Background: Overall adult HIV prevalence in Papua New Guinea (PNG) is 0.9% (UNAIDS, 2016), higher (1.1%--1.68%) among key populations (KPs), including female sex workers (FSW) (14.9%), men who have sex with men (MSM)/transgender women (TG) (8.5%) (NDoH, 2017). Two-thirds of women experienced gender-based violence (GBV) (Darko et al., 2015), and 41%-45% of FSW and MSM/TG reported sexual violence in the last 12 months (Kelly-Hanku et al., 2017). GBV increases HIV risk yet decreases service utilization. Sociocultural factors inhibit GBV disclosure and service uptake for all survivors; laws criminalizing sex work and sodomy heighten this inhibition for KPs. In 2015, FHI 360 began integrating gender and GBV interventions into its USAID-funded Strengthening HIV/AIDS for KPs in PNG project (2012-2018) to prevent GBV and to increase post-GBV service uptake. Initial interventions prepared service providers to offer KP-friendly, comprehensive post-GBV clinical services and then moved to GBV prevention, awareness and referral among KP, communities and other service providers.
Description: Interventions implemented in five health facilities and the outcomes are listed below. Disaggregated descriptive and trends analyses were conducted using health facility program monitoring data (fiscal year (FY) 2015-2017) to understand results from routine GBV screening and post-GBV care uptake.

Interventions implementedOutputs/outcomes
KP sensitization trainings for service providers (health care workers and GBV hotline counsellors).Service providers: ? Understand KPs'' vulnerability to violence, their rights to live lives free from violence and to access friendly and welcoming services should they experience GBV. ? Become more receptive to KPs accessing GBV and other services.
Development of a GBV screening protocol; Implementation of routine GBV screening among clients accessing HIV/STI services; Introduction of a minimum package of post-GBV care at health facilities with onward referral for non-health services.The 5 participating health facilities (1 in Madang Province and 4 in the National Capital District) have: ? Simple one page GBV screening protocol available to all HIV service providers ? The ability to provide the minimum 5 essential post-GBV services (psychological first aid, emergency contraceptives, post-exposure prophylaxis, prophylaxis for STIs and vaccination against tetanus and HepB). First sites offering GBV services specifically for KP. Number of all-population GBV service sites in Port Moresby increased from 1 to 5, and from 1 to 2 in Madang Province, increasing access in a community where travel between and among neighborhoods can be dangerous.
Training of HIV/STI service providers on the GBV screening protocol and the post-GBV care minimum package.Health care workers screen all clients accessing STI, HIV testing and ART services and provide the minimum post-GBV care package.
Sensitization of communities on GBV prevention/bystander interventions and post-GBV services. Strengthening post-GBV care referral linkages between communities and health facilities.Community leaders aware of GBV and its relationship to HIV, and where and how to access post-GBV care. Telephone counsellors working with GBV hotline counselling service became conversant with the referral pathways for post-GBV services and make referrals. Increase in number of referrals (including self-referrals) from the community.
Inclusion of GBV empowerment and safety planning in the community outreach minimum HIV prevention package. Training KP peer educators and GBV hotline counsellors towards engaging clients on GBV/post-GBV care referral pathways.Peer educators provide education to KPs on GBV, GBV prevention and identification and referral of survivors for post-GBV care. A standard operating procedure on GBV prevention, recognition and referral, and GBV safety planning tool kit developed. More KPs reached with GBV prevention and post-GBV care.
Revision of HIV data collection and reporting tools to capture relevant data on GBV screening and post-GBV care.Program monitoring data on GBV screening and uptake of post-GBV care available (disaggregated by sex, KP type, KP/general population, year), including: ? Number of individuals screened for GBV ? Number and proportion of GBV-survivors among those screened ? Number of self-referred GBV-survivors ? Number and proportion of GBV-survivors receiving post-GBV care.
[Interventions implemented to integrate GBV into HIV/STI services and outcomes]

Lessons learned: The number of GBV-screened individuals among clients accessing HIV/STI services increased from 718 (2015) to 8,426 (2017). The percentage of individuals screened and identified as GBV-survivors remained low compared to survey results (Darko et al., 2015). The number of GBV cases expanded exponentially. The percentage of survivors seen (including walk-ins/referrals) receiving post-GBV care for both sexes increased sharply before a 2017 slight decline. The percentage of GBV survivors among KPs who received care increased sharply (2015-2017) (MSM/TG: 0% to 86.1%, FSW: 33.3% to 86.5%).

Trends in Post-GBV Service Uptake
[Trends in Post-GBV Service Uptake]

Conclusions/Next steps: In this context, increasing the number of service points, providing integrated KP-friendly and comprehensive GBV services combined with community GBV awareness and referral had a dramatic impact on post-GBV care uptake. However, proactive screening did not increase the proportion of GBV survivors identified by much, suggesting other factors exist affecting GBV survivors'' disclosure.