1. 1 What is Analysis and Advocacy? The philosophy & tools of A 2 40 th Summer Seminar on Population June 2 nd – July 2 nd, 2009 East-West Center, Honolulu

2. 2 Strengthening strategic information for better HIV/AIDS programming in Asia

3. 3 A 2 is: An outgrowth of a growing sense of frustration

4. 4 We know what to do about HIV in Asia… We understand Asian epidemic dynamics We have examples of effective responses Low or no risk females Clients Low or no risk males MSMIDUs FSW Thailand – 6 million infections averted

5. 5 …but we’re not doing it Coverage is low… …and HIV epidemics continue to grow

6. 6 What’s Gone Wrong? Lots of data, but no one puts together the “big picture” Despite 2 nd generation surveillance guidelines, existing information on -Past and present responses -Epidemiology (HIV and STI) and -Behavioral data is not being analyzed in integrated fashion Critical analysis of response alternatives missing Data quality improvement is not being done Data is not being used for effective advocacy

7. 7 In short, the data collected is not influencing decisions….

8. 8 …and the understanding and political commitment needed to make the right decisions is lacking!

9. 9 So what can we do about it? A 2 Integrated Analysis and Advocacy

10. 10 How is A 2 done?

11. 11 1. Local teams gather & synthesize existing data Existing data collected & critically analyzed: –Epidemiological/behavioral/biological (IBBS,BSS) –Sizes of key populations –Responses: programs and policies –Program costs and coverage Key trends in HIV, behaviors and responses Identify gaps & quality issues in data systems Current state of the epidemic and response

12. 12 The process itself builds understanding of our data and its limitations Bangladesh A 2 –How many are at risk? –Involved government, NGOs, communities in meetings on specific populations –Reviewed service statistics, scientific studies, expert opinions Outputs –Consensus on size of risk populations –New estimates of PHA

13. 13 Careful review identifies issues in data systems & aids interpretation Vietnam national estimates and A2 –Inconsistent trends -> protocol issues in the field –HCMC trends explained

14. 14 2. Develop a local model of the epidemic the Asian Epidemic Model (AEM) Sizes & behavioral trends in Clients Sex workers IDUs MSM Population at large AEM Calculation Engine Observed HIV trends (white lines) Injecting drug usersFemale sex workers Adult malesAdult females Probabilities of transmission and start years

15. 15 Use the model to determine where new infections come from… Help in deciding appropriate focus for effective programs –Clients and sex workers, IDU, MSM –At advanced stages husband to wife & MTCT

16. 16 …and to tell us where the epidemic is going Determine levels of current, cumulative and new infections in the country –Adult and child Make projections to assess future needs and impacts –ART needs –Affected children (in development)

17. 17 Dhaka – high risk rapidly growth epidemic

18. 18 3. Evaluate the impact of different programs choices & resource allocation decisions ….. Responses and resources needed for maximum impact Through linked AEM/GOALS Modeling The GOALS model: 3 modules… − Resource needs module − Impact module − Capacity module

19. 19 GOALS relates programs, costs & behaviors BudgetCoverageProgram mix Program support Policy Interventions Prevention Mitigation Care and treatment $ $ $ $ $ % % % Improved Policy environment Behavior change -age at first sex -number of partners -condom use -STI treatment -safe injections AEM for epi impact Increased care, treatment & mitigation Treatment coverage

20. 20 GOALS Resource Needs Module Inputs: –Population size, –Unit costs and –Coverage (current and to be achieved). Answers crucial policy questions: –What are the costs to achieve a specific prevention goal? –What financial resources are required to implement a national/provincial HIV plan?

21. 21 Allows costing of prevention plans Yunnan provincial plan based on targets in National 5 Year Action Plan (2006-2010) 2006: US$25.3 m 2010: US$64.2 m Note: numbers are not final and are for illustration only

22. 22 How much will care cost us? ART costs in Thailand Source: Thai MOPH, World Bank, East-West Center, Expanding Access to ART in Thailand, 2005

23. 23 Allows determination of resource gaps Guangxi, China By 2010: RMB 1.5b (US$190m) Gap between funds to implement the latest national HIV/AIDS plan & available funds Raises the issue: How to increase resources and choose most effective program combinations Note: numbers are not final and are for illustration only

24. 24 Goals, Objectives and Intervention choices Pre-Intervention: 40% of IDU reached with peer education & outreach Post-Intervention: 90% of IDU reached with peer education & outreach Baseline Behaviors Risk Behavior before Interventions Risk Behavior after Interventions IMPACT MATRIX # sharing partners % HIV+ among IDU % sharing needles Freq of injecting Impact AEM # sharing partners % HIV+ among IDU % sharing needles Freq of injecting Impact matrix based on published studies of program effectiveness GOALS Impact Module behaviors for AEM Based on program coverage & resource allocations

25. 25 HCMC explored impact of 4 policy alternatives: Scenarios Scenario AScenario BScenario CScenario D Clients and FSWMSM & MSWIDU Recommended Scenario Migrant workers60%30% 50% Workplace60%30% 50% High school students30% Out of school youth50%30% 40% Women in community30% Direct FSW70%60% 65% Indirect FSW70%60% 65% IDU counseling & testing30% 80%60% Needle and Syringe Program10% 30%20% Methadone Program12.8%15.8%16.8%13.4% Naltrexone Program5% Peer outreach for MSM30%80%30%50% Peer outreach for MSW30%80%30%50% Prevention Costs in 2010 $4,008,976$4,003,596$4,005,579$4,006,138 VND 63.74 billionVND 63.66 billion VND 63.69 billion VND 63.70 billion

26. 26 Comparison in relation to the baseline: New HIV infections under various policy scenario alternatives (A-D)

27. 27 4. Turn strategic information into action Interactively engage policymakers, communities, program managers, donors & others to: –Build a common understanding of epidemic –Identify realistic alternative program packages –Evaluate costs, effects, & benefits of packages Show them the consequences of their choices Implementation of the most effective policies and programs, and mobilization of adequate resources

28. 28 Policy mapping Identify policy processes and who to engage: policy makers, program managers, communities, donors, other stakeholders Analyze impacts of response alternatives GOALS/AEM Meet decision makers (formal/informal) Increase understanding Identify issues Present impacts of response alternatives Solicit input on what to change Reprioritize & redefine response Reevaluate who is engaged in process Evidence for decision making Interactive engagement Policy briefs, meetings, data for planning, M&E

29. 29 How is this done in practice? Methodology in the field

30. 30 Synthesis specialist(s) Advocacy specialist(s) A 2 core team at local institution Technical Working Group Advocacy & Data Use Group Regional A 2 Team (EWC, FHI, HPI) In-country technical support, review and advice Regional technical support, review and tools development A 2 in-country Policymakers Decision makers Affected communities Program managers International NGOs & donors The public and the media Who to engage, involve & inform Researchers

31. 31 Features of the A 2 process Inclusive – engages those it targets Leverages existing local data & capacity Remains focused on responses Aims for sustainability by engaging local agencies

32. 32 Where does A 2 operate? The 5 formal A 2 sites supported by USAID: –Bangladesh (FHI Bangladesh) –Guangxi, China (Guangxi Center for AIDS and STD) –Ho Chi Minh City, Vietnam (HCMC PAC, NIHE) –Thailand (PRI, Burapha University) –Yunnan, China (Yunnan CDC) –Started in late 2004 Variants in –Hong Kong (Special Preventive Program) –Various Chinese provinces Future site –Malaysia (Malaysian AIDS Council)

33. 33 What has A 2 achieved to date? Mobilization

34. 34 Put prevention back on the map in Thailand Working with Director General DDC & MOPH –Thailand adopted and announced goal of cutting new infections in half by 2010 –Office of Health Security allocated 500M Baht Organizing prevention consortia for key populations as input to National AIDS plan Supporting provincial planning in Chonburi –Responds to decentralization of plans & budgets –Mobilized local funds for AIDS

35. 35 Sized up the situation in Bangladesh First size estimates for at- risk populations Provided donor inputs on need for focus –USAID, DFID, World Bank Promoted scale up of FSW & MSM programs

36. 36 Gave prevention focus in HCMC Adapted National Action Plans for comprehensive focus on at-risk pops Formally recognized MSM as at-risk pop Expanded budget for at-risk pops – 1.4B VND in 2005 –21.9B VND in 2007 Expanding to Haiphong

37. 37 Expanded local to national level in China Informed local planning in Yunnan & Guangxi –MSM focus added –Resource gaps assessed YN/GX as resource for other provinces & NCAIDS Adapted tools for China –Chinese GOALS –AEM now being applied for national projections Providing input to national planning –GFATM consolidation

38. 38 Mobilized MSM responses in Hong Kong Data showed HIV growing rapidly among MSM Prepared scenarios on what was possible & costs of inaction Met with MSM community, policy makers, AIDS Trust Fund Results –$9M HKD special fund –Community mobilization –Prioritization of MSM prevention Comparison of ART costs with and without effective MSM prevention Impact of effective MSM prevention

39. 39 What has A 2 achieved to date? Policy change & resource mobilization in real time

40. 40 What are some of the issues arising in the field? Mutations

41. 41 Staffing and sustainability Process requires dedicated staff –Often difficult to get full time people –Sometimes responsibilities divided No natural locus in some places –Limited capacity of organizations –Requires engaging multiple skills sets Requires resources and funding –Staff salaries, travel and training, etc. Best analysts not always best advocates –Requires a strong team approach

42. 42 Devolution and decentralization In many countries, responsibility is or is becoming local (provincial or state) –Sometimes limited capacities for analysis –Less data available –Resource decisions made at this level A 2 process in current form challenging –Efforts underway in Chonburi & Haiphong to learn to work at this level

43. 43 Time and tools Process is time consuming –Data collection & analysis is the bulk –Only true the first time Tools and analysis require substantial training –Addressed through regional trainings –Need for more comprehensive guidelines and training materials Tools need simplification and automation –Will increase ability to use locally –Try to reduce data input needs

44. 44 Ownership and obfuscation Data sometimes cannot be used in public –“Data is power” Transparency can be a problem –Hard to justify conclusions if data inaccessible –Advocacy needs to be done “behind closed doors” Provincial-national linkages can be problematic

45. 45 Partnerships, planning and prioritization Current M&E systems weak –Lots of indicator collection, little synthesis & analysis –Sustained data quality issues A 2 can fill gap in analyzing/improving data systems and responses, but… –Need access to data being collected in such systems –Need to form bidirectional links to ongoing M&E Being holistic, A 2 offers real evaluation of responses Need closer collaboration with.. –National programs, strategic planners, communities, donors

46. 46 The benefits of the A 2 process Information from multiple sources collated and analyzed for first time Data gaps identified and filled Better evaluations of program effectiveness: past, present and future More informed decision makers –Better decisions –Increased resource mobilization Empowered communities

47. 47 And ultimately, as understanding grows …. Stronger responses, fewer infections, and better care

48. 48 The end