HIV Prevention targeting Sex Work in Mongolia: 面对预防艾滋病经性途径传播经验 - 蒙古

1. HIV Prevention targeting Sex Work in Mongolia:面对预防艾滋病经性途径传播经验- 蒙古 approaches and lessons learnt 蒙古国的方法与经验 Dr. L. Jambaljav Director General Medical Services Division, MOH Mongolia

2. Mongolia – a low HIV/AIDS prevalence & High vulnerabilitycountry蒙古： 一个艾滋病感染率低，但是感染风险高的国家 • Population: 2.5 million • 50% of the population are under 23 • High mobility: internal and external • 人口：250万 • 一半人口在23岁以下 • 国内和国际人口迁移频繁 * NCCD, MOH, 2006 ** WHO/UNAIDS, 2006

3. Mongolia – a low HIV/AIDS prevalence & High vulnerabilitycountry蒙古： 一个艾滋病感染率低，但感染风险高的国家 • Territory: 1.5 million square km • Landlocked • 领土： 150万平方公里 • 内陆国家

4. Mongolia – a low HIV/AIDS prevalence & High vulnerabilitycountry蒙古： 一个艾滋病感染率低，但感染风险高的国家 • 28 confirmed cases since 1992 - 5 before 2005 - 23 since 2005 自1992年以来，蒙古共确认28例HIV感染者，期中2005年之前5例，2005年之后23例。

5. Mongolia – a low HIV/AIDS prevalence & High vulnerabilitycountry蒙古： 一个艾滋病感染率低，但感染风险高的国家 • 8 female (3 SWs, 2 in ANC) • 20 male (15 MSM) • 15 from Mongolian citizens within Mongolia < 500 estimated cases • 8名女性 (3名性工作者，2名在产前门诊) • 20名男性（15名男男同性恋者） • 15名是蒙古籍公民 　 ＜估计感染人数约为500人左右

6. Mongolia – a low HIV/AIDS prevalence & High vulnerabilitycountry蒙古： 一个艾滋病感染率低，但感染风险高的国家 • Limited knowledge among the population - The 16.8% of mobile men who correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions: • 人口知识水平有限 - 16.8%的迁移人口知道预防艾滋病的相关知识 * SGSS, 2005 ** NCCD, MOH, 2005

7. Mongolia – a low HIV/AIDS prevalence & High vulnerabilitycountry蒙古： 艾滋病感染率低，但感染风险高国家 • Increased high risk behaviours, such as multiple sex partners, unprotected hetero- and homosexual practices, drug and alcohol use • 越来越多的高危行为：多性伴，无保护异性和同性性交，毒品和酒精的滥用 • Increased mobility, widespread poverty, restricted access to prevention and care services for vulnerable populations • 人口流动性频繁、贫困，脆弱边缘人群获得预防和保护相关服务受限

8. Mongolia – a low HIV/AIDS prevalence & High vulnerability country (cont.)蒙古： 艾滋病感染率低，但感染风险高国家 • High prevalence of STI among the general population and the high risk groups • 人口性病感染率高 *SGSS, 2005

9. Sex workers 性工作者 • Mostly freelance type, very few establishment based- Hard to reach out 大部分为自由职业者 - 很难全部发现 • An average sex worker in Mongolia reported two clients on the last day she had commercial sex 　蒙古平均每个性工作者最近一天接客两名 * SGSS, 2005 ** 0.5% of women 15-49 years of age

10. Sex workers 性工作者 • Approximately 4,000 SWs in the country 　－　Up to 8,000 clients risk contracting theinfection in a single day • Low condom use among the male population 　 －　Consistent condom use of mobile men with SWs was 30.6%* in 2005 • 全国各大概有4000名性工作者 － 每天有约8000名客人暴露在感染艾滋病的风险下 • 男性安全套使用率低 　－　流动人口中和性工作者发生性行为坚持使用安全套 　　　比例30% 左右

11. Sex workers 性工作者 • Legal environmentSW and Entertainment Establishments are prohibited by Mongolian Law • Inhibits prevention efforts by various Government agencies • 法律环境 　性工作在蒙古是非法的，一些政府部门阻碍了预防工作

12. Clients* 客人 41.2% Mobile traders & truck drivers 游商，卡车司机 Sex Workers 性工作者 21.4% Government workers 公务员 15.7% Businessmen 商人 1.5% Foreigners外国人 Source: SWs from central/urban areas (border area SW clients may be different) 20.2% All others其他 *SGSS, 2005

13. Comprehensive HIV prevention & support for CSW in Mongolia对性工作者的艾滋病预防和支持综合项目 Main Areas of Interventions • Community outreach and peer education (Legal support, medical services, empowerment, SRH education) • 100% Condom Use Programming (incl. green card) 主要干预： • 社区外展和同伴教育（法律支持，医疗服务等） • 百分百安全套使用项目（绿卡）

14. Comprehensive HIV prevention & support for CSW in Mongolia对性工作者的艾滋病预防和支持综合项目 • Male/Female Condom supply (incl. social marketing) • STI servicesDrop-in centres for CSW Special interventions for CSW working abroad (in border-areas) • 男/女用安全套供应（包括社会营销） • 性病服务 • 性工作者活动中心 • 对在国外工作的性工作者进行特殊干预

15. Comprehensive HIV prevention & support for CSW in Mongolia对性工作者的艾滋病预防和支持综合项目 Local Administration 地方政府 (Intervention of Regulatory authorities) Local Health Authorities 地方卫生部门 (Condom supply, STI services, health education, oversight/ reporting on compliance) Other Government 其他政府部门 Sectors (e.g. FP, Social Welfare) Media媒体 (Human Rights, BCC) Private sector私人部门 (Compliance of owners and workers of sex establishments (hotel, massage, sauna) and sex workers) Main role-players 主要角色 Police 警察 (management of Non-cooperative Establishments) NGOs/CBOs 非政府组织 (Condom Social Marketing, self-support groups, legal advise, empowerment) Policy Makers 政策制定者 (Creating an enabling environment for HIV prevention) Bilaterals/UN System 联合国系统 (Advocacy, technical and financial support)

16. Comprehensive interventions in Mongolia among SWs对性工作者的艾滋病预防和支持综合项目 • An obligation from the National Public Health Committee, signed by the Prime Minister of Mongolia, May 2005 • Community mobilization (capacity building, peer education and community outreach by the CBOs and NGOs) • Provincial and city governors’ resolutions on establishment of local 100% CUP Committees and start of the programme • 自2005年5月成为对性工作者的艾滋病预防和支持成为政府义务，由国家公共卫生委员会负责，蒙古总理签署。 • 社区动员（能力建设，同伴教育，社区外展） • 省市政府官员决意建立地方100% 安全套项目委员会，且已开展项目

17. Comprehensive interventions in Mongolia among SWs对性工作者的艾滋病预防和支持综合项目 • 100% CUP Committees and owners of entertainment establishments cooperate in implementing the 100% CUP • Logistic supports (condoms, STI services, education material) • Monitoring and evaluation of the programme • 100% 安全套项目委员会同娱乐场所合作推广项目 • 后勤支持（安全套，性病服务，教育材料） • 项目监督与评估

18. Sites implementing 100% CUP in Mongolia项目执行地点 Ulaanbaatar HU UV SE BUL BU DA ZA DO OR AR KHE KHO TU SB UV GA GS BKH DU DG UM Sites implementing 100% CUP Starting in 2006

19. Successes– at the pilot site试点成功 Condom use rate STI prevalence

20. Training for police officers organized by local health department

21. Successes– Participation成功经验：参与 • Community mobilization and participation of SWs • 动员社区，性工作者积极参与 • A Green cardsaves them from many risks, including police harassment. Green card was initiated by the SWs. 多功能“绿卡”的作用，包括：应付警察、“绿卡”是由性工作者想出的点子。 • Voluntarily come to the 100% CUP, no need for surprise mass arrests to find them 　自愿参与100%安全套项目

22. Successes– Participation成功经验：参与 • The private sector – owners of the EEs collaborated • 私人部门——老板们的合作 • Not a single EE was closed down or otherwise punished for non-collaboration • 没有一个娱乐场所被关张，或被处罚。 • Voluntarily involved their staff in training • 工作人员自愿参与培训 • Notified the CBO and the health workers of new SWs 向社区和医疗卫生人员通知新的性工作者

23. Training for Commercial Sex Worker on how to apply Female Condom

24. Successes– Green Card成功经验－绿卡 • A card is used to track the freelance SWs with a unique ID number (no name) and stamps from the local health provider regarding the dates of • 可用来跟踪自由性工作者的状况，只有一个来自卫生人员的唯一的编号和印鉴日期 • Blood test 血型测试 • Smear test 涂片测

25. Successes– “Side effects”成功－　“副作用” • Community ownership (self help group was formed), solidarity among the women • 女性自立自救团队形成 • SWs learned about safety at “workplace”and now avoid getting in or being victims of serious crimes – police likes this • 由于有了“安全的工作场所”，性工作者不再暴露于其他犯罪的威胁下 • Police officers learned that arresting and fining does not stop sex work – more respect for human rights of SWs and other people 警察不再对性工作者进行逮捕，尊重他们的权利

26. Obstacles – slower progress障碍： 较慢的进展 • Freelance SWs – effects of the 100% CUP can be seen much later than in countries with mostly EE based SWs 相对以固定场所性工作者为主的国家来说，蒙古由于大多是自由性工作者，100% 安全套项目的效果看起来要迟很多 • EE owners in Mongolia do not have same negotiating power as in those countries • 蒙古娱乐场所的老板们不像其他国家有那么强的沟通力

27. Obstacles – slower progress障碍： 较慢的进展 • Need extensive involvement of NGO/CBOs • 需要广泛的非政府部门、社区部门参与 • Need capacity building of CBOs • 需要加强社区机构的能力建设

28. Obstacles – slower progress障碍： 较慢的进展 • Payment after vs prior to sex • 交易原则：后付钱还是先付钱 • limited opportunities for the SWs and EE owners to enforce “No condom - No sex” principle 限制性工作者和娱乐场所老板，坚持执行“No Sex- No Condom”原则。

29. Obstacles – legal barriers障碍：法律方面 • Legal obstacles　法律障碍 • low participation of the police, mass arrests, TV and newspaper exposure of the SWs and their clients • Illegal nature of sex work • In some provinces police does not recognize 100% CUP and the Green card approach as legal • 警察参与项目不多，大量的逮捕，媒体对性工作者和客人的曝光 • 性工作非法化 • 一些省份仍然对100%安全套项目认识不清，不承认“ 绿卡”的合法作用

30. Obstacles – CBO capacity障碍：社区的能力 • Even in successful provinces many struggle to understand the legality of work of the government agencies among illegal groups (SWs) 　项目成功的省份也仍然存在争议，如何加强政府机构的对性工作者干预工作的理解 • Low capacity of CBOs • 社区的能力低下 • to find and gain trust of SWs • 发现并获得性工作者的信任

31. Obstacles – CBO capacity障碍：社区的能力 • to train peer educators and outreach workers －训练同伴教育者和外展工作者 • to obtain funding for activities and incentives for the peer educators ad outreach workers • 获得开展活动的资金支持以及加强同伴教育者和外展人员的动机 • to gain collaboration from the local authorities and the police －获得其他政府部门和警察的支持

32. Future plans未来计划 • Further expansion to the remaining 10 provinces 将外展和推广到其他的10个省 • Creating enabling legal environment – needs big discussion 争取创立合法环境　－　需要广泛的讨论

33. Future plans未来计划 • Advocating the local governments for allocation of funds 　倡导地方政府拨款 • to support local CBOs doing outreach work among SWs 支持地方社区开展外展工作 • to cover regular testing and STI treatment of SWs 覆盖性工作者的常规检查和性病治疗 － Procurement of condoms － 获取安全套

34. Future plans未来计划 • More attention to be paid to the sustained common understanding of the key role-players (elections, staff turn-over, etc.) 关注关键人物对外展工作的持续性的理解（关键人物的更换） Future plans未来计划

35. Future plans未来计划 • Regular training, experience sharing for the police officers, peer educators, outreach workers and entertainment establishment workers • 对警察，同伴教育者，外展工作者，固定性工作者的常规培训和经验分享 • Capacity building of CBOs • 社区的能力建设

36. Future plans 未来计划 • Establishing condom revolving funds at local levels 在地方建立安全套可持续发展基金 • Introducing microbicides when they become available: 在适当时候介绍杀微生物剂　 • Jell • Vaginal rings • Cervical diaphragm

37. Thank you!