M&E of HIV/AIDS Prevention Programs

1. M&E of HIV/AIDS Prevention Programs BY Dr. D.C. Tshibangu Pretoria, South Africa

2. SESSION OBJECTIVES • Reasons for intensification call for HIV prevention program • Different types of HIV Prevention Programs • Is Prevention Program loosing steam?

3. SESSION OBJECTIVES (CONT’D) • Defining ‘Prevention’ • Different levels of Prevention • Barriers to scaling-up HIV Prevention Program

4. WHY M&E OF HIV/AIDS PREVENTION PROGRAM? HISTORIC BACKGROUND • In 2004: UNAIDS is requested to produce a global strategy to intensify HIV prevention • In 2005: UNAIDS: ‘The AIDS epidemic can only be reversed if effective HIV prevention measures are intensified in scale and scope’.

5. WHAT IS THE ULTIMATE AIM OF THIS NEW INITIATIVE? • To improve the universal access to HIV prevention and treatment • WHAT DOES SUCH A STATEMENT IMPLY? - Failure of HIV prevention program? OR - Ineffective HIV prevention program? OR - Effective and efficient HIV prevention program?

6. INDICATIONS Are that everything in HIV Prevention Program is not what it should be. • The general impression is that HIV Prevention Program is loosing steam vis-à-vis Treatment program.

7. WE SPEAK ABOUT HIV PREVENTION PROGRAM, WHAT IS IT? Current HIV Prevention Program is composed of four main categories: • Prevention of sexually transmitted Is • Prevention of blood borne Is • Prevention Mother-to-child HIV • Legislation, Policy and other supports

8. WHAT PREVENTION MEANS? In the health context, the word Prevention can have two interpretations: • A narrow definition:It simply means inhibiting the development of a disease/problem before it occurs; • In modern epidemiology:It includes measures that interrupt or slow down the progression of a disease/problem. For that, we distinguish several levels of prevention.

9. LEVELS OF PRVENTION • Primary Prevention: involves prevention of the disease by altering susceptibility or reducing exposure for susceptible individuals; • Secondary Prevention: is the earlydetection and treatment of disease (it applies at pre-clinical and clinical stages); • Tertiary Prevention: is the alleviation ofdisability resulting from disease & attempts to restore effective functioning (it’s appropriate in the stageof advanced disease or disability)

10. PRIMARY PREVENTION Consists of two major categories: • General Promotion: includes provision of conditions at home, work, school and other settings that favor healthy living (good nutrition, adequate clothing, shelter, rest & recreation). It also includes areas of health education (instruction in hygiene) and sex education. • Specific protective measures: includes immunizations, environmental sanitation (blood bank, purification of water supplies) and protection against accidents and occupational hazards.

11. SECONDARY PREVENTION This refer to early detection and prompt treatment of disease. The results of SP are: • Sometimes possible to either cure disease; • Slow its progression; • Prevent complications; • Limit disability; and • Reverse communicability of infectious diseases. Example: Early treatment of STI provides at once secondary prevention for the infected and primary prevention for his/her potential contacts.

12. TERTIARY PREVENTION This consists of limitation of disability and rehabilitation where disease has already occurred and left residual damage. • Limitation of disability: Example: Early physiotherapy to an affected limb to restore motion and prevent contractures; • Rehabilitation: attempts to restore an affected individual to a useful, satisfying, and, where possible, self-sufficient role in society. Its major theme is maximal utilization of the individual’s residual capacities.

13. TEN MINUTE CLASS EXERCISE • Divide yourself into 2 groups (TB & HIV): • Use TB or HIV provided framework to identify different levels of Prevention as defined above. • Report & Explain your answers

14. TB NATURAL HISTORY & LEVELS OF PREVENTION Diseased Incidence of infection Incidence of TB Infected Non-Infected Cure-rate Incidence or attack rate Contagious Non-human pool Transmission chain function • Bacilli outlet • Conducive Environment • Entry point to host

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

16. CONCEPTUAL FRAMEWORK FOR HIV/AIDS CHALLENGES Individual Characteristics Not Infected Community Characteristics Not Infected Sick Infected Death Infected Programmatic Characteristics

17. PREVENTION PROGRAM: CATEGORY 1 PREVENTING SEXUAL TRANSMISSION (It involves) • Behavior change, which involvesadopting safer sex behaviors (delay first sexual encounter, abstinence, condom use and decrease number of sexual partners) • HIV testing,knowing one’s HIV status results in self-protection and protection of others

18. PREVENTION PROGRAM: CATEGORY 1 • PREVENTING SEXUAL TRANSMISSION (Cont’d) • Diagnosis and Treatment of other STIs: since these infections increase the risk of HIV transmission, their early diagnosis and treatment help reduce that risk

19. PREVENTION PROGRAM: CATEGORY 2 PREVENTING BLOOD BORNE TRANSMISSION (It involves) • Harm reduction for injection drug users: provision of clean needles & syringes reduces the risks of HIV transmission among injection drug users; • Blood supply safety: routine screening of the blood supply eliminates the risk of HIV, hepatitis B transmission through donated blood;

20. PREVENTION PROGRAM: CATEGORY 2 PREVENTING BLOOD BORNE TRANSMISSION (Cont’d) (It involves) • Infection control in health care setting: through ‘universal precautions’ such as wearing gloves & masks reduce HIV transmission in health care settings.

21. PREVENTION PROGRAM: CATEGORY 3 PREVENTING MOTHER-TO-CHILD TRANSMISSION (It involves) • Antiretroviral drugs: such as Nevirapine reduces MTCT by almost 50% • Breastfeeding alternatives: reduce HIV transmission in prolonged breastfeeding mothers by 50%. • Caesarean delivery: reduces MTCT of HIV

22. PREVENTION PROGRAM: CATEGORY 4 This category involves legislation, policy, political and Other likewise initiatives • Anti-stigma measures:that prevent discrimination against people with HIV and other vulnerable groups; • Gender-equality initiatives: develop programs for women’s education and economic independence; and also laws to combat sexual violence and trafficking;

23. PREVENTION PROGRAM: CATEGORY 4 (Cont’d) • Involvement of community & HIV infected individuals in people’s education about HIV, in developing, implementing & evaluating HIV programs; • Visible political leadership that prioritizes a comprehensive response to HIV epidemic including prevention, treatment and care.

24. WHY IS PREVENTION LOOSING STEAM?

25. WHY IS PREVENTION LOOSING STEAM?

26. WHY IS PREVENTION LOOSING STEAM? • Poor appreciation of positive impact of preventive activities; • Poor resources allocation (human, funding, training and consumables) to these activities; • Lack of innovative ideas on how to blend culture, positive messages and healthy life style;

27. WHY IS PREVENTION LOOSING STEAM? (Cont’d) • New and strong emphasis on ART • Poverty, alcoholism and other social hardships

28. BARRIERS TO SCALING UP HIV PREVENTION All the above plus: • Poor planning, inappropriate prioritization, low capacity to track and show results; • Limited human and institutional capacity to manage and deliver prevention programs;

29. BARRIERS TO SCALING UP HIV PREVENTION (Cont’d) • Lack of access to commodities; • Lack of effective and efficient co-ordination mechanisms among stakeholders at all levels.

30. STEPS NEEDED TO DEVELOP AN EFFECTIVE M&E PREVENTION PROGRAM • Use M&E Frameworks (Andy) • Use Indicators (Delphin) • Use Developing M&E Plans(Delphin) • Use Data sources (Delphin)

31. NEW DEVELOPMENTS IN THE PREVENTION FIELD OF HIV • Male circumcision • Microbicides • Pre-exposure prophylaxis with ARV • HIV vaccines • Cervical barriers (diaphragm)

32. Successful Microbicide Story • In the making is the story of ‘Tenofovir’ vaginal gel, first microbicide to prevent HIV and HSV-2 (Herpes simplex virus 2) • This story was presented at the XVIII International AIDS Conference on 21 July 2010 in Vienna, Austria by Prof. Quarraisha Abdool Karim and Prof. Salim Abdool Karim from the University of KwaZulu-Natal in Durban, South Africa.

33. Successful Microbicide Story (Cont) • The study design was a randomized, double-blind, placebo-controlled centres in Kwa-Zulu Natal province. • They enrolled 889 sexual active HIV sero-negative women at high risk for HIV infection at an urban and a rural site in KZN. 843 women completed the study. • HIV infection in KZN is a substantial problem where prevalence varies between 21.3% among 17-18 years old pregnant women and 51.1% among 23 to 24 years old.

34. Successful Microbicide Story (Cont1) • Women in the trial were instructed to: • 1. insert a single-use prefilled applicator of gel containing 1% of tenofovir (N=422) or placebo (N=421) up to 12 hours before intercourse, and again as soon as possible (up to 12 hours) after sex, with a maximum of 2 doses in a 24 hour period. • Participation in the study varies between 1 year and a maximum of 2.5 years. All participants received monthly HIV risk-reduction counseling, condoms, and treatment for STIs. They were also tested for HIV infection.

35. Successful Microbicide Story (Cont2) • The results: 1. Wome using tenofovir gel before & after intercourse showed a 39% lower risk of being infected with HIV compared with women using a placebo. • During the trial, 38 women in the tenofovir group and 60 women in the placebo group became HIV positive. • The incidence of HIV infection in tenofovir group was 5.6 per 100 women-years vs 9.1 per 100 women-years in the placebo group.

36. Successful Microbicide Story (Cont3) • Women who used gel in more than 80% of their sex acts showed a 54% reduction in HIV infections, a 38% reduction if they used it 50 to 80% of the times. • With regard to HSV-2, 434 women tested negative at the beginning of the trial and 426 were evaluated at the end of the trial.

37. Successful Microbicide Story (Cont4) • Among 202 women using tenofovir gel, 29 became infected (an incidence of 9.9 per 100 women-years) vs 58 of 224 women in the placebo group (incidence of 20.2 per 100 women-years. • Protection against HSV-2 increased with the number of prefilled applicators used per month. Women who used at least 6 prefilled applicators a month experienced a 62% lower risk of being infected with HSV-2.

38. COMPREHENSIVE PHC SYSTEM CONCLUSION: • The call for intensifying HIV prevention in scale and scope must be interpreted within an integrated and comprehensive PHC system that avoids duplication, fragmentation and inefficiency.

39. COMPREHENSIVE PHC SYSTEM • CONCLUSION (Cont’d): • All three levels of prevention are part of the same and unique system; meaning that effective primary prevention will yield less cases for secondary & tertiary preventions, which are usually more expensive to manage.

40. COMPREHENSIVE PHC SYSTEM CONCLUSION (cont’d): • HIV prevention and treatment should be recognized as equally important and supportive of each other • Potential benefits of emerging innovations must not be offset by population-level increases in riskier behavior

41. COMPREHENSIVE PHC SYSTEM CONCLUSION (cont’d): • Uganda and other countries that have successfully mobilized to change behavioral norms may offer essential programmatic inspiration.

42. REFERENCES • UNAIDS/WHO Policy Statement on HIV testing. UNAIDS, June 2004. • Monitoring and Evaluating Voluntary Counseling and Treatment Services (Module 7). Monitoring HIV/AIDS Programs: Facilitators Training Guide. FHI, 2004. • Tools for Evaluating HIV Voluntary Counseling and Testing. UNAIDS 2000 • VCT Service Delivery and Program Management (Module 5). Voluntary HIV Counseling and Testing: Manual for Training of Trainers. WHO Regional Office for South East Asia. 2004 • National AIDS Programmes: A Guide to Monitoring and Evaluation. UNAIDS. Geneva: June 2000. • AIDS 2010: XVIII international AIDS Conference Abstract TUSS0504. Presented July 19, 2010. Science Express. Published online July 19, 2010.

43. REFERENCES • Monitoring and Evaluation Toolkit: HIV/AIDS, Tuberculosis, and Malaria. WHO, UNAIDS, The Global Fund to Fight AIDS, Tuberculosis & Malaria, USAID, US Department of State, US Department of Health and Human Services, CDC, UNICEF, World Bank: June 2004 • Mausner & Bahn: Epidemiology-An Introductory text, W.B. Saunders Company, Philadelphia, 1985 • D. Wilson et al. Handbook of HIV Medicine, Oxford University Press Southern Africa, Cape Town, 2004. • Pretoria University: M&E lectures, SHSPH, 2006

44. MEASURE Evaluation is funded by the U.S. Agency for International Development (USAID) through Cooperative Agreement GPO-A-00-03-00003-00 and is implemented by the Carolina Population Center at the University of North Carolina in partnership with Futures Group, John Snow, Inc., ORC Macro International, and Tulane University. Visit us online at http://www.cpc.unc.edu/measure.