1. PLACE METHOD

2. SESSION OBJECTIVES Define PLACE 1 Decide when to use it Identify its relationship with other data sources Identify the objectives of PLACE How to use it The five steps of PLACE implementation Determine whether it is Quantitative or Qualitative method 1 For more detailed information on the method, refer to MEASURE Evaluation, A Manual for implementing the PLACE Method

3. DEFINITION P = Priorities L = Local A = AIDS C = Control E = Efforts

4. DATA COLLECTION TOOL It is a rapid assessment tool used to monitor and increase the coverage of the HIV/AIDS prevention in the areas most likely to have higher rate of transmission.

5. KEY ELEMENTS OF THIS DEFINITION Rapid assessment tool To monitor and To increase coverage Areas with higher/highest transmission rate

6. OBJECTIVES OF PLACE To assist local managers to allocate resources to any preventive programs that reduce/prevent transmission To identify gaps in current prevention programs To improve program delivery To track program coverage over time

7. PLACE Rationale 1: The concept of geographic targeting Epidemiological data show geographic clustering of HIV transmission risk. Prevention should focus in geographic areas where HIV incidence is high. In the absence of HIV incidence data--which are rarely available– a national team of knowledgeable people can review and interpret epidemiologic and contextual data to identify areas in a country where incidence is likely to be high. PLACE calls these areas Priority Prevention Areas (PPAs), High Transmission Areas (HTAs) or Zones d’ Intervention Prioritaires (ZIPs)

8. PLACE Rationale 2: New sexual and needle sharing partnerships have a critical role in the spread of HIV infection HIV transmission models reveal the importance of the rate and pattern of new sexual partnerships. Within Priority Prevention Areas, prevention programs should focus on preventing transmission among new sexual and needle-sharing partnerships.

9. Health outcome Demographic outcome Biological determinants Proximate determinants Underlying determinants Rate of Contact of susceptible to infected persons Efficiency of transmission per contact Duration of infectivity HIV incidence STI incidence Mortality New Partner acquisition Mixing patterns Concurrency Abstinence Condom use Concurrent STI Risky sexual practices Chemotherapy Treatment Context Socio-economic Socio-cultural Intervention programmes VCT STD control Condom promotion

10. Acute Infection

11. PLACE Protocol Overview 1 Prepare a PLACE Strategy 2-4 Conduct rapid assessment in each area 2 Identify venues where people meet new partners 3 Visit, characterize, map all venues 4 Confirm high partnership formation rates at venues 5 Use results to improve programs

12. Step 1: PLACE Strategy A PLACE Steering Committee reviews and interprets available epidemiologic and contextual data to identify areas with high incidence Consider geographic convergence of risk Unemployment, urbanization, poor housing, crime congested population, alcohol abuse, limited STI care, migrant labor, border stations, others? Steering Committee selects Priority Prevention Areas, selects key populations and programs, and adapts protocol

13. 8/9/2015 Some Decisions That Need to Be Made Should PLACE identify “hot spots,” or venues where vulnerable groups such as gays, CSWs, youth, or IDUs socialize? Will PLACE assess changes in program coverage over time? Will PLACE assess effectiveness of venue- based prevention programs? Will PLACE obtain indicators that can be compared with other HIV/AIDS indicators?

14. Ethical Review and Data Confidentiality Steering committee is responsible for local ethical review and approval of the protocol Research ethics and regulations protect human subjects by ensuring: ∆ meaningful informed consent ∆ social/scientific value of research ∆ proper risk benefit ratio of research

15. Staffing

16. Step 2: Ask 300-500 community informants where people meet new partners? Probe based on strata of interest for mixing  Young women and older men  Commercial sex workers  Mobile and resident populations  Military and civilian Ask until no new venues Output: List of venues with number times reported

17. Use epidemiologic context to guide selection of community informants Type of informants available:  Officials, taxi drivers, bar workers, shebeen owners, STI patients, youth, hostel residents, teachers, sex workers, police, health care providers, hairdresser, mobile populations, street sellers

18. Step 3: Visit, Characterize, Map Venues Reported venues are visited, mapped and an interview is conducted with a knowledgeable person on-venue to obtain characteristics of the venue Mapping can be done by hand, onto an air photo, or using GPS

19. Characteristics of venues Obtained from interviewing a knowledgeable person at the venue To Gauge Prevention Program Coverage and Potential at Venues Type of venue Condom availability Evidence of AIDS prevention Busy times Maximum occupancy Number of staff Venue stability To describe patrons of venues Male: Female ratio Busiest times Regular patrons Where patrons reside Whether patrons include commercial sex workers, gay, military, mobile, youth, locals, unemployed Whether people meet new partners at venue

20. City or District OUTPUT after step 3: Venues in PPAs located

21. Venue Based Indicators from Step 3 Eastern Cape, South Africa  Venues where new partners are met 234  % with condoms always available 5%  % with condoms never available 80%  % willing to have AIDS program 92%  % with alcohol consumption at venue 88%  % with student patrons 27%

22. Percentage of Venues that Never had Condoms in the Past Year 3 PPAs in South Africa

23. Percentage of Venues with Commercial Sex Six urban areas in Africa -- 4 PPAs in RSA----------

24. Percentage of Venues with Alcohol Six urban areas in Africa

25. Step 4: Interview Venue Patrons Interviews at busy times at venues Interval sampling strategy with probability of selection proportional to size is used to select venues where interviews with patrons will occur Opinion:  Do other people come here to meet new partners? Socio-demographic & behavioral characteristics  Have you ever met a new partner at this venue?  Have you ever injected drugs?  Number of new and total partners in the past four weeks, year?  Where else do people meet new partners?  Condom use?  Exposure to intervention? Output  Cross-sectional, self-reported data from non-representative sample that defies risk group labels

26. Percentage of Patrons Who Have Ever Met a New Sexual Partner at the Venue

27. Mean Number of New Sexual Partners in the Past 4 Weeks in South Africa Townships and Business District

28. Patrons: East London, South Africa Township  Male unemployment 48%  Attend venue weekly or more 77%  Mean number venues visited / day 2.5  Never used condom (men) 64%  Of sexually active men, (88%): % with new partner in past 4 weeks 40% % paid for sex <1%

29. 8/9/2015 STEP 5 Inform Interventions Maps can show where condoms are needed

30. PLACE can help… Provide understanding of the size and shape of the sexual networks and mixing patterns in a community Identify intervention venues Provide indicators for monitoring prevention- -- particularly exposure to programs

31. Limitations of PLACE Could miss important sites Could miss very clandestine networks – both sexual and IDU Transitory sights  Site-based interventions need site stability No biomedical validation of method (yet) May not be appropriate for all contexts

32. How is PLACE different than other methods? DHS DHS is large-scale, expensive household survey that obtains information on a range of health topics including HIV. PLACE focuses on HIV and is implemented within PPA at a fraction of the cost of the DHS. DHS provides national-level health indicators using population-based data. PLACE data are not representative of the general population, but monitor behavior & prevention programs among persons most likely to acquire and transmit HIV in key target areas. Since it is a household survey, DHS may miss mobile populations, under-represent young men, and be conducted in a setting where people are less likely to report extra-marital partnerships. PLACE interviews persons who are socializing at venues identified as places where people meet new sexual partners and thus often includes a large number of sexually active youth and mobile populations. PLACE can miss persons who do not visit public venues.

33. How is PLACE different than other methods? Targeted Risk Group Surveys Targeted risk group surveys require operational definitions of target groups to develop the sampling frame. PLACE avoids having to define “men who have sex with men” or “sex workers” during data collection because it samples from all venues where any persons meet sexual partners. Indicators for particular groups can be obtained during the analysis phase. Results from targeted risk group surveys are usually specific to the defined target group. PLACE data allows generalization to the population that visits venues where people meet new sexual partners and allows examination of the overlap between groups. PLACE results serve local programs immediately by providing maps of program coverage and identify priority venues where AIDS prevention programs are needed. A package of venue based prevention programs is being developed to increase the effectiveness of PLACE based outreach efforts.

34. WHEN ARE YOU LIKELY TO USE PLACE? 1. Anytime? 2. After a HIV/AIDS prevalence survey? 3. After an intervention? 4. Other?

35. PLACE Is likely to take place after 2 & 3 activities because It needs the findings of these activities to 1. identify areas with higher prevalence 2. identify determinants of higher rate in these areas.

36. IS PLACE QUANTITATIVE/QUALITATIVE TOOL? Quantitative? = Qualitative? =

37. MORE LIKELY QUANTITATIVE WITH QUALITATIVE ASPECTS 1. It uses descriptive epidemiology to initiate its investigations 2. It does not have a denominator 3. It attempts to capture some of the subtlety of human experience 4. It captures more of the ‘truth’ about the world, and is less likely to allow comparisons.