1. M&E of HIV/AIDS prevention programs Prof Maretha Visser Department of Psychology University of Pretoria

2. Objectives Why is HIV prevention important? Different types of HIV prevention Different levels of prevention Development of HIV prevention strategies How will you know if prevention is effective? Case studies Barriers to scaling up HIV prevention

3. Why is HIV prevention important? 2004 UNAIDS is requested to develop a global strategy to intensify HIV prevention AIDS epidemic can only be reversed if effective HIV prevention measures are intensified in scale and scope – need large scale change to change epidemic Health: no cure, prevention only Economy: costly, cannot treat whole community

4. Why is M&E of prevention important? Need evidence of success to know if intervention successful and money spent wisely Need evidence to identify best practices, to scale up good programs and improve ineffective interventions

5. Different types of HIV prevention Biomedical HIV prevention interventions Social and behavioural prevention interventions Structural HIV prevention interventions – (stigma reduction, gender equality) Legal and policy interventions

6. Different levels of prevention Prevention: strategies that prevent development of diseases or interrupt progression of disease Primary prevention: reduce exposure or susceptibility – promote good health; sex education; protection Secondary prevention: early detection and treatment, reduce risk (treat Sti’s) Tertiary prevention: limits disability as result of disease - ARV

7. Development of preventive interventions Develop a model of factors to address Based on the drivers of HIV in community Needs of the specific target group Strategies available and relevant (education/motivation/peer education/skills building) Involve all ecological levels in implementation: individual, peer group, institutional (school/clinic) and community level (leadership/policy) Finding: multilevel, multimodal interventions most effective

8. Support/Barriers of Healthy Behaviour Behavioural beliefs Attitude towards behaviour Normative beliefs Subjective norms Control beliefs Perceived control Behavioural intention Intrapersonal: self- esteem, self- efficacy, level of depression, life satisfaction Level of support: parents, school, peer group Community/cultural climate: Socio-economic status /safety/stigma/ violence / role models Community infrastructure/public policy: Resources: clinics/condoms/services Contextual Factors Interpersonal influence : social norms, modelling, pressures or support of family and friends Individual factors Knowledge about HIV&AIDS, risk perception Personal Factors

9. How will you know prevention is effective? Research evidence needed

10. Biomedical HIV prevention interventions Male circumcision (MC) – meta analysis 65% effective Highly Active Antiretroviral Therapy (HAART) RCTs on HAART* reported 60% to 80% reductions in new infections Prevention of mother to child transmission (PMTCT) best evidence – reduce from 35% to 1% Condoms (Male and Female) best evidence 90% safe Treatment of Sexually Transmitted Infections (STI) limited evidence – 40% effective Microbicides and cervical barriers – some results 30% effective/no evidence HIV vaccine – promising evidence in Thailand

11. Social and behavioural prevention The goal is to reduce HIV-risk behaviour: (primary & community wide) Increase knowledge decrease stigma increase access to services increase testing rate (intermediate goals) delay the onset of sexual intercourse reduce the number of sexual partners increase condom use decrease shared needles or equipment reduce or eliminate substance (alcohol) use (Risk groups) adherence to ARV’s; behaviour change

12. Social and behavioural prevention interventions Abstinence-only and ABC interventions Voluntary Counselling & Testing (VCT) Stepping Stones counselling intervention Concurrent sexual partnerships “ Behavioral HIV prevention works. Some have been pessimistic that it’s possible to reduce HIV risk behaviors on a large scale, but this concern is misplaced” Dr. Helene Gayle, co-chair of the Prevention Working Group

13. Evidence of effective behavioural prevention Best evidence: rigorously evaluated Significant effects in reducing risk Longitudinal design – 3month follow-up 70% retention rate Promising evidence: evaluated Significant effects in reducing risk 1 month follow-up 60% retention rate Significant change in more than one outcome No evidence of critical limitation in design

14. Social and behavioural prevention interventions Abstinence-only and ABC interventions – 13 RCT US, 7 no change in risk- no evidence Voluntary Counselling & Testing (VCT)- meta- analysis 11 studies, <68% risky sex for HIV+; 27 studies, no effect for HIV- Stepping Stones counselling intervention (50hours)- men vs control : <partner violence (2 years); <transactional sex (I year); < problem drinking (1 year); --- promising evidence no effect on HIV incidence Positive prevention (with HIV+) - < risk behaviour in pilot study – RCT underway

15. Structural HIV prevention interventions IMAGE intervention with micro-finance for women and HIV training programme RCT in rural Limpopo Experience of intimate partner violence (IPV) reduced by 55%. No effect on unprotected sex with a non-spousal partner No effect on HIV incidence Communication programmes – Soul City, Love Life No evidence of impact

16. Evidence-based HIV behavioural interventions in the US CDC’s AIDS Prevention Research Synthesis (PRS) project identified 18 best evidence, theory- based behavioural interventions demonstrating “best evidence” of efficacy for reducing HIV risk; targeted at heterosexual men and women, MSM, Youth, PLWHA and low income populations, etc.

17. Case studies

18. Case study: discussion 1) Which level of HIV prevention needed? 2) Formulate objective of intervention. 3) What intervention strategy can be used. Suggest one strategy to intervene. For this strategy, discuss: Indicators – various levels How measured Evaluation design Issues involved in intervention and M&E plan How will you know if it was successful?

19. Case study: Southern African community Risk behaviours: (men and women under 39 years) multiple partners (44.2% of men and 25% of women); non-consistent condom use (38% non-consistent use); alcohol use (36.1% men reported sex when drunk) Underlying factors: Socio-economic situation – poor/for financial gain Gender roles – women not empowered Silence about men’s risk behaviour (cultural) Government taking responsibility – no incentives to stay HIV- Medicalization of HIV – medical answer

20. Case study: Adolescents in schools Baseline data found: < HIV knowledge among younger learners 49.4% of boys and 30.5% of girls 16years+ sexually active 7% learners reported sexual debut under15 years old 44% of sexually active report inconsistent condom use > peer pressure > gender inequality – different norms for groups < role models and community support < socio-economic – money related to prestige > culture of alcohol abuse

21. Barriers to scaling up HIV prevention Lack of appreciation of prevention: cannot see immediate results – only long-term Lack of resources allocation (human/financial/training) Lack of innovative ideas, difficult to address societal issues that drive HIV Poverty, alcoholism, negative life conditions more serious (HIV only one life stressor, only future consequences)

22. Barriers to scaling up HIV prevention – M&E Lack of M&E to identify best practices – keep on doing same, do not know effect. No short term effect Research design has to distinguish between particular intervention and various community wide campaigns to show effect. Need to measure behaviour change or non occurrence of behaviour

23. Difficulty in M&E to determine cause of change Debate related to what bring about change – how can components be separated and tested? Uganda: prevalence from 15% to 5%, later sexual debut, less concurrent partners. Why? ABC model or addressing gender equality? Success because of extensive social mobilisation at every level + strong political leadership + empowerment of women + sexual responsibility of men + observing many people dieing of AIDS (Murphy, Greene et al., 2006 PLoS Med, 3(9), e379).

24. Effective change in Zimbabwe HIV prevalence decrease with 50%. Why? Increased interpersonal conversation about HIV High exposure to AIDS mortality (die at home) Understanding of sexual transmission Deteriorating economic situation – lower income prevent men from socialising in bars Shift in social norms: STI’s became cause of shame

25. No “Magic Bullet” for HIV “It is critical to note that there is no “magic bullet” for HIV prevention. None of the new prevention methods currently being tested is likely to be 100 percent effective, and all will need to be used in combination with existing prevention approaches if they are to reduce the global burden of HIV/AIDS.” Source: Global HIV Prevention Working Group (2008)

26. Highly active prevention

27. The AIDS epidemic has taught us to be innovative and to invent, test and implement new interventions. We now have evidence of HIV prevention strategies that work!

28. However, despite our innovation, inventiveness and compelling evidence of effective strategies, the “killer virus” is still chasing and killing us!