1. Centre for University Continuing Education under mandate from the Federal Office of Public Health Universität Bern Evaluation in Public Health – Lessons Learned and Future Directions Monitoring and evaluating HIV Michel Caraël, Université Libre de Bruxelles 17 June, Zentrum für universitäre Weiterbildung, Bern,

3. World time 2 milestones in HIV evaluation at global level 1993-94. At the peak of global vulnerability to HIV: Sense of failure to mobilize and respond to a global threat. Need to increase program effectiveness. 2001-2002. Redefinition of AIDS as a human security and development issue at global level. Massive investment in HIV response generated strong accountability demands.

4. Global program on AIDS M&E pioneers searching for a case study Pablo Picasso

5. 30 20 10 0 35 25 15 5 Million 19801985199019952000 2005 1.1 The first momentum o o 1993,124 countries with national AIDS program & medium term plan & 80 external national program reviews conducted o 1994, Evaluation unit created in WHO GPA o 1994, Methods package : Evaluation of national AIDS program; prevention of HIV infection People living with HIV 2010

6. Lessons learned in GPA 1.Recognition of the need to use standardized approaches in the evaluation of AIDS program 2.Bringing in behaviors and integrate HIV surveillance with behavioral surveillance 3.Tension between M&E for reporting and for program improvement 4.Fragmentation of M&E efforts across many agencies: need for harmonization and coordination 5.Implementation of M&E by National programs requiring strong capacity building

7. 30 20 10 0 35 25 15 5 Million 19801985199019952000 2005 1.1 2d momentum: HIV as global priority 2000, UN Security Council resolution on AIDS 2000, UN Security Council resolution on AIDS 2001, UNGASS declaration on HIV 2001, UNGASS declaration on HIV 2001, The Global Fund 2001, The Global Fund 2003, The three ones principles: one M&E framework 2003, The three ones principles: one M&E framework People living with HIV 2010

8. Estimated global resources for HIV % of countries with M&E systems N° of global M&E guides & indicators 0 8 billion US $ 19961998200020032005 Declaration of Commitment on HIV/AIDS 1,000 75% with M&E Systems

9. The M&E army  UNAIDS, WHO, UNICEF, and the US Government have placed over 80 M&E experts in priority countries.  Role is to assist national governments in the implementation of unified M&E systems.  Focus is on capacity- building of national counterparts in evaluation.

10. Interconnected world 156 million hits for « HIV » 46 millions hits for « HIV evaluation »

12. Challenges and directions for the future in HIV 1.M&E system for program improvement and/or accountability? 2.M&E: a need to strengthen E ? 3.Evaluation of complex systems: are gold standards still gold?

13. 1. Reporting, accountability and/or management Accountability demands tend to overthrow program improvement. Most M&E frameworks are not designed as management tool. Tension between bottom-up and top-down design

14. 2. Still great evaluation needs Some saturation of HIV information Continuous need for strategic data for policy level Knowledge is lacking on which combinations of prevention and treatment strategies work best, under which conditions. The evidence base for designing effective packages of national programs against HIV is still thin.

15. 3. Gold standard debate in impact evaluation of HIV response What is “evidence”? Methodological orthodoxy versus appropriateness, especially for complex multi-dimensional programs Evaluation of HIV combination prevention requires the use of variety of different methods.

16. Results of 40 interventions 38 RCTs to prevent sexual transmission of HIV Type of InterventionHIV prevention efficacyTotal Positive effect Adverse effect No effect Behavioral & Microfinance --- 88 Diaphragm --- 11 Vaginal Microbicides 11 1113 Male Circumcision 3--- 14 HIV Treatment, PrEP --- 11 STI Treatment 1--- 89 Vaccines 1--- 34 Total61 3340 Hayes R et al. AIDS, 2010

17. Why flat trials? 1. Invalid concept or inadequate intervention 2. Limitations in the delivery or intensity of interventions 3. Issues in trial design or conduct limited duration of follow-up over-riding influence of cultural norms and socio-economic factors inadequate power (poor adherence, losses to follow up) high intensity of intervention in control arms; Contamination between arms Biases associated with self-reported sexual behaviour.

18. Combination prevention & Evaluation