INTRODUCTION TO HIV SITUATION AND NEEDS ASSESSMENT IN PRISONS 7 December 2011 Addis Ababa, ETHIOPIA

1. INTRODUCTION TO HIV SITUATION AND NEEDS ASSESSMENT IN PRISONS 7 December 2011 Addis Ababa, ETHIOPIA

2. Dr FabienneHariga Expert - HIV/AIDS Unit, UNODC VIENNA Dr. Caren Weilandt Scientific Institute of the German Medical Association (WIAD) Bonn, Germany Dr. Robert Greifinger City University of New York, USA Participants of the Expert Group Meeting March 2009, Vienna, AUSTRIA Participants of the Regional Consultation Meeting 09 June 2009, Pretoria, SOUTH AFRICA Contribution of the experts who sent their comments Acknowledgements

3. Definition of Words For purposes of this workshop, the terms • “ prison” will be used refer to: • Structures build or designed to hold people in conflict with the law, Correctional facilities, Places of detention, Police holding cells, Remand centers, etc. • “Prisoner” will be use to refer to: • An individual residing in prison (excluding children living with their incarcerated mothers), Inmate, Remandee, Detainee, etc. • “Prison settings” will be used to refer to: • a prison environment where there are prisoners, prison staff and to some extend, the surrounding community within the prison vicinity, e.g. staff quarters.

4. A snapshot of the 'present' used to plan for the future. Defining a SITUATIONALAssessment A situational assessment influences planning in significant ways by examining the legal and political environment, stakeholders, the health needs of the population, the literature and previous evaluations, as well as the overall vision for the project.

5. Defining a NEEDS Assessment A needs assessment is the process of identifying performance requirements and the "gap" between what performance is required and what presently exists

6. Situational and Needs Assessment Like all other assessments, situational and needs assessment focuses on collecting data on community/population BUT it also considers the broader social, economic, political and environmental context affecting community health needs. Situational assessment also considers strengths, assets and capacities, not just problems or needs. A situational assessment includes, but is not limited to the use of the following types and sources of information: Key facts, trends, and recommendations from the literature; Data and analyses obtained from population health assessment and surveillance; Legal and political environments; stakeholder perspectives; and recommendations based on past experiences, including program evaluation information

7. Summary As the name suggests, there are two components: a situation assessment and a needs assessment, BOTH conducted sequentially, but with a concurrent purpose. A situation assessment measures the status quo, while a needs assessment identifies gaps between the status quo and an accepted standard or pre-existing goal. The concurrent purpose is to design, resource, implement and monitor and evaluate interventions to bridge the identified gaps. As it applies to HIV/AIDS, the pre-existing goal might be, for example, consistency with the National AIDS Action Plan.

8. Goal And Objectives The goal of the situation and needs assessment is to complement existing information in the country with regard to HIV and other communicable diseases. The gathering of additional information will allow governments to set more specific targets for achieving universal access for prisoners to comprehensive and evidence-based HIV prevention, treatment, care and support interventions.

9. Goal And Objectives… The specific objectives of the stepwise approach are to: Assess the HIV prevalence (and other diseases of interest where possible) in the prison population generally, and in sub-groups such as women, people who use drugs, remand and convicted prisoners, and unauthorised immigrants; Identify specific risk factors which may be associated with the transmission of bloodborne pathogens and airborne infections, including TB, among prisoners and staff; Assess the level of knowledge, attitudes, behaviours and practices (KABP) on HIV/TB (hepatitis and other STIs) in all target groups within the prison, including prison staff; Determine the availability of and quality of health services, prison conditions, associated infrastructure and national policies and legal framework to identify feasible and appropriate opportunities for improvement; Strengthen the information and training for prisoners and prison staff; and Provide a baseline for ongoing monitoring and evaluation of the resulting intervention programmes

10. A needs assessment should: Describe needs and available resources; Document lessons learned; Be feasible, timely, acceptable and applicable; Have limited costs and use of resources; Be accurate enough to provide decision-makers with information to take appropriate actions; Have a dynamic plan of action which can be revised on an “as-needed basis”; Use multiple sources of information and methods to help ensure validity and reliability; and Be sustainable and able to be monitored.

11. A multidisciplinary approach The very first activity, prior to conducting a situation and needs assessment, should be the establishment of a Steering Committee, defining its role, tasks and responsibilities. Involving other stakeholders is critical to the success of situation and needs assessments. These stakeholders include representatives from the prison staff (wardens, custodial staff, health service members, and treatment and prevention delivery staff), prison governors and management boards, as well as from the prisoners themselves, all key stakeholders in the criminal justice and health systems, N. Drug authorities; NGOs, Prisoners, PLWH;Staff association; ombudsman; rep. from Human Rights association; technical partners, etc The role of this committee is to guide and monitor the design and implementation of the exercise and its involvement will facilitate the implementation of programme interventions because of the strong interest among the key institutions and partners. To the extent possible, consensus among members of the Steering Committee should be obtained.

12. Steering Committee Membership

13. Defining Clear TORs

14. Step 1: Select a qualified team and provide training • Independency from all Ministries • Well qualified PI and team • Multidisciplinary (including criminologist, Microbiologist) • Skills of Surveyors: • Ability to do field work, Interviewing skills, Data recording and management skills, Ability to communicate in a relevant local language, Non-judgmental attitude . • Confidentiality (template of a confidentiality agreement is attached in Annex 3. ) • Training of the surveyors

15. Step 2: Consider costs and resources • develop a comprehensive budget and work plan that should include personnel time and resources to conduct the needs assessment. • The budget should include the cost of each of the ten steps of the study process. • reflect in-kind contributions (e.g. rapid tests provided by a Ministry, transport for the team made available by a partner). • Template in Annex 4.

16. Step 3:Obtain ethics committee approval • Protocol developed by PI and reviewed by SC must be approved by National research ethics committee • WHO Ethical standards and procedures for research with human beings. • National guidelines for ethical research must be met • Most countries have ethics committees at national and local levels. • If not, then university/teaching hospitals • If not, then establish an ad hoc committee

17. Ethical considerationsAnd Ethical Clearance All research involving human participants must be conducted in an ethical manner which respects the dignity, safety and rights of participants, and recognises the safety, security and responsibilities of research team members. The guiding ethical consideration in serological and behavioural situation and needs assessments is to ensure that the basic human rights of individuals are not violated in the course of the assessment. Meeting human rights principles and minimum rules for the treatment of prisoners. Respects the dignity, safety and rights of participants voluntary, anonymous and confidential Informed consent Unlinked serorologic test + VCT Ethical committee

18. Step 4: Collect and analyse available information (secondary data) • to determine what information is available from secondary sources ( + reliability and validity • And identify gaps • Completeness of the data: • Representativity of the data: • Age of the data: • Limitations of the data source

19. Records of training and qualifications of staff • Data/information/records from the medical department of the prison (e.g. urine test records, HIV, HBV, HCV, and TB screening and/or surveillance data, treatment records) • National reports and strategies on HIV, TB, viral hepatitis, STIs and risk behaviour in the general population • National guidelines for prevention and treatment of HIV, TB, viral hepatitis, and STIs Sources of secondary data • Literature review • Policy documents regarding drug use and HIV and AIDS prevention and treatment • Ministry of Justice or Ministry of Interior reports • Penal system reports • National human rights reports • Reports by prison inspection bodies (national or international) • Civil Society Organisation reports • Arrest data on people using drugs and sex workers

20. Step 5: Collect and analyse the national framework and prison conditions (primary and secondary data) • Analysis of the national framework and prison conditions • Analysis of national TB and HIV policies and framework • Checklist in Annex 5

21. Sources of data Desk top analysis (mainly national legal and policy framework) Key informant interviews (living conditions, food/nutrition, hygienic conditions, sanitation, access to care, risk behaviours such as violence and drug use in prisons) Prison visits, including interviews with key prison staff and prisoners (all aspects listed on the checklist, including the information gathered by desk top analysis) Focus group discussions (providing insight on prison realities and explaining attitudes and behaviour at several levels)

22. Step 6: Interview staff and prisoners (primary qualitative data) • Objectives • generate descriptive data; • plan pre-test questionnaires; • identify possible risks that were not envisioned by the investigators; • monitor effectiveness of programmes in operation; • provide explanations of attitudes and behaviour; • and generate hypotheses for quantitative collection. • How: • Interview and focus groups

23. Step 7: Survey prison risk behaviour and ascertain HIV prevalence (primary quantitative data) A. Cross-sectional voluntary anonymous survey on communicable disease and related risk-behaviour among prisoners B. HIV testing methodology to determine prevalance • Tuberculosis • Cross-sectional voluntary anonymous survey on HIV and related risk-behaviour among prison staff

24. Cross-sectional voluntary anonymous survey on communicable disease and related risk-behaviour among prisoners • KABP survey on HIV, HIV-TB • Careful field preparation • Questionnaire: • Self-administered preferably • Languages • A template questionnaire and standard information for the recruitment in Annex 6 and 7. • Do not avoid sensible questions or questions on unknown behaviours • Use local “wording” (ex: name of drugs) • Pretesting

25. Cross-sectional voluntary anonymous survey on communicable disease and related risk-behaviour among prisoners (Cont.) • Sampling methodology (annex 10) • Depends on the prison system • Pre-sentenced/ houses of arrest/ prisons/ etc. • Women, (children ?) • Random sampling • Inclusion criteria:All prisoners incarcerated on a given day, including migrant prisoners who speak the languages of the instrument. • Exclusion criteria:

26. Cross-sectional voluntary anonymous survey on communicable disease and related risk-behaviour among prisoners (Cont.) • Recruitment of prisoners • Information of the objective • In agreement but independently • Anonymity and confidentiality • template for standard oral information for prisoners is attached in Annex 6. • Location of data collection and surveyors • Services provided to prisoners during the survey including VCT • Keeping data anonymous

27. B. HIV laboratory testing methodology

28. C. Tuberculosis the collection of epidemiological data on the TB problem, e.g. prevalence, case notification and mortality rates, population demographics, treatment outcomes, risk factors etc. from representative prisons an examination of structural and administrative aspects that impact on TB control, e.g. existing health service provision, management and co-ordination of prisons, rules and regulations, availability of food, accommodation, etc.

29. TB epidemiologic secondary data • Based on notifications data (laboratory; district hospitals; etc.) • Try to estimate a prevalence (but problems with denominator) • If Possible : • Disaggregated by type: • total smear positive TB cases /year • Total RX; Total clinical ass. • Total non pulmonary TB • new cases and total re-treatment

30. TB epidemiologic secondary data Survey • Co-morbidity: • HIV • malnutrition • Mortality • Case fatality rate: N. deaths/Nr. TB Cases

31. TB Survey • Depending on the size: • Sputum (direct supervision / trained staff) • RX + sputum • If 1 sputum positive, need reconfirmation

32. D. Cross-sectional voluntary anonymous survey on HIV and related risk-behaviour among prison staff • Objective: • KABP on infectious diseases but also drug use • Methodology: • Questionnaire (see annexe 9) • Anonymous, voluntary • Possibly with serologic test • Information (see annexe 8) • Preparation important

33. Step 8: Analyse and interpret survey data identify populations that are infected with HIV and describe their key characteristics understand the trends and the impact of HIV and AIDS in a prison system identify groups or populations at risk of acquiring or transmitting HIV and identify prevention needs determine the characteristics of HIV-infected persons and persons engaged in high-risk behaviours determine the indicators of risk in the prison population describe the distribution of the disease (geographically and by population) identify trends over time, if any

34. Step 9: Prepare a final report: Suggested chapters Executive summary with key results, findings, conclusion and recommendations for further action Contextual assessment of prison settings Healthcare resource assessment Intervention and policy assessment (prison management, healthcare management, HIV, TB programmes, National AIDS policies &Programmes, National TB policies & Programmes) Methodology :- Sampling, data collection, etc HIV prevalence and knowledge, attitude and behaviour assessment in both prisoners and prison staff Gap analysis and identification of needs Discussion of the results (obstacles faced, recommendations for improvement, etc) Conclusions Recommendations

35. Step 10: Focus interventions • Alternatives to imprisonment • Health services equivalent to those in the community: prevention, curative, reproductive and palliative; • Include “prison settings” in national AIDS and Tuberculosis plans (including monitoring); • Preventing of physical and sexual violence • Providing safe and appropriate health /dental services • Providing comprehensive HIV Prevention, treatment care and support in prison settings

36. Providing comprehensive HIV Prevention, treatment, care and support Services • Information on modes of HIV transmission and ways to reduce those risks, on testing, and treatment; (IEC, Peers-prevention) • Access to essential prevention commodities: male and female condoms, sterile injection equipment, and safe tattooing/piercing, shaving equipment; • Voluntary confidential HIV testing and counselling services; • Prevention and treatment of sexually transmitted infections; • Drug dependence treatment, including opioid substitution therapy (OST); • Provide appropriate diet and nutritional supplements; • Provide antiretroviral treatments, preventing and treating tuberculosis, other opportunistic infections and other blood-borne infections such as hepatitis B and C; • Providing access to reproductive health care services; • Prevent mother-to-child transmission (PMTCT); and appropriate care to children • Providing post-exposure prophylaxis (PEP) to people having been exposed to a risk; • Palliative care and compassionate release for AIDS and terminally ill patients. • Organise continuity of care at entrance and upon release

37. Providing comprehensive HIV Prevention, treatment, care and support Services Encourage and support the participation of prisoners Prevent stigma and discrimination Provide a safe environment for prison staff: Universal precautions, protective equip. ; training; IEC Include “prisons” in national AIDS plans and national TB plans Monitoring and evaluation

38. 1:Templates of informed consent forms for prisoner survey participants • 2:Template of informed consent forms for focus group participants • 3:Template of a confidentiality agreement for assessment team members • 4:Template of cost plan for the assessment • 5:Checklist for the analysis of the national framework and the prison conditions • 6: Template for standard oral information for prisoners on the survey • 7:Template for a prisoner questionnaire • 8:Template for standard information for prison staff on the survey • 9:Template for prison staff questionnaire • 10:Sampling Methodology Annexure

39. Join us…. For an oral abstract presentation 30 Million People Each Year, at Risk for HIV and TB, Forgotten in Prisons: Collect the Evidence! HIV/TB Situation and Needs Assessment Toolkit Room A3: Fasiledes [566] 14:00 – 15:30

40. For a Satellite Session on HIV Assessments in Southern African Prisons For an oral abstract presentation Join us…. 30 Million People Each Year, at Risk for HIV and TB, Forgotten in Prisons: Collect the Evidence! HIV/TB Situation and Needs Assessment ToolkitRoom A3: Fasiledes 14:00 – 15:30 • Results of Studies conducted in Lesotho and the condom distribution intervention • Swaziland • Zambia Room B3: Shalla 17:30 – 19:00

41. The Toolkit: Implementation How Zimbabwe did it How Lesotho did it

42. Thank you NthabelengMotsomi-MoshoeshoeUNODC-ROSAFhttp://www.unodc.org/southernafrica/en/hiv/prison-settings.htmlnthabaleng.motsomi@unodc.org+27 12 432 0875