Training Module for Strengthening M&E for TIs

Training Module for Strengthening M&E for TIs Facilitator’s Guide with Technical Notes

Overview • Day 1 • Context Setting: NACP III, TI, SIMU and M&E for TIs • Session 1: Welcome, introduction, Sharing of Expectationsand Objectives • Session 2: Introduction to NACP III, TIs and SIMU • Session 3: M&E for TIs: Why, What, Who and How • Day 2 • M&E Systems and Processes for TIs: Operational Understanding • Session 1: Data Collection Tools and Formats • Session 2: Ensuring Quality, Data Entry, Analysis and Reporting • Day 3 • Learning by Doing: Data Entry, Analysis and Reporting • Session 1: Take-Home Exercise from the Previous Day • Session 2: The Lab Component: Data Entry, Analysis and Reporting

Day 1: Overview • Main Theme of the Day: • Context Setting: NACP III, TI, Strategic Information Management and M&E for TIs • Sessions: • Session 1: Welcome, Introduction, Sharing of Expectationsand Objectives • Session 2: Introduction to NACP III, TIs and SIMU • Session 3: M&E for TIs: Why, What, Who and How

Day 1: Session 1 • Welcome • Introduction • Sharing of Expectations • Objectives • Discussion on Monitoring, Evaluation & Reporting Team (MERT) • Formation of MERT Team

Welcome, Introduction & Pre-test Evaluation • Welcome all the participants in the training workshop • Introduction of the facilitator and other trainers • Introduction of the participants; their NGO/CBO and HRG covered by NGO/CBO • Administer the pre-test evaluation to all the participants

MERT • MERT: • Monitoring Evaluation Reporting Team • A team of 3 persons for monitoring, reporting and evaluating the training program on a daily basis • Rationale: • It will lead to higher involvement in the training program • participants will be exposed to the idea of monitoring and reporting on a daily basis during the training program which will instill the importance of M&E in participants

MERTcontinued….. • The Monitor responsible for: • deciding the start time, tea/coffee break, lunch time and the ending time in consultation with the trainees; will ensure that the Reporter and the Evaluator are doing their respective work properly • Evaluator responsible for: • taking feedback from participants on the day’s proceedings; preparing the report based on feedback; and presenting the report on the following day morning. • Reporter responsible for: • recording the day's proceedings; preparing a summary of the day’s proceedings; and presenting the report on the following day

MERT continued ….. • First 15 minutes every day for presenting MERT reports • Identify 3 persons for each day • 3-days training program will involve 9 trainees in MERT

Objectives of the Training • Overall objective: • to strengthen skills in monitoring and evaluation through an understanding of: • National HIV/AIDS scenario; national AIDS control program III; the targeted interventions; and SIMU • The concepts and issues concerning M&E • The need and role of indicators for measuring program performance

Objectives continued…… • Through an understanding of: • Major steps in data collection, processing, and reporting on program monitoring at outreach, clinic and project level • Data flow and maintaining the quality of data • Analyzing; interpretation and reporting the data; and • Use of monitoring data for TI performance tracking and providing feedback to appropriate staff

Day 1: Session 2 • HIV/AIDS Scenario in India; • NACP (1-III); • Targeted Intervention (TI) • Importance of TIs for HIV prevention among High Risk Groups (HRGs) • Core Groups (FSW; MSM; IDU) • Bridge Populations (Truckers and Migrants) • Principles of “Three Ones” • Need and role of Strategic Information Management Unit (SIMU) in the national HIV/AIDS program.

NACP - I • The objectives of NACP-I were: • To control the spread of HIV infection • To expand infrastructure of blood banks • To develop infrastructure for the treatment of STDs in district hospitals and medical colleges • To initiate HIV sentinel surveillance system • To involve NGOs in prevention interventions with the focus on awareness generation This programme led to the capacity-development at the state level with the creation of State AIDS Cells in the Directorate of Health Services in states and union territories.

NACP II • The objectives of NACP-II were: • To reduce the spread of HIV infection in India • To strengthen India’s capacity to respond to HIV/AIDS on a long term basis

National AIDS Control Policy - 2002 • HIV/AIDS was considered to be a development problem and not merely a health issue. • The policy aimed at • Prevention of further spread of HIV • Reducing the impact of HIV on people and on the health and socio-economic system • To integrate horizontally with other national programmes (RCH, TB, PHC system)

NACP III Shift from NACP II to NACP III NACP II Aim to shift the focus from raising awareness to behaviour change Through interventions, particularly for groups at a high risk of contracting and spreading HIV Aim at saturation of coverage of the core target population (80%) Guiding Principles: 3 Ones principle Evidence-based planning A & B districts – more focus Decentralization

HIV/AIDS Scenario in India • National AIDS Control Organization collects data on infections among high risk group populations and general populations through sentinel surveillance every year • This data is then extrapolated to get estimates of HIV prevalence in India • The annual HIV sentinel surveillance covered 1,215 sites in 2008-09 • An estimated 2.3 million HIV positive persons in India, with an estimated adult HIV prevalence of 0.34% (0.25%–0.43%).

NACP-III: Goal & Objectives • Goal: To halt and reverse the epidemic in India over the next five years • The objectives of NACP-III are: • Prevention of new infections (saturation of HRG coverage and scaling up interventions for the general population) • Increased proportion of PLHIV receiving care, support and treatment • Strengthening capacities at district, state and national levels • Strengthening nationwide strategic information management systems

NACP-III: Goal & Objectives…..continued The specific objective of NACP-III is to reduce new infections as estimated in the program’s first year by 60% in high prevalence states so as to obtain reversal of the epidemic, and by 40% in the vulnerable states so as to stabilize the epidemic.

NACP-III at a glance Care, Support & Treatment Prevention Capacity Building Strategic Information Management Care & support Monitoring and Evaluation High risk populations Low risk populations Institutional Strengthening • Blood safety • Integrated Counselling and Testing including PPTCT • STI care • IEC and social mobilisation • Mainstreaming • Targeted Interventions • STI care • Condom promotion • Enabling environment • ART • HIV-TB co-ordination • Treatment of opportunistic infections • Community care centres • Post-Exposure Prophylaxis • HIV Sentinel Surveillance • Behavioural Surveillance • Monitoring and Evaluation • Operations research • DAPCU • Technical resource groups • Enhanced HR at NACO, SACS and districts • Enhanced training activities

Consolidate gains Scale up treatment services Focus on youth and adolescents Decentralize to district & sub-district level Saturate coverage of High Risk Groups Normalize use of condoms Summary: Priorities under NACP-III Stigma & Discrimination

Targeted Intervention (TI) Model & TI Components

Epidemiology of HIV in India • An estimated 2.3 million HIV positive persons in India • HIV prevalence of 0.34% (0.25%–0.43%). • Concentrated epidemic • Certain regions/districts • HIV prevalence among the high risk groups (HRG) very high compared to the general population • The sexual mode continues to be the major mode of transmission • Transmission through injecting drug use and Men having Sex with Men on the rise in many new pockets

Why Certain Population Groups? • Certain population groups at a greater risk of acquiring and transmitting HIV infection due to: • their more frequent exposure to HIV because of higher levels of risky behavior; and • insufficient capacity to protect themselves. • Such population groups: Female commercial sex workers (FSW), injecting drug users (IDUs), men who have sex with men (MSM), truckers, and migrant workers.

Why Targeted Intervention? Evidence shows that any epidemic has following four stages- Wave IV Wave III Wave II Wave I Adolescents Spouses & Children of Male STD Pts Sex Workers/ IDUs Male STD Pts, Mobile Groups Long-term socio-economic impact, Orphans Survivors, AIDS Pts, ANCs, Pediatric AIDS Spread of HIV, STD patients Trauma, illness & death, STD & TB patients

HIV infection among different population groups In India, HIV/AIDS concentrates upon High Risk Groups (FSW, MSM and IDU) and Bridge Population (Truckers & Migrants). The need, therefore is to actively control HIV/AIDS among these groups.

HIV Positive contacts per year Population 1,000 100,000 25% infected, 400 partners per year FSWs 1,000 clients (e.g. migrants, truckers) 2% infected, 12 partners per year 240 The importance of working with core groups – FSWs

The importance of working with core groups – MSM • Truckers • Taxi/auto drivers • Single male migrants • Panthis Client or other category MSM – not focus of TI • Hijras • Regular partners of kothis Locus of intervention – typically ‘cruising sites’ or hotspots High risk MSM – focus of TI • Male sex workers • Kothis • Double deckers Anal receptors Anal receptors & penetrators Anal penetrators

The importance of working with core groups – IDUs Wives and Wives and girlfriends of Clients of FSWs girlfriends of Substance users clients ofFSWs Female Sex Workers IDU “Feminization” of the epidemic HIV Husbands and boyfriends of FSWs RISK RINGS Substance Users

The importance of working with core groups – Migrants/Truckers

Main focus of TI • Prevention • Reversal of the progression of the infection and Reduction in the overall level of prevalence • Evidence-based approach

Guiding principles of TI • In any health condition, with any population, the uptake of prevention service depends on outreach. • This holds more true in the case of marginalized populations such as sex workers, MSM, and IDUs. • The core of FSW/MSM/IDU HIV prevention efforts is therefore about outreach and the provision of dedicated services, which can be accessed by these marginalized groups.

Targeted Interventions Under NACP-III 1. More focused approach Bridge Population Truckers Migrant Workers Core Groups FSWs IDUsMSM 2. Specific package of services for HRGs 3. Emphasis on CBO-led Interventions

Components of TI Management of STIs Behaviour Change Communication Condom Promotion HRGs Enabling Environment Referrals & Linkages Community Mobilization

Condom Promotion • It is important to ensure accessibility and availability of condoms in a TI • Every person should have access to condoms when he/she needs it • Every person should be able to avail condoms when s/he needs them • Primary Strategy: Free supply of condoms to HRGs through TI NGOs/CBOs • Secondary Strategy: promoting social marketing of condoms through Social Marketing Organizations

Community Mobilization • Community members get to participate in collective decision-making • Formation of various committees like DIC Management Committee and Clinic Committee empowers the community • It creates community norms for service uptake and safe sexual behaviours • It helps in enabling environment and helps in project implementation also

Referrals & Linkages • Linkages to STI and health services with strong referral and follow-up • Promotion/distribution of commodities including free condoms, lubricants, needles/syringes • Linkages to other health services (e.g. for TB) and voluntary counselling and testing centres (VCTCs) • Provision of safe spaces (DICs)

Management of STIs • STI services: an opportunity for prevention education to the individual as well as to his/her partner • Planning for STI services done with the HRGs • Clinicians should have an attitude of respect towards the community. • Availability of services should be as per the needs of the community (for e.g. late-night access) • Accessibility of services at optimal locations (i.e. not too far from the major sex work sites)

Enabling Environment • To enable HRGs to negotiate safer sex, TIs must address several vulnerabilities • Vulnerability within the sex circuit includes aspects such as violence, and exploitation by clients • Broader socio-economic vulnerabilities include factors such as poverty and illiteracy • Reduction of vulnerabilities entails creating a crisis response system • It also calls for advocacy with policy makers, law enforcers and opinion leaders

Behaviour Change Communication • It is vital to change the community’s behaviour to ensure that they indulge in safer sex • This involves creating awareness about the importance of using condoms, services available for STIs and the importance of regular screening • It also means creating a demand for these services • TIs need to encourage analytical thinking and problem-solving among HRGs so as to help them overcome their barriers to HIV/STI risk reduction

Remember! • HIV is no longer a killer disease • It is a manageable disease, just like diabetes and blood pressure • But for this it is necessary to • regularly check one’s status at VCTCs • use condoms during every sexual act • If HIV+, regularly take the medicines & live a healthy life • Hence TIs should develop their linkages with government departments, VCTCs, Hospitals, ART centers, CCCs and such like

To conclude this section on TIs • The focus of the TIs should be that • all key populations are being met regularly • all key populations are able to access condoms and use it correctly and consistently • all are regularly screened for STI and HIV • all in need of care and support are able to access the same • the environment around sex work is safe • With sincere efforts, the HIV epidemic can be reversed much before 2015, as desired by the Millennium Development Goal (MDG)

“Three Ones” • NACP III identifies central principle of “Three Ones” • One HIV/AIDS action framework that provides the basis for coordinating the work of all partners; • One National AIDS Coordinating Authority with a broad base multi-sector mandate; • One country level monitoring and evaluation.

SIMU • To fulfill the third principle i.e. one country level monitoring and evaluation system, Strategic Information Management Unit (SIMU) has been established at national and state levels • The information channels of SIMU: • Monitoring and evaluation • Surveillance • Research.

SIMU …..continued • Objective of SIMU: • To address strategic planning, monitoring and evaluation, surveillance and research • To maximize effective use of all available information and implement evidence based planning • To track the epidemic and the effectiveness of the response • To help assess how well NACO, SACS and all partner organizations are fulfilling their commitment to meet agreed objectives

SIMU …..continued • Activities of SIMU comprise: • Monthly collection and analysis of data from reporting Units through SACS, District AIDS Prevention and Control Unit (DAPCU), Regional Coordinators and divisions • Surveillance • Research • Quarterly & Annual reports preparation

Day 1: Session 3 • Why M&E? • The role of information gathering and reporting in national HIV prevention program and TI; • Difference between monitoring and evaluation; • Objectives & Indicators • Concepts of input, process, outcome and impact; and • To outline the role and responsibilities of M&E officer in TI

Why M&E? • Developmental programs are time bound with specific goals and objectives; • Need of periodic monitoring during the implementation period; • To assess the achievements against the inputs and outputs of the program against planned activities and as per requirement. • Therefore, all the developmental programs need to have a strong M&E plans to assess the performance periodically against the objectives set to achieve ultimate goals of the program

Guiding Principles of M&E • Monitoring is not • a means to find faults in the implementation process • gathering of information to be used only for research purposes • gathering of only quantitative information • Monitoringis • diagnostic, i.e. to identify opportunity gaps in the project implementation • supportive, i.e. to help bridge the opportunity gaps for optimum implementation of the project • participatory, i.e. HRGs, NGOs/CBOs and SACS/TSU are equal partners in monitoring

What is Monitoring? A continuing function that uses systematic collection of data on specified indicators to provide management and the main stakeholders of an ongoing development intervention with indications of the extent of progress and achievement of objectives in the use of allocated funds

Monitoring …..continued • Monitoring involves counting what we are doing. • Monitoring involves routinely looking at the quality of our services. • So, monitoring is keeping track of day-to-day program activities. It is the routine tracking of information of interest about a program, its inputs and its intended output. Good monitoring should provide regular information of activities in progress. In other words, monitoring involves routine record keeping and regular assessments.

Training Module for Strengthening M&E for TIs