1. Background

A brief description of the organization receiving RRF and why funding was requested.

The issue of male to male sexual behaviours has profound implications for the STD/HIV/AIDS epidemic in Nepal and whether its rise can be halted or reduced. Due to cultural, religious and social reasons, these behaviours are to a large extent invisible, often difficult to access in terms of standard sexual health promotion frameworks, and not contained within a heterosexual/homosexual framework. In fact anecdotal and direct research indicates that levels of male to male sex in Nepal are very high, that a significant number of males involved in these activities are married or will become married, and that many boys and male youths are also involved in these activities.

What appears to exist in Nepal is a range of sexual networks that cut across class, religion, age, ethnicity and income status. However, male to male transmission of STDs and HIV will be invisible because of the relatively low levels of testing of males and because such behaviours are denied by the boys/men themselves. Further many of these males will also have sex with females, thus having an impact upon women's reproductive and sexual health. From our evidence, most of this sexual behavior is risky and unprotected.

Blue Diamond Society (BDS) was founded in 2001, following a five-month consultation, in an effort to address the needs of MSM. Its initial efforts focused on distribution of condoms and lubricants to MSM living in Kathmandu. BDS has developed services in Kathmandu, including outreach education, a social support group and general support to individuals. At present, BDS conducts the only STI and HIV/AIDS prevention programme in Nepal that targets the MSM community.

A rapid ethnographic study of male-to-male sexual life and related sexual health issues in Kathmandu, Nepal was commissioned by Family Health International (FHI/Nepal) and was carried out between 18 November and 7 December 2001.

Blue Diamond Society organized a two-day training workshop from 24-25 November 2002 for MSM in Kathmandu, sponsored by UNAIDS. The aim of the workshop was to gather together men from amongst the nascent communities and networks of MSM in Kathmandu and to begin a process of outreach training and self-exploration.

BDS organized another special consultation meeting on "Male Reproductive and Sexual Health" from 11-13 January 2002. Participants went through a 3-day process of identifying issues, clarifying needs, and generating recommendations for action. There were 30 participants, representing a broad spectrum of Kathmandu residents from different social, economic and ethnic backgrounds, and of various geographic origins. A number of guests and observers were invited to participate including representatives from UNAIDS, World Food Programme (WFP), FHI, and from local NGOs working on similar issues.

Because of social stigmatization, invisibility and denial, there were almost no STI/HIV services focused on the issues of male-to-male sexual behaviors nor on anal sex as a high-risk behavior. Reproductive and sexual health information and services are primarily focused on so-called "heterosexual" behaviors, i.e. vaginal sex, and ignore the high levels of anal sex between males, many who also have female sexual partners, including wives.

With the rapid ethnographic study and the needs of MSMs/MSWs/Clients in mind, funding was requested to address the lack of appropriate provision of sexual health promotion for males who have sex with males in Kathmandu through the development of appropriate outreach STD/HIV/AIDS education, condom promotion, and empowering such males to access STD treatment services to reduce risks of STI/HIV transmission.

2. Activity Objectives

This project has been in development in the four months preceding April 2002. The project seeks to address the lack of appropriate provision of sexual health promotion for males who have sex with males (MSMs) and male sex workers (MSWs) in Kathmandu. This has been addressed through the development of appropriate outreach STI/HIV/AIDS education, condom promotion, and empowering such males to access STI treatment services to reduce the risk of STI/HIV transmission to their partners.

Through outreach activities the MSMs/MSWs have been contacted and provided with repeated one-on-one educational contacts to encourage them to promote the adoption of safer sex practices including partner reduction, correct and consistent condom use and alternative sex (masturbation, frottage, avoiding anal sex).

i. Capacity-building of BDS through the establishment of an office/drop in center, team-building exercises and recruitment and training of community based outreach educators.

BDS, a registered NGO, has established its office for this Behavior Change Information (BCI) project. The Kathmandu office supports program management, coordination, and networking activities.

1. Establishment of office cum drop-in center. Services at the drop-in center include: (1) Interaction with MSMs/MSWs and clients, provide information, Information Education Communication (IEC) materials, condoms, lubricant and counseling and (2) A team of 7 staff including 6 outreach educators in the project.
2. Team building/planning workshop: After the recruitment of outreach educators, BDS has organized a team building/planning workshop for the staff. The following training was provided to appropriate staff: (1) Outreach, interpersonal communication skills and advocacy training; and (2) HIV/AIDS/STI counseling training. BDS has developed a curriculum guideline as well as training materials to conduct mentioned training.

2. Outreach education/Awareness raising activities on HIV/AIDS & STIs

The major component and central focus of the project is outreach activities including contacting (identifying) MSMs/MSWs and their clients and regular one-on-one educational contact by outreach educators. This approach aims to first create awareness, and then bring about changes in high-risk behaviors, among the primary target groups namely MSMs/MSWs and their clients. Outreach activities have intrinsic value since information flows directly to the target audience, thus the quality of information can be controlled. The community based outreach educators visit the MSMs/MSWs and their clients at different locations, where they feel accessible and comfortable, to have behavior change interactions and discussions.

Initial contacts with newly contacted MSMs/MSWs and clients are individual. Group interaction and social meeting is done at a later stage, especially with the established MSMs/MSWs and clients. The outreach educators educate clients on basic and general information on: HIV/AIDS/STIs and condoms; and different aspects of safer sex practices (including consistent and correct condom use, reduction of non-regular sex partners and alternative sex practices like non-penetrative sex activities etc.) Outreach educators perform demonstrations of correct condom use during the interactions. At the same time, IEC materials and condoms are provided. An important component of the project, supporting targeted BCI, is awareness creation among the MSM population in the project area. Awareness raising activities are comprised of interactive dialogues, condom promotion, IEC distribution, HIV/AIDS awareness related audio/visual programs, etc. IEC materials for creating and raising awareness among the targeted population are developed by BDS itself. Besides this, other relevant IEC materials are acquired free or purchased from different institutions and distributed to the primary and secondary target populations. BDS provides the IEC materials and condom wallet.

1. Identify MSMs/MSWs and their clients while preserving their anonymity.
   
2. Conduct one to one educational contact
   
3. Train MSMs/MSWs and clients on safer sex practices
   
4. Conduct basic orientation training on HIV/AIDS/STIs and condom use and safer sex practices to MSMs/MSWs and their clients
   
5. Develop simple IEC materials targeted to for MSMs/MSWs and clients
   
6. Conduct HIV/AIDS related Audio/ Visual programs to raise awareness among MSM
   

Ten peer educators (PE) were to be identified from the group of contacted MSMs (eight) and MSWs (two) and trained. These individuals are to serve as an asset for the future in aiding BDS's pilot BCC project for behavior change interactions and interventions such as one-on-one repeated educational contact, condom use demonstration and condom distribution and awareness raising activities like interactions, IEC material distribution, camps and campaigns. Besides this the MSMs and MSWs will be encouraged to make use of a hotline at the Drop-In Center (DIC) of BDS. BDS accomplished these objectives.

1. Select/identify peer educator(s)
   
2. Train at least ten peer educators
   

Condoms are available in the project areas but the MSMs/MSWs and clients do not have access when required. Most of the contacted MSMs/MSWs and clients do not use condoms during sex.

BDS will provide knowledge and skill on correct use of condoms and lubricant as well as foster increased use of condoms by increasing accessibility to the primary target group. Condoms and lubricant will be obtained at no cost for free distribution from The Foundation for Integrative AIDS Research (FIAR; http://aidsinfonyc.org/fiar). Condom distribution will start from beginning of Month 2.

There were many exciting results since April 1, 2002. Perhaps the most significant outcome has been the trust and community sense that has been developed between Blue Diamond Society and the MSM community all of whom are working and helping each other with dedication and commitment. This made for a stimulating four months raising many issues and indicating the way forward for future activities for Blue Diamond Society. Here are some of the objectives achieved:

From the 1^st of April Blue Diamond Society has rented a space in Lazimpat, Kathmandu as an office cum drop-in center. Office equipment and materials have been procured as required. Six community-based outreach educators (OE) were recruited immediately.

Through outreach, BDS shares knowledge, awareness, and provides information on practicing safer sex. Outreach workers have been conducting field research since, 1^st April 2002 with the help of Family Health International (FHI). Before the outreach programme, BDS had conducted two 2-day and two 3-day outreach sessions under the collaboration of UNAIDS and FHI. After implementing the outreach programme, BDS has been able to complete four months of outreach beginning 1^st April 2002. In these four months, BDS has implemented its outreach programme, administration work, and a drop-in center. Its achievements, plus and wishes are described below.

For four months, BDS, with the help of six outreach workers six days a week, has been doing field work. Working in areas of the Kathmandu Valley where MSM gather, meet, and choose sex partners, the following places were initially targeted:

• Ratna Park
  
• Pashupatinath, surrounding areas, and the jungle
  
• Bishalbazaar
  
• Newbuspark
  
• Thamel
  
• Different public toilets
  

Other areas have been identified and covered subsequently.

While doing outreach, the above places were found to be most accessible for the MSM community because of the following:

• The MSM community has met in these areas for 30-40 years, during its gradual formation.
  
• It is enjoyable to pass time in such areas.
  
• It is easier to have sex because of brushy areas and hidden spaces.
  
• These areas have public toilets, which are a common venue for sex.
  
• It is easy to call clients in these areas.
  
• The above places are central areas for foot traffic.
  
• Due to unemployment, people pass time in these areas.
  

The outreach workers went to theses places six days a week. While working there, workers were able to acquire a large amount of information and faced some difficulties, challenges, and feedback, which are as follows:

• Nepal bandhs (general work stoppages) - the political situation results in difficult working conditions.
• Some people think negatively of workers distributing condoms and lubricant.
• Clients wanting to have sex with the outreach workers.
• Thugs, police, and robbers give difficulties to the outreach workers.
• Clients threaten outreach workers so the workers will solve their unemployment problems.
• Some MSM don't want to talk about condom and safer sex. The outreach workers were scolded often.
• While doing outreach, crowds gathered around outreach workers.
• Other people took condoms while disturbing MSM.

• The outreach programme should launch in others parts of the country as well.
• There should be clinics for the MSM in the convenient areas.
• There should be free health check-ups for MSM who are economically poor.
• There should be a rehabilitation center for MSM affected by a deadly sexual disease.
• Condoms should be a bit thinner and the lubricant should not be scarce.

By working in the field and gathering all the information: total number of condoms distributed, total number of lubricants distributed, number of clients referred to STD treatment organizations, numbers of people using or not using condoms in different sexual activities, and awareness by MSM if they are HIV negative or positive, the responses are stated in the diagram and flow chart (see the attachment"chart")

Likewise, during different sexual activities, condom usage has increased drastically as compared to before the last four months. This may be due to counseling by the outreach workers, as the data represents that after a month, condom usage had greatly increased. The Blue Diamond Society has considered these changes in behavior as a measurable success.

Within the last four months, several drop-in clients were given counseling. These clients were given sexual health as well as psychosexual counseling. Since there is no clinic at Blue Diamond Society, they were referred for treatment to Chechen Clinic of Boudha. Because of its specific issues, there is a need for a separate clinic for the MSM community.

Workshops and trainings related to HIV/AIDS, STDs, and safer sex were organized on different dates. Through outreach workers, many members of the MSM community of the Kathmandu valley were met and called for the programme.

Blue Diamond Society has been organizing different social functions, gatherings, and meetings for the MSM community so that they can come together, show support to one another, and share their joys and sorrows. The following are the main programme organized by Blue Diamond Society for the MSM community in the past four months:

• Blue Diamond Society celebrated the Nepali new year on the 1st of the Nepali month, Baishak, 2059. All the MSM were invited and many came and introduced themselves in Blue Diamond Society's office. This was the first time that many of the MSM met together. They encouraged Blue Diamond Society to take further initiative. With the celebration of the new year, a new strength and motivation rose in everyone's mind.
• According to our culture and traditions, we celebrated Mother's Day on 12^th of May 2002.
• On 26^th May 2002, Blue Diamond Society organized a cultural programme on the topic "HIV/AIDS." It took place in the Hotel Park Village at Budhanilkantha and was coordinated by the International Red Cross Society. The programme was highly praised by the national and international participants.
• On Anti-torture Day, 26^th June 2002, the director of Blue Diamond Society, with four other members, went to the Human Rights Commission and presented the "tortured statement" and was able to bring attention to the people of the MSM community.
• On the same day, 26^th June2002, the advocator Sapana Malla Pradhan talked on "Homosexuality and Law." This gave the participants a type of counseling, which showed what they could and couldn't legally do. The speech also demonstrated what could they do for the tortured. Ms. Pradhan even promised to help the MSM community, which was a great inspiration.
• On 25^th June and 5^th July, there was a discussion about a separate MSM clinic. For that, FHI and NCASC representatives came and listened to the problems faced by the MSM community. No commitment has been made.

In addition to the above programme to raise the voice of the MSM community in different parts of Nepal, Blue Diamond Society has been successful in giving information in different newspapers of Nepal on different subjects like health and social problems. Within a small period of time, Blue Diamond Society has become a hugely successful organization in raising the awareness the people of Nepal.

In the span of four months, Blue Diamond Society (BDS) has been conducting various staff training and general sexual health training programmes. The following points demonstrate the strengths of BDS. The single greatest achievement is the vast improvement in services offered by BDS now compared to when the organization first began. The following are the achievements of Blue Diamond Society in the span of four months:

• CONFIDENCE FROM EXPERIENCE: While working in the field, outreach workers have become more confident. At first, there were feelings that there may be difficulties from family, society, and the public.
• COMMUNICATION SKILLS: The format of how to speak with clients has been improved. Workers have learned how to communicate more effectively.
• PROBLEM SOLVING: Workers have learned to solve individual problems according to the situation.
• FRIENDSHIP BUILDING: Many workers, while in the field, made new friends in this new environment. Even the workers who rarely spoke became closer after doing outreach.
• WORKING AS A TEAM: Teamwork is vital to completing tasks such as fieldwork, report writing, and group discussions. Outreach workers learned to coordinate their efforts and work well together.
• LEARNING MORE ABOUT THE COMMUNITY: While working in this environment, outreach workers became aware of the hardships MSM face, such as abuse and harassment from thugs, police, and thieves. Through interviews and conversations, workers also learned about MSM's economic status, awareness of STDs/HIV/AIDS, and social status with society and family.

• FEELING OF HELPING OTHERS: While working in the community, workers were helping one another and members of the community, which helped them feel fulfilled.
• RESPECT: Working together, workers have used active listening skills and learned to respect their peers and clients.
• UNDERSTANDING WHAT MAKES A COMMUNITY: Through their work, while facing challenges and sharing joys, the group of workers came to know the value of community.

• INTERACTING WITH OTHERS: Visiting frequently in the center has allowed drop-in clients to meet many new people and experience many different personalities. They were able to express their problems and difficulties while gaining the experience of others.
• SKILL DEVELOPMENT: Drop-in clients became volunteers, who gained experience in administration duties such as record keeping, monitoring, and report writing, as well as basic counseling.
• SHARING INFORMATION: Drop-in persons have been able to share knowledge and skills with each other such as languages, computer training, dancing, and health education.

• HIV/AIDS, STDs, AND SAFER SEX: A great achievement of the workshop was that participants learned about issues like HIV/AIDS, STDs, safer sex, sexual hygiene, and condom negotiation.
• A CHANGE IN THINKING: Through the training, the concept of what and who they are profoundly changed among participants. Before the training, they viewed themselves as second-class citizens, but after the training, they view themselves as an important part of society, the same as any other male.
• CHANGES IN BEHAVIOUR: Before the training, they had unsafe sex, but now they use condoms. This is a great change in their behaviour, and a major success of Blue Diamond Society.
• FEELING OF RESPONSIBILITY: MSM have an expanded sense of responsibility after working with BDS.
• LEARNING TO DO OUTREACH EFFECTIVELY: Through training, workers learned how to cope with problems associated with outreach, making their work effect and benefiting the clients.

There is a substantial difference in the behaviour of MSM now from their behaviour four months ago. Many MSM used to follow anyone they found attractive without thinking about their actions or if they had a condom with them. MSM rarely, if ever, carried condoms. Now, when they meet someone for sex, they check to make sure they have condoms, or they call and meet an outreach worker for a new supply. Because of the outreach workers' efforts, there is no shortage of condoms in the community. MSM now insist upon using condoms for sex. This is one of the biggest achievements of Blue Diamond Society. With the change in behaviour of MSM, Blue Diamond Society has increased its hopes to obtain its goals and objectives, and to further serve the MSM community.

Even though Blue Diamond Society has been established for a short period of time, it has been able to positively affect the MSM community in many ways. MSM have faced such problems as physical health problems, mental health problems, and social issues. Being a MSM usually accompanies many societal pressures, stigmas, and fears of being ostracized. BDS has reacted by integrating social and psychological issues into its objectives. With this commitment, the organization hopes to improve the lives of MSM community members.

Total number of Manuals produced during the three months: 6

First phase of OE 3 days training workshop on Outreach, IPC (interpersonal communication ) and advocacy was conducted on 7^th-9^th April, 2002. Outreach Education was started from the second week of April, 2002.

IEC and BCC materials was designed in the month of April and distributed for testing.

On 8^th- -9^th of May, 2002, 2 days training workshop for 25 MSMs on Basic HIV/AIDS/STI and safer sex was conducted. Another similar training for another 25 MSMs was conducted on 24^th – 25^th, of May, 2002.

In the month of June from 23^rd- 24^th two days training workshop for 10 MSWs on Basic HIV/AIDS/STI orientation training was conducted.

In the month of July from 3^rd- 5^th 2002, three days training workshop for staff on Pre/post hiv test and psychosexual counseling training was conducted. Number of participants :10

On 23^rd –24^th July 2002, Peer communication training for 16 peer communicator was conducted.

The total number of MSMs (distinctions such as Meta, Ta, Gay are self proclaimed) reached overall is 5258 of whom 2636 were new in the past four months; 13171 condoms and 1843 lubricants were distributed in Kathmandu.

Please find the attachment for other details: Chart

A brief description of any major lessons learned by the organization from this activity

• More Confident through experience
• Communication skills
• How to deal with problems
• Friendship building
• Working as a team
• More knowledge about the community

• Helping each other
• Respect each other
• Understanding what makes community

• How to interact with each other
• Skills development
• Sharing information

• HIV/AIDS/STIs, safer sex, condom use and related interventions
• Change the way of thinking
• Behavior change
• Knowing the responsibilities
• How to do outreach effectively

And the most important achievement for Blue Diamond Society is that for many MSMs, using condoms has become a habit.