3. Do you believe that some discussion of why people selected their position on the continuum
might have brought people together? Why or why not?
Summarise key findings: Depending on how participants respond in this activity, what can you learn about
their awareness around drug and alcohol use and their view of drug and alcohol users? If participants
appear judgmental or narrow in their views, you may transition the closing conversation about how that
would apply to a clinical setting.

Knowledge Session ±45 minutes

The Link Between Drug Use and HIV Transmission
Although the link between non-injection drug use and HIV is not fully understood and may be complex,
some studies correlate drug use with higher incidence of HIV infection.

l Drug use may be linked to HIV and hepatitis risk, especially through the sharing of contaminated
injection equipment and unprotected sex with a serodiscordant partner while under the
influence of these drugs.
l Drug use can lead to high-risk sexual behaviours (including unprotected sex and anal sex)
because certain drugs lower sexual inhibition.
l Use of some specific drugs such as cocaine or methamphetamines is associated with interruptions
in antiretroviral therapy (ART), which can increase the likelihood of HIV transmission.
l Among sex workers, gay men and other MSM who are being treated for STIs, drug use is linked
to a higher likelihood of HIV and hepatitis transmission.

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Drugs Commonly Used in Zimbabwe

LIST OF DRUGS STREET NAME EFFECTS

Alcohol, including Kachasu, Maragadu, Relaxation and happiness (can lead to aggression, heart and
both legal and Musombodhiya, Tegu- liver disease and cancer)
illegal forms) is Tegu, Zed
a stimulant in
small doses and
a depressant in
larger doses

Cannabis is a Mbanje, Weed, Marijuana State of relaxation and happiness

hallucinogen

Cocaine is a Upfu, coke, blow Extreme happiness, confidence, sexual arousal (but then
stimulant causes agitation, depression, paranoia and decreased appetite)

Codeine (including BronCleer, Bronco Get ‘high’, get excited and impulsive (but then causes
cough syrups) is an breathing problems, low blood pressure, vomiting)
opiate

Crystal Meth- Meth, crystal, ice High energy, confidence, invincibility and impulsiveness (but
amphetamine is a then causes agitation, depression, suicidal tendencies, loss of
stimulant memory or muscle control)

In the Participant Handbook you will also find a list of symptoms of commonly abused drugs.
This list of warning signs of drug use is also included in the Training Handbook.
Warning Signs Of Commonly Abused Drugs
l Marijuana: Glassy, red eyes; loud talking, inappropriate laughter, followed by sleepiness; loss of
interest or motivation.
l Depressants (including Xanax, Valium): Contracted pupils; drunk-like; difficulty concentrating;
clumsiness; poor judgment; slurred speech; sleepiness.
l Stimulants (including amphetamines, cocaine, crystal meth): Dilated pupils; hyperactivity; euphoria;
irritability; anxiety; excessive talking followed by depression or excessive sleeping at odd times; dry
mouth and nose.
l Inhalants (glues, aerosols, vapours): Watery eyes; impaired vision, memory and thought; secretions
from the nose or rashes around the nose and mouth. headaches and nausea; appearance of
intoxication; drowsiness; poor muscle control; anxiety and irritability.
l Hallucinogens (LSD, PCP): Dilated pupils; bizarre and irrational behaviour including paranoia,
aggression, hallucinations; mood swings; detachment from people; absorption with self or other
objects, slurred speech; confusion.
l Heroin: Contracted pupils; no response of pupils to light; needle marks; sleeping at unusual times;
sweating; vomiting; coughing, sniffling and twitching.

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Ask the group to read and discuss the following article (it is also in the Participant Handbook).
Encourage the group to share their experiences of drug use in their facilities as well as the common drugs
used in their areas.

Article adapted from the Zimbabwe Civil Liberties and Drug Network
Newsletter June 2018 Issue. No.%. Volume 1.
“Cocaine, crack cocaine, meth, codeine, diazepam… it just depends on the kind of high
a person is looking for"
This is Crispen. No. That's not his real name. Crispen is a Zimbabwe drug lord based in Harare. He
agreed to talk to Khuluma Afrika, on condition of anonymity. Crispen was born in Mbare, a densely
populated neighbourhood some 5km outside the city center. Crispen sells all kinds of drugs, except
for crystal meth, which he claims is sold out of Highfields, another high-density suburb 12km from
the city centre. Zimbabwe's rising drug abuse epidemic is a new phenomenon. Until recently, the
only available drugs were marijuana and 'bronco' – a cough syrup manufactured in South Africa.
But cocaine has made its way. "Everyone now wants upfu (mealie meal) – (the street name for cocaine),"
Crispen says. Crispen claims he pushes big volumes. He sells in town, and sends boys to places
where large numbers of people gather to party. He also uses sex workers to push drugs to clients.
On the street, a gram of cocaine sells for $80. Other drugs like meth sell for $50 a gram.
This makes them out of reach for the majority of Zimbabweans. But Crispen has come up with
a plan. "We sell a fix. Like one sniff (cocaine) we make it about $10," he says. A lot of the drugs are
manufactured outside of Zimbabwe and then smuggled through the border. It is a lucrative
business, which those involved claim is turning them into millionaires.
"Anything with codeine is my prime product. But lately I now move a lot of ephedrine. Even ecstasy pills
are now big bucks" Crispen spends most of his day at Bosman station, shipping boxes of prescription
medication. His main transporters are bus drivers who hide the boxes in luggage compartments.
Most discussions about drug abuse in Zimbabwe neglect substances like cocaine, heroin and
alcohol, traditionally because substance abuse has been limited to marijuana and recently
prescription cough medication. But experts contend the 'imported banned substances' problem
is bigger and includes drugs traditionally thought to be impossible to find in Zimbabwe and those
not thought to be dangerous. "By far the drug most abused is alcohol due to its ease of acquisition
and price. Illicit illegal alcoholic drinks are smuggled into the country, mostly from Mozambique. These
are untested and their ingredients are not known. For US 50c, one can purchase a 300ml bottle of these
concoctions which are believed to contain toxic, dangerous chemicals like isopranol, a disinfectant
found in mouthwash or skin lotions, or methanol, a solvent founds in paints and industrial cleaning
fluids" says Benson Mudiwa, a Zimbabwean medical doctor based in Swaziland.

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The statements below can help providers sharpen their overall interviewing skills sensitively and
sensibly. Try them out for yourself. Does this help you improve communication with people who use or
inject drugs?
Normalising
“Many people find it difficult to talk about sex and drugs.”
Transparency
“I need to ask you some very specific questions about your drug use in order to better
understand your health needs and provide the best possible care”
Asking permission
“Would it be alright if I asked you some questions about your alcohol use?”
Option of now answering question:
“If you are not comfortable answering any of these questions you don’t have to answer
them”.
Avoid asking for judgments or opinions:
Don’t say,
“How often do you drink in a week or how many drinks do you have in one sitting?”
Better to ask,
“Do you get drunk? Do you drink often?”
Ask specific instead of general questions:
“Have you ever used mbanje? Have you ever used cocaine?

A healthcare provider’s role is to support a client to better understand the role of drugs in their
life, providing accurate information and taking the necessary steps to reach the client-directed
position. It is the service provider’s role to serve, not judge!

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Drug and Alcohol Use Screening Tools
While this module does not replace clinical guidance on management of clients’ drug use, delivery of
harm reduction interventions or clinical guidance around diagnosing abuse and/or dependence, it does
include helpful tips for healthcare providers who may be interested in supporting key populations who
use drugs and alcohol.
It is ultimately the client’s decision to stop, modify or maintain drug use depending on their personal
goals. The best method for assessing the way forward is:
1. Identify the client’s goals in relationship to drug use.
2. Engage in an open discussion about whether or not the client’s cur­rent use aligns with where
they want to be. The role of the healthcare provider is to motivate the client to talk about their
personal goals and come to a clear understanding of where they stand with their goals in relation
to their current drug and alcohol use.
Regardless of the outcome of such discussions, healthcare providers should aim to provide accurate
information about drugs, including risks of death (e.g. from overdosing) and any relevant local
information to help prioritise personal safety and security (e.g. taking possible measures to avoid a
drug-related arrest or losing a job).
Providers can effectively screen for drug and alcohol use in a general history taking session when asking
lifestyle-related questions such as diet, exercise, or sleep. A single question being used by healthcare
professionals in primary care asks clients the following question:
“How many times in the past year have you used illegal drugs or used a prescription
medication for non medical reasons?
A response of at least one time is considered positive for drug use.
Learning Exercise: Sharing Experiences ±30 minutes
Ask participants what they currently do to screen clients for drugs and alcohol. Share experiences in
the group. Ask the group to look at the tools summarised in the Participant Handbook. How can they
help? Do they need adapting? Discuss.
Approaching Drug Use in the Clinical Setting
As mentioned earlier, drug and alcohol use is a difficult topic for both healthcare providers and their
clients. It is therefore important for providers to be sensitive to their own anxiety as well as that of their
client, when discussing drug use. Healthcare providers should use appropriate language when asking
questions about drug use. Some principles to consider are:
l Begin by building rapport and confidence with the client.
l Remind clients that any information they share will be kept confidential. If information will be
shared, providers must tell the client with whom it will be shared and under what circumstances.
This is the same for information that the provider documents. Clients have a right to know if
what they disclose will be documented and how that information will be used.
l Remember to use a nonjudgmental and non-confrontational approach when discussing drug
use with clients.

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MODULE TEN:
Action Planning
Introduction
Change cannot happen from a workshop alone. Planning for change is important.
This module provides time for participants to develop Action Plans that document
their commitment to initiating positive change in their own practice and in their
workplace. This module also takes a practical approach through the inclusion of a site
visit to a healthcare facility that is already working well to support key populations.

It is best if participants work with others from the same facility when going through this final module, so
they can think together about how to improve their own institutional environment. But each individual
should also consider their own actions, and what they can do, even in the absence of wider change in their
facility, to make their services more friendly to key population members. Failing to plan is planning to fail!

Learning Objectives
After completing this module, participants will be able to:
l Share a simple, clear plan of action to improve services for key populations at the health facilities
where they work.
l Share their experience and gain insights from a field visit to an established KP healthcare site in
Zimbabwe.
l Network with health personal with experience of supporting key populations.

Resources
Time: This module needs a minimum of a full day to complete.
Flip chart and pens, Participant Handbook, transport and logistics for a local health facility site visit.

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Module Activities
Action Planning: ± 2 hours
Refer participants to the Action Plan Template in their Participant Handbooks, which includes the following
headings:

Topic Objectives Activities Time Inputs Responsible Expected Cost

Frame Person Outcome

Participants should work together to think about how to improve the institutional environment where
they work. But each individual should also consider what they can do, even in the absence of wider
change in their facility, to make their services more friendly to key populations.
l As facilitator, circulate among the groups and provide suggestions during the planning process.
l Encourage participants to think realistically and identify feasible ‘small steps that do not have
significant cost or resource implications’.
l At the end of the session, groups should present their plans.
l Ideally, there will be ongoing monthly feedback meetings for trained service providers and they
should hold each other to account for demonstrating efforts made to implement their Action
Plans over time.
l Encourage participants to include regular follow-up in their action plans.
Linking & Learning Session: ± 5 hours (Site Visit)
On the final day, participants should attend a Sisters with a Voice clinic or other MoHCC identified and
approved site to see the set-up, meet clinical staff, and talk to any key population clients who are
waiting for/ exiting services. If possible, a community mobilisation session should be organised for
trainees to observe.
After any site visit, make sure to have a de-briefing session with the group. The de-briefing
should include discussion about the facility itself, the services and the approaches used, as well
as how they felt about the services and approaches and finally, how they can begin to emulate
the same where they work.

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SOME ISSUES TO CONSIDER IN MAKING THIS TRAINING MORE EFFECTIVE
Clinic Attachments
Participants will benefit greatly from time spent at a healthcare facility experienced in supporting key
populations. This could be done on a rotational basis.
l During the attachment, trainees ‘shadow’ the clinic’s programme staff, working and treating key
population members.
l A feedback meeting can be held every month with all trained public health nurses, the programme
nurses, outreach workers and peer educators.
Meetings are aimed at reflecting on how the programme is going, sharing experiences on
working with key population members, as well as members of key population groups sharing
their experiences working with the nurses from the public system. This is an extremely valuable
part of the programme as it provides service providers with ‘hands on’ experience in working
with a group with whom they have little familiarity; this further helps to reduce stereotypes
about key populations and increases their willingness to serve them.
Monthly Lunchtime Meetings
Following training, monthly lunchtime meetings can be arranged to bring the trained nurses together
with any local peer educators and nurses from KP project sites to discuss on going progress with
implementing Action Plans, whether KPs are starting to come to their facilities and to share experiences
and identify solutions to any challenges they face. The peer educators also report any feedback from
local KP members about the ‘friendliness’ of the public health clinic.
Gain support from local stakeholders is critical
Authorities responsible for managing public sector health services need to be on board with the idea of
sensitising service providers to better meet KPs’ needs.
l The training programme needs approval and support so that staff in local clinics understand that
undergoing the training and changing their attitudes are both expected and encouraged from above.
l Before organising any training workshops, it is thus important to engage local health authorities.
Staff turnover can negatively impact sustainability of the training
l Clinic staff often move on, which means that the ‘friendliness’ of the clinic may decrease in their
absence.
l All trained staff should complete the clinic rotation or at least attend monthly follow-up feedback
meetings to build momentum for improved services to key populations.
l This challenge can be ameliorated by holding regular training opportunities so new staff
can benefit from them, and encouraging attitudinal change within whole facilities, not just
individuals.

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REFERENCES AND OTHER RESOURCES

Centre for Sexual Health and HIV/AIDS Research, Sisters with a Voice: Manual for Training Health Care
Workers, CeSHHAR: Harare (2018)

COC Netherlands, Proud & Healthy. An Overview Of Community-Based Needs Assessments On The Sexual
Health of LGBTIs in Southern Africa, COC: Amsterdam (2014)

Gays and Lesbians of Zimbabwe, Understanding Human Rights Recognition & Integration, GALZ: Harare (2017)

KP REACH, Championing Health For All: Supporting Health Service Providers to Know More about Persons
from Key Affected Populations Toolkit, SAfAIDS: Harare (2017)
Ministry of Health and Child Care, Zimbabwe National HIV and AIDS Strategic Plan (ZNASP III) 2015-2018,
MoHCC: Harare (2015)

MSMGF Johns Hopkins Bloomburg, Promoting The Health Of Men Who Have Sex With Men Worldwide: A
Training Curriculum for Providers, Johns Hopkins Bloomburg School of Public Health: Oakland (2014)
Population Services International, Strategy for Identifying Populations at High Risk of HIV Infection in
Zimbabwe. PSI: Harare (2016)

Positive Vibes, Setting the Levels A Process Guide For Participatory Monitoring Of Health Services, Positive
Vibes, Johannesburg (2017)
SAfAIDS, Health For All Toolkit: A Handbook for Service Providers: HIV & GBV Prevention for Key Populations,
SAfAIDS: Harare (2018)
The Desmond Tutu Foundation, Health Care Provision for Men who have Sex with Men, Sex Workers, and
People who use Drugs: An Introductory Manual for Health Care Workers in South Africa, The Desmond Tutu
Foundation: Johannesburg (2013)
Van Dyk, D. & Matlou, J. Binaries & Boxes, Understanding Human Sexuality. OUT Wellbeing (unpublished), (2010)
World Health Organization, Guidelines for managing advanced HIV disease and rapid initiation of
antiretroviral therapy, WHO: Geneva (2017)
World Health Organization, Consolidated guidelines on HIV Prevention, Diagnosis, Treatment And Care For
Key Populations, WHO: Geneva (2014)
World Health Organization, Consolidated guidelines on HIV Prevention, Diagnosis, Treatment And Care For
Key Populations Policy brief update WHO: Geneva (2016)

World Health Organization, Department of HIV/AIDS Guide To Starting And Managing Needle And Syringe
Programmes, WHO: Geneva (2007)

ZNNP+, A Manual To Support Community Antiretroviral Treatment Literacy In Zimbabwe, ZNNP+: Harare (2016)

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Journal articles

HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender
men who have sex with men in 8 African countries: A cross-sectional analysis, Tonia Poteat, Benjamin
Ackerman, Daouda Diouf et al., PLOS, Nov, 2017, Accessed June 2018

Web resources
https://www.crnbc.ca/Standards/CertifiedPractice/Documents/ReproductiveHealth/719STI
AssessmentDST.pdf
http://www.mhinnovation.net/sites/default/files/downloads/resource/Friendship%20Bench%20
Training%20Manual.compressed.pdf
https://www.youtube.com/watch?v=opxpE4ktFEY
https://www.youtube.com/watch?v=vjAHlBck5PA
https://doi.org/10.1371/journal.pmed.1002422

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NOTES

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