This month, in the framework of our project on addressing the HIV epidemic in the Western Balkans, we have conducted an interview with Lana Gobec, Executive Director of Legebitra, in Slovenia. Throughout the 2010s, decentralized Community Based Voluntary Counselling and Testing has been a key element of HIV prevention in the country and we wanted to talk with Lana to get a better understanding of this success story and its impact on fighting the HIV epidemic among the MSM population. Back in 2018, the organisation’s CBVCT) and outreach work was acknowledged by the World Health Organisation as one of the best practices in the health sector response to HIV in the European Region.
Legebitra first started CBVCT back in 2009, a piloted community-based testing programme through which fifty HIV tests were conducted. Year after year, the practice evolved to become one of the organisation’s biggest programs. By 2013, Legebitra tested around 600 people each year and had established good relations with relevant ministry directorates, experts and NGOs. Individuals could be tested for HBV, HCV and HIV infection, syphilis and oral/anal gonorrhoea. Testing for HIV and HBV infection was available since 2009, testing for syphilis and oral gonorrhoea was added in 2012 and testing for HCV infection and anal gonorrhoea became available since May 2015.
By 2015, through funding from the Norwegian Financial Mechanism, Legebitra, in partnership with Škuc Magnus, DIH, Helseutvalget for bedre homohelse/Gay and Lesbian Health Norway, Slovenia’s Clinic for Infectious Diseases and the Institute for Microbiology, started a new project "Respone to HIV" with strong focus on the community; Confidential CBVCT services (for HIV, HBV and HCV infection, gonorrhoea and syphilis) were successfully established in MSM meeting venues outside of Ljubljana. Services included counselling and providing psychosocial support to people living with HIV.
Lana argues that this approach has brought about a big change in community behaviour: differently from before, people started not only to get tested more regularly, but also to benefit from a de-medicalized, community based and non-judgmental program where they could also get information, education and feel free to express themselves. Through the years, the organisation managed to lower the months between testing from fifteen to eight. In 2019, 1400 tests were performed compared to 600 in 2015. Over time members of the community built their trust and confidence in the service.
For every person with a reactive HIV test, the organisation arranges an appointment at the Department for Infectious Diseases, Ljubljana University Medical Centre for a confirmation test, including the offer to be accompanied by a peer counsellor to reduce stress and anxiety during linkage to care. People living with HIV are also offered psychosocial support from their peers to cope with life after a positive diagnosis. Support is available 365 days per year; continuous development efforts include monitoring relevant policy and legislation implementation while remaining sensitive to the needs of people living with HIV. Legal support is also provided in reported cases of discrimination.
Providing HIV testing at the community centre alone, is of course not enough. A major step forward in increasing the number of tests was offering of the service at Club Tiffany, in bathhouses and smaller towns. Staff travels regularly in different locations across the country and in cooperation with local NGOs - who offer their spaces for testing - provide testing and counselling. Differently from the capital, in these spaces, the best way to reach out to the community is through chat rooms and dating apps like Grindr and Romeo. The community is much more hidden and discreet but over the years they have also built confidence and trust in the service. In the counselling sessions, participants can freely discuss with a counsellor their sex lives and ways to reduce the risks of HIV and STIs.
Challenges: funding, space & testing beyond MSM
Community based voluntary counselling and testing does come with challenges. Over the years, the organisation has increased the number of services in the community centre and now bigger and better premises are much needed.
Secondly, and quite importantly, the organisation is advocating for provision of the service not only to the MSM population, where the epidemic is concentrated, but also to other groups such as trans persons, sex workers or the women partners of MSM. Lana argues that the Ministry of Health (MoH) needs to be aware of these issues when developing its HIV program, and include such groups in the community testing programs.
Funding, of course, remains a challenge, which the organisation needs to address regularly. At the moment, funds are available until November 2022, and the new National AIDS Strategy which will run until 2025 will keep MSM as a key priority. The Ministry will fund the organisation for the next three years. One problem however, remains the fact that they expect the organisation to do chlamydia testing without additional funds.
Privacy and Confidentiality
In some countries and contexts, the community is not confident to get HIV testing and counselling at an LGBTI community centre. For those who wish to have their sexual orientation hidden, fears of being outed might discourage them to seek the service. While this might be the case for some individuals, Lana argues that for Legebitra professionalism and confidentiality are very important standards. Slovenia is a small country and the LGBTI community even smaller, so through work and dedication the organisation has gained the trust of the community as a safe and reliable place. In their last assessment beneficiaries have rated their service 4.8 out of 5.
Different communities are present in different spaces (community centres, clubs, saunas, cruising areas etc.) and it is important through the community outreach program to reach all of them. Those in saunas are more closeted while those in community centres are more at ease. One population they are struggling with, however, are the elderly who are the hardest to find as well as people from rural areas who are more discrete and more afraid to ask to get tested. They promote their testing hours and days in their social media as well as advertise them in dating apps like Grindr and Planet Romeo or hook up sites and chat rooms. Such spaces are especially important for cities and towns out of Ljubljana.
The services were established in 2009 when community-based testing was provided for 50 people. In 2017, 1018 people were provided with services (total number of all types of tests: 5358). Since 2015, the proportion of reactive clients has declined slightly: positive test rates were 1.32% in 2015, 1.26% in 2016 and 0.92% in 2017. Rates of first-time testers have been measured since 2016: they were 17.1% in 2016 and 16% in 2017 (average 16.55%). Linkage to care has also been measured since 2016: the rate is 100% – meaning that all clients with a reactive HIV test result have been included in the public health care system for confirmatory tests and treatment. Information on the confirmation of diagnosis has only been gathered since 2017: out of the nine reactive HIV test results, seven have been confirmed (rate of 78%) by laboratory testing at the Public Specialist Clinic for Infectious Diseases.
The programme shows normalization of testing within the MSM population and qualitative development of the service as a whole, with impressive satisfaction rates. The proportion of late HIV diagnoses among MSM had a decreasing tendency between 2012 and 2016, coinciding with increasing coverage with HIV testing in the community.
Financial support for piloting community-based testing programmes was provided by the MoH from 2010 to 2014. Key resources for developing the programme were provided in 2015 and 2016 through the Norwegian Financial Mechanism. However, a substantial increase in resources for implementing high-quality safer sex promotion programmes and early testing among MSM has been provided by the MoH from 2017 after adoption of the new National HIV prevention and Control Strategy 2017–2025.
The MoH of Slovenia finances 93.32% of the programme. The remainder of funding is allocated by the Municipality of Ljubljana, the Foundation for Funding Disability, NGOs and the Student Organization of the University of Ljubljana. Strategic partnerships have been formed between NGOs, health care providers, laboratories and the MoH, which guarantees long-term implementation and development of the CBVCT programme.