Overview

1. Why Develop a Taxonomyof HIV Behavioural Prevention Activities, and Why Specify Quality, Intensity and Coverage? • Barbara O. de Zalduondo, Anindya Chatterjee, Richard Delate and Terhi Aaltonen and the Prevention Reference Group Content Team • Department of Policy Evidence and Partnerships • UNAIDS UNAIDS

2. Overview • The challenge: why are we calling a UNAIDS Prevention Reference Group meeting on this topic? What do we hope to achieve together? • Why are we calling a meeting on this now? • Why did we propose to focus on the 5 activities/interventions, as opposed to many others? • Some definitions of our own – please see flip chart page • “activity, “intervention,” “measure” or “programme” • Critical element • Quality • Standards UNAIDS

3. Why is UNAIDS calling this Reference Group meeting on HIV prevention? • 4.3 million new infections in 2006 (3.6-6.6 million)** Coverage of prevention measures is incredibly low; must be scaled up e.g. In 2005, only 20% of the people most at risk and most in need of HIV prevention services, world wide, were getting them.*  e.g., 9% of men who have sex with men worldwide received HIV prevention services (from 4% in Eastern Europe to 24% in Latin America).* Results of prevention activities have often been inadequate e.g Botswana - only about one in three young people aged 15–24 both correctly identified ways of preventing the sexual transmission of HIV and rejected major misconceptions about HIV transmission.** UNAIDS

4. To improve prevention impact (decreased HIV incidence) countries could require: • More effort/investment in prevention(Eye-dropper problem) • Better planned and allocated prevention activities • Better implementation • All of the above How to tell? UNAIDS

5. to Do Better – advising countries that are spending prevention effort in ways unlikely to impact new infections Figure 1 Mismatch between funding and HIV epidemiology observed in a west African country Source: Courtesy of World Bank MAP, (2005) UNAIDS

6. ReducedNew Infections Reduced risk behaviour Changed KABP and more enabling environment Design/Mix of Prev. Actions to meetcurrent needs + + Effective Prevention Programme evaluation and comparison should complement prevention research. Can we compare: Accurate costing, Budgeting, and Capacity Development Adapted to local settings Implemented Correctly (“faithfully”) and to Scale UNAIDS

7. Prevention programmes for people living with HIV Special populations Condom social marketing Public and commercial sector condom provision Improving STI management Prevention of mother-to-child transmission Blood safety Post-exposure prophylaxis Safe medical injections Universal precautions And now, Male circumcision e.g. UNAIDS Resource Needs Model – 19 “types” in 2005 Mass media Community mobilization Voluntary counseling and testing Youth in school Youth out of school Programmes focused on sex workers and their clients Programmes focused on MSM Harm reduction programmes for IDUs Workplace interventions “Comprehensive prevention” – from UNAIDS policy position paper to operational definitions UNAIDS

8. To build prevention knowledge, and to offer guidance on prevention planning we need: • Clear terminology for each prevention activity – at operational level What exactly do we mean by “focus on young people” – or - “school-based education?” What are the critical ingredients? When we analyze the outcomes of several “school-based education” activities, how do we know we are comparing the same things? • Information on scaling each one: how much? how much will/should it cost? • The answers depend on definitions of quality, intensity and coverage • 3) Information about the most effective mix of programmatic and policy actions. • cf. UNAIDS policy position paper: Intensifying HIV prevention • (7 principles, 10 programmatic actions, and 11 policy actions) UNAIDS

9. Quality – a value in every health and development field. Definitions vary in specificity and generality • Quality management methods, continuous quality improvement etc. are widely available. They all entail: • building technical consensus on the terms and definitions (Mike Sweat’s presentation= • establishing consensus on critical elements • establishing agreement on the criteria or dimensions of quality (Nancy Padian’s presentation) • specific methodology – what content, goal, method, intensity, etc. – which can be costed. • Specifications of quality, intensity and coverage need to be gathered, made explicit, and cited, for behavioural interventions, just as they are for clinical services. We will be discussing a framework for guiding this. UNAIDS

10. Testing the framework against SELECTED prevention actions: • We are developing a model/framework to assist countries and expert organizations • We do not expect to arrive at the answers – only to establish the need, and to define the processes that will follow this meeting • We selected a few prevention actions because in this initial meeting, time is short. • The choice was made in order: • to illustrate the diverse kinds of prevention interventions • to focus on areas where international guidelines have not been established or widely publicized UNAIDS

11. Why raise these issues now? • 4.3 million new infections.... • Global Resource Needs estimation process • Using best available “legacy categories,” definitions and cost data • UNAIDS and World Bank are training people to gather cost and expenditure data • Laying the groundwork to provide more and better data for the 2009 estimates • The need for behavioural prevention will go on for the next generation – so it is time to strengthen the foundation of prevention science. • Because of the urgency of responding to HIV, we have been in too much of a hurry .... for 25 years As a result, we are still working with legacy categories and ad hoc definitions that make it difficult to build knowledge. UNAIDS

12. Challenges of terminology • Quality (discussed earlier) • Activity/Measure/Intervention • An input, activity, or component of an HIV prevention programme that is designed and managed as a unit to achieve a specific outcome or result. • Critical components/core elements • Elements, steps or features that are necessary to the effectiveness of an HIV prevention activity/intervention/measure • Standards • “something established by authority, custom, or general consent as a model or example”*“something set up and established by authority as a rule for the measure of quantity, weight, extent, value, or quality* * Source: Merriam-Webster’s Online Dictionary UNAIDS

13. In Sum: UNAIDS seeks your advice and recommendations for a 2 year plan to clarify building blocks of prevention science: First 12 months: • an agreed taxonomy (“list,” with definitions) of HIV prevention activities/interventions that are used and combined in successful national HIV programmes • an approach to defining minimum standards for each prevention activity, including the behavioural ones, to permit realistic costing and budgeting for HIV prevention Longer term (now through 2008?): • a process, or series of activities, to engage key stakeholders to translate the agreed terminology and standards into practice, at country and global levels UNAIDS