Update: National AIDS Programmes FHI, Horizons, HHS-CDC & HRSA, Macro, Measure, Synergy, USAID, WHO,UNAIDS Katherine Marconi, Ph.D., MS Presenter A Guide to Monitoring and Evaluating HIV/AIDS Care and Support

History Two years ago USAID with CDC organized a Care and Support Monitoring and Evaluation (M&E) Workgroup to review core indicators for monitoring and evaluating HIV care and support. HRSA agreed to co-chair the group and FHI, Measure-Macro, also joined it. WHO agreed to participate with UNAIDS.

History, cont. We defined a set of measures, piloted their meaning and feasibility in Ethiopia, Kenya, and The Dominican Republic. A pilot in Cambodia is scheduled for next week. WHO/UNAIDS took the lead in refining and publishing a version of the revised indicators as part of its new M&E workbooks.

History, cont. WHO sponsored an international meeting in March, 2003 to review and revise the indicators and to review the draft content of a guide. A final draft was produced by UNAIDS 5/03 and is being reviewed by participants of the international meeting, the original workgroup, and others.

History, cont. The guide will be finalized. It defines (1) what care and support programmes are, (2) what a care and support M&E system should be, (3) indicators for monitoring and evaluating different care and treatment components, (4) operations research, and (5) related readings. It is an interim document for use until more experience is gained in international HIV care and support.

Clinical Care (medical & nursing) VCT, PMTCT preventive therapy (OIs, TB) management of STIs and OIs palliative care, nutritional support antiretroviral therapy Human Rights & Legal Support stigma & discrimination reduction succession planning PLHA participation Socioeconomic Support material support economic security food security Psychosocial Support counseling orphan care community support services spiritual support Adults and Children Affected by HIV/AIDS r e v e t p i n o n Comprehensive HIV/AIDS Care and Support

. Objectives The objectives of HIV/AIDS care and support programmes should be: To assure equitable access to diagnosis, medical care, pharmaceuticals, and supportive services. To reduce morbidity and mortality from HIV/AIDS and related complications. To promote prevention opportunities within care and support service delivery. To improve the quality of life of both adults and children living with HIV/AIDS and their families.

Care and support M&E Pipeline INPUTS Funds Supplies Training PROCESS HIV testing OUTPUTS # of clients receiving VCTs OUTCOMES Referral Participation in care IMPACT Mortality MONITORING “Process Evaluation” EVALUATION “Effectiveness Evaluation”

Indicators Core IndicatorsMethodsFrequency CS1 The number of individuals receiving HIV testing and counselling in the last 12 months a)The number of individuals who received HIV testing b)Percent of those tested who received pre-test counselling c)Percent of those tested who were positive d)Percent of those tested who received their results through post-test counselling services Programme reports Annual CS2 The percent of districts with at least one health facility providing ART Programme reports Annual CS3 The number and percent of persons with advanced HIV infection receiving ART (UNGASS) Programme reports /modelling Bi-annual

Indicators, cont. Core IndicatorsMethodsFrequency CS4 The existence of comprehensive HIV/AIDS care and support policies, strategies and guidelines Interviews / record review Every other year CS5 The percent of facilities that either provide comprehensive care and support services onsite for people living with HIV or through an effective referral system Health facility survey Every 2-4 years CS6 Percent of health facilities that have the capacity and conditions to provide basic level HIV testing and HIV/AIDS clinical management Health facility survey Every 2-4 years CS7 Percent of health facilities that have the capacity and conditions to provide advanced level HIV care and support services, including provision and monitoring of ART Health facility survey Every 2-4 years

Indicators, cont. Core IndicatorsMethodsFrequency CS8 The percent of designated laboratories with the capacity to monitor ART according to national/international guidelines Health facility survey / special lab study To be determined CS9 The percent of persons aged who have been chronically ill for 3 or more months in the last 12 months whose households received free basic external support in caring for the chronically ill person Household survey Every 2-4 years CS10 The percent of orphans and vulnerable children less than 18 years whose households received free basic external support in caring for the child Household survey Every 2-4 years

Additional Indicators MethodsFrequency CS-A1 The existence of national monitoring and evaluation capacity for HIV/AIDS care and support programmes Interview / record reviews Every other year CS-A2 The percent of health facilities with record keeping systems for monitoring of HIV/AIDS care and support Health facility survey Every 2-4 years

Measurement methods To track the multiple levels of care and support, multiple measurement methods are proposed for both M&E. These include: National program reports review Interviews and record review Health facility surveys Household surveys Special studies

Districts providing ART Definition:The percent of districts with at least one health facility providing ART. Numerator:Number of districts with at least one health facility providing ART. Denominator:Total number of districts. Rationale and what it measures: This indicator is important to measure the coverage of ART within a country by looking at the number of districts where this treatment is available.

Districts providing ART, cont. Measurement tools and how to measure it: The numerator will include different types of NGO or government health facilities (social security, military, etc.), depending on the level of involvement of those sectors in the provision of ART. The following methodologies are recommended: (1) Reco rd reviews of the District Medical office or District AIDS Office, which may have a listing of all facilities providing ART (2) Record reviews of the NAP, or through a national drug management system of the MoH that should also have a listing of the facilities to which ART is being distributed (3) Health facility survey It is useful to have data on district population and the prevalence per district to compare how the availability of services matches the needs.

Districts providing ART, cont. Strengths and limitations: The method for measuring this indicator will depend strongly on the ability of the national and/or district levels to collect and provide this information. This indicator is particularly useful in countries where ART is first being initiated and/or in places where ART is only available in a few districts. As more districts begin to provide ART, countries should move to measuring the total coverage- the number of people who are receiving ART over the total number of people in need. Therefore, this indicator will need to be adapted as services become widely available in order to be useful. If a health facility survey is employed, it must be noted that purposeful sampling of facilities that provide ART is necessary.

Measurement challenges Quality of care Adapting measures for diverse settings Sampling units, e.g., hospital units, households vs. individuals Indicator definitions such as paid vs. unpaid services Measurement issues such as stigma and access to care and treatment of special at- risk populations

US Ryan White CARE Act AIDS Drug Assistance M&E Content Client Utilization Funding Formulary Eligibility Criteria Cost Saving StrategiesCost Saving Strategies – Drug Pipelines Drug Pricing Data CoordinationCoordination of Multiple Funding Streams

Lessons Learned Identifying program commonalities for M&E is a challenge, but is feasible. Diversity of nations and cultures must be recognized. Indicators, measures, methods must be practical and specific, and supported with skills and resources.