M&E Framework for Programmes for Most-at-Risk Populations Regional Workshop on the Monitoring and Evaluation of HIV/AIDS Programs February 14 – 24, 2011 New Delhi, India

What is a Concentrated Epidemic? Epidemics are concentrated if transmission is mostly confined to individuals with high-risk behaviors and those in their sexual and drug use networks, and where protecting these groups would protect society more broadly Epidemics are generalized if transmission occurs mainly outside vulnerable groups and would continue despite effective vulnerable group interventions

Who are Most-at-Risk Populations (MARP)? These are sub-populations with elevated levels of HIV-related risk behavior and where there is potential for HIV transmission Populations may include: Female sex workers (FSW) Clients of FSW Injecting drug users (IDU) Men who have sex with men (MSM), including male sex workers (MSW)

What are HIV-related High-risk Behaviors? Unprotected sex with multiple-partners Unprotected sex with a partner who has multiple partners Unprotected anal sex with a male partner Sharing injecting equipment …occurring in the presence of HIV

Purpose of framework A “road map” or logic model for planning appropriate assessment, monitoring and evaluation in concentrated and low-level epidemic settings Can be used to bring stakeholders together to compile and analyze data in order to plan more effective intervention and improve programs Can be used as a capacity-building tool to identify strengths and weaknesses in planning, implementing and using strategic information at national and sub-national levels

Understanding the problem and potential response: 1 Understanding the problem and potential response: 1. What is the problem? The Answer Describes the nature, magnitude, and course of the overall HIV epidemic and related sub-epidemics Data Sources HIV prevalence from surveillance Estimates of the size of affected MARP populations Proportion of infections in MARP and projected course of the epidemic from modeling

HIV Prevalence in IDU and female sex workers This slide shows the very high levels of HIV infection among intravenous drug users in select urban areas in Asia. In all but two sites, over 1/2 of the IDU tests were found to be HIV positive. HIV prevalence among sex workers is much lower (though this is not the case in Mumbai). However, sexual contact between these two groups could mean rapid spread of HIV to these sex workers and then to their clients. Source: AIDS in Asia: Face the Facts. MAP Report 2004

Source: Strategizing Interventions among MSM in the Greater Mekong Sub-region (GMR) CDC-GAP/USAID-RDM/FHI-APD Workshop, 2004

Understanding the problem and potential response: 2 Understanding the problem and potential response: 2. What are the contributing factors? The Answer Describes determinants of HIV infection and contributing factors at the structural, community, and individual level Data Sources Rapid assessments and situation analysis Knowledge, attitude, and behavior surveys; Epidemiologic studies

Source: PLACE in Central Asia: A regional strategy to focus AIDS prevention in Almaty and Karaganda, Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 2002

Understanding the problem and potential response: 3 Understanding the problem and potential response: 3. What interventions are effective? The Answer Identifies appropriate and effective interventions to address the problem and the sub-populations affected Data Sources Review of existing information on what interventions are efficacious and effective Operations research, evaluation studies, and other special studies This step should include a review of the existing evidence and discussions with technical experts to determine which interventions are effective

Understanding the problem and potential response: 4 Understanding the problem and potential response: 4. What interventions and resources are needed? The Answer Identifies the specific interventions and resources that are needed to mount an effective and comprehensive response Data and Sources Needs analysis, costing, Response analysis including an assessment of current programming and estimated coverage

Monitoring and evaluating the response: 5 Monitoring and evaluating the response: 5. What are programs doing and are they doing it right? The Answer Assesses whether project activities are being implemented as planned and assesses the value of what a project or programme has achieved in relation to its planned activities and objectives. Data Sources Routine data from project monitoring systems, special process evaluations including assessments of service quality

Source: PSI Burma, 2007.

Example: Assessing Quality and Use Source: MEASURE Evaluation & IPSR, 2006

The Answer Data Sources Monitoring and evaluating the response: 6. Are programs being implemented as planned and are they reaching the target population? The Answer Determines whether or not the project is reaching its target population Data Sources Monitoring of program outputs and estimates of coverage based on 1) project records aggregated across partners combined with estimates of population size or 2) surveys.

Example: Monitoring Coverage Exposure to various types of NGO-related information sources about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998 – 2002. Source: FHI, BSS Source: FHI Bangkok

Monitoring and evaluating the response: 7. Are interventions effective? The Answer Examines program outcomes (e.g. HIV-related risk behaviors) and determines whether or not changes are attributable to interventions Data Sources Outcome evaluation studies with control or comparison groups, operations research, health services research, formative research, and other special studies.

Example: Outcome Evaluation The Sonagachi Project of Calcutta Intervention: community-based intervention to increase condom use among sex workers Design: randomized multiple group community trial conducted over a 15 month period Results: Condom use increased by 39% in the intervention group compared to 11% in the control group. Consistent condom use increased by 25% in the intervention group compared to 16% in the control group. Source: Basu, Janaand Rotheram-Borus, 2004

Monitoring and evaluating the response: 8 Monitoring and evaluating the response: 8. Are collective efforts impacting the epidemic? The Answer Assesses whether or not there are changes in HIV-related risk behavior and HIV prevalence in the population targeted by programs, and whether or not these changes are plausibly linked to overall program effort Data Sources Monitoring outcomes (e.g. risk behavior) and impact (e.g. HIV prevalence) using surveys and surveillance, triangulated analysis

Example: Data Triangulation Source: FHI Bangkok

Challenges to Collecting Data among MARP Political and/or legal environment may lead to discrimination, threat of prosecution if attention is brought to members of the sub-population Stigma may keep populations hidden making them hard to reach for programs or M&E

Ethical Considerations Follow a “do no harm” approach Maintain the confidentiality of client information Respect privacy and anonymity Informed consent Data collection should go hand-in-hand with programming These populations may already be socially vulnerable or marginalized for their behaviors, and data collection efforts that identify or bring attention to these populations may place them at additional risk.

MEASURE Evaluation is a MEASURE project funded by the U.S. Agency for International Development and implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill in partnership with Futures Group International, ICF Macro, John Snow, Inc., Management Sciences for Health, and Tulane University. Views expressed in this presentation do not necessarily reflect the views of USAID or the U.S. Government. MEASURE Evaluation is the USAID Global Health Bureau's primary vehicle for supporting improvements in monitoring and evaluation in population, health and nutrition worldwide.