Post on 20-Dec-2015
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Monitoring and Evaluation: HIV/AIDS Programs
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Learning Objectives
At the end of this session, participants will be able to:• Identify M&E implications of the global HIV/AIDS
program context• Identify M&E and information systems implications
of the HIV/AIDS program environment• Apply basic M&E concepts to an HIV/AIDS
program component• Explain the implications of broadened HIV/AIDS
programs, particularly treatment scale up, for monitoring program impact
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Context
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Global Summary of the HIV/AIDS
Epidemic December 2004
Number of people living with HIV/AIDS Total 39.4 million (35.9 - 44.3 million) Adults 37.2 million (33.8 - 41.7 million)
Children under 15 years 2.2 million (2.0 - 2.6 million)
People newly infected with HIV in 2003 Total 4.9 million (4.3 - 6.4 million)
Adults 4.3 million (3.7 – 5.7 million)
Children under 15 years 640 000 (570 000 – 750 000)
AIDS deaths in 2003 Total 3.1 million (2.8 – 3.5 million)
Adults 2.6 million (2.3 – 2.9 million)
Children under 15 years 510 000 (460,000 – 600,000)
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Global Action to Address the HIV/AIDS Epidemic
2000 2001 2003 2004
Word Bank multi-sectoral AIDS Project (MAP)
United Nations General Assembly Special Session on
AIDS (UNGASS)
Global Fund for AIDS, Malaria, and Tuberculosis
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
World Health Organization's call to provide treatment to 3 million people by 2005 (WHO 3x5)
(Announced December 1, 2003)
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GOALS: Global
• Millennium Development Goal 6: Combat HIV/AIDS, malaria, and other diseases
Target 7: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
• WHO 3 by 5 Goal: Universal access to antiretroviral therapy for all living with HIV/AIDS
Target: Treating 3 million people by 2005
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Goals: US Presidents Emergency Plan
• Prevention of 7 million new infections
• Treat 2 million HIV-infected people
• Care for 10 million HIV-infected individuals and AIDS orphans
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What Are the Goals of HIV/AIDS Programs?
• Prevent new HIV infections
• Extend and improve life for those already infected with HIV
• Mitigate the social and economic impacts of the epidemic
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Key HIV/AIDS Program Areas
Prevention• Behavior Change and Communication
– e.g. sexual behavior, condom use, injecting drug use (IDU) behaviors• Medical Interventions
– e.g. PMTCT, VCT, blood safety, universal precautions, STI treatment etc.Care and Treatment
• Care and support to PLWHA and their families• Prophylaxis and treatment of opportunistic infections (including tuberculosis)• Treatment with antiretroviral therapy (ART)
Impact Mitigation• Support to Orphans and Vulnerable Children (OVC)• Reduction of stigma and discrimination• Addressing gender disparities
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M&E Implications
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M&E Implications
• High emphasis on accountability– Mandatory’ reporting on international indicators (MDG
and UNGASS)– Donor-reporting requirements linked to large influx of
money
• Drive toward standardization
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The Three Ones: Principles for the coordination of national AIDS responses
• One agreed-upon HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners.
• One national AIDS authority, with a broad-based multi-sectoral mandate.
• One agreed-upon country-level monitoring and evaluation system
Source: UNAIDS. 2004. Commitment to principles for concerted AIDS action at country level
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M&E Challenges
• Complex multi-sectoral M&E plans
• Wide range of information needed
• Different approaches needed in concentrated versus generalized epidemics
• Each HIV/AIDS program component has specific M&E needs and challenges
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M&E Challenges I
ALL COMPONENTS
•Rapid scale-up of new/routine systems
•Denominators – identifying eligible people
•Double counting in service statistics
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M&E Challenges I
PREVENTION
•Quality of reporting of sensitive behaviors
•Identifying size of most-at-risk population
VCT & PMTCT
•Measuring impact
•Quality of services
•Service cascade
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M&E Challenges II
CARE AND SUPPORT•Little M&E experience •Often community-based•Minimum care standards•Integration with TB-tracking referrals
ARV•Patient-level tracking systems•Adherence
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M&E Challenges III
OVC•Little M&E experience•Often community-based•Minimum package of services•Psychosocial support measurement •Ethical & methodological issues in data collection
STIGMA & DISCRIMINATION•Definitions•Measurement tools – validity in different contexts•Selection bias – only disclosed PLWHA observed
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Applying General M&E Principles to HIV/AIDS Programs
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General M&E Principles
• Determine how data are to be used• Prepare M&E Plan
– M&E Framework– Indicators– Data sources and data-collection schedule– Evaluation-design / targeted-evaluations needs– Data reporting and utilization plan
• Implement M&E Plan• Use data for program decision-making and reporting
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Information for Decision Making
• Global Level: Are we achieving global goals?• National Level: What should be the national policy on
PMTCT?• Program Level: Are we distributing services to meet the
need?• Facility Level: Are we providing enough services to meet
the need?• Provider Level: What is quality of a care for this patient?• Community Level: What are we doing as a community to
meet the need?• Individual Level: Where should I get treatment?
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Frameworks for HIV/AIDS Programs
• Different types of frameworks can be used (e.g. Results framework, log frame)
• Different, inter-related frameworks for different program areas (e.g. VCT, PMTCT, care and support) likely to be needed for a comprehensive program.
• Output of one program activity may be the input to another
• HIV/AIDS frameworks based on relevant documents such as a national AIDS strategy.
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HIV/AIDS Indicators
Program-level, National- and Global-level Indicators (Guides/Sources)
First-generation• 2000: General HIV/AIDS programsSecond-generation• 2004: HIV/AIDS Care and Support• 2004: Prevention of HIV in infants and young children (PMTCT)• 2004: HIV/AIDS programmes for young people • 2005 update: UNGASS (Millennium Development Goals)• 2005: ARV • 2000-2005: All UNAIDS and partner HIV/AIDS guides• To be released: OVC program guide (FHI), Concentrated
Epidemics M&E Guide, and revised GFATM Toolkit (2005/06)
Information sources for HIV/AIDS M&E
• Document review and key informant interviews– National Composite Policy Index– AIDS Program Effort Index
• Routine program information– Annual condom sales– Providers trained in VCT etc.
• Routine health information systems– No. client visits for VCT etc.– ARV drugs distributed etc.
• Medical records/patient tracking systems– ART adherence– No. patients on ART
• PLACE (Priorities for Local AIDS Control Efforts)– Identification and characteristics of sites where risk behaviors take place– Sexual partnership formation at sites
Information sources for HIV/AIDS M&E
• Facility surveys– Coverage of HIV/AIDS services (facility-based)– Readiness to provide quality HIV/AIDS services– Appropriate STI management
• General Population surveys– Sexual behavior – HIV seroprevalence
• Targeted Population Surveys/Behavioral Surveillance Surveys– Sexual and other risk behaviors – HIV seroprevalence
• Surveillance– HIV seroprevalence
• Vital Registration– AIDS mortality
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Information Storage: CRIS
Country Response Information System• Purpose:
To enable the systematic – storage– analysis– retrieval– dissemination of collected information on a country’s response to HIV/AIDS
• Structure: Integrated system with 3 modules– Indicator – Project / resource tracking– Research Inventory
Reporting Schematic
Linkages 1 March 15, 2005
National AIDS Council
NASCOP Intervention-specific databases
Persons with HIV/AIDS
Health Facility offering HIV/AIDS related services Community-based
organization offering HIV/AIDS related services
Households affected by HIV/AIDS
Orphans and vulnerable children
DASCO
CACC
DTC
PASCO
Community-Based Routine Information System
HMIS
Routine Program Information (e.g., mass media, training, etc…)
Periodic surveys (DHS, SPA, BSS)
ANC surveillance
Research
Information from Line Ministries
CRIS, MDG, UNAIDS Stakeholders (e.g., funders, implementers, users)
NASCOP: National AIDS and STI Control Program, MOH PASCO: Provincial AIDS and STI Control Officer DASCO: District ASCO DAT: District AIDS Team CACC: Constituency ACC
Reporting from National AIDS Council Information flow
General Population
ARV, OI prophylaxis and treatment
VCT, PMTCT, PEP, STI
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EXAMPLE: VCT
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Illustrative Questions for VCT programs
• Are VCT services being provided as planned?• Do services meet minimum quality standards?• Is utilization of services increasing?• Are there reductions in riskier behavior (among those
seeking services)?• Are there increases in use of care, support, and treatment
services (among those seeking services)?
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Illustrative Process and Output Indicators
• Number of people trained in providing VCT according to national and international standards
• Number of people who receive counseling (by sex) • Number of people who receive testing (by sex)• Number of clients who test positive for HIV• Number of HIV+ clients referred to treatment, care, and
support services
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Percentage of Facilities Providing VCT Services
15
11
0
2
4
6
8
10
12
14
16
%
Ghana (n=428) Uganda (n=226)
Source: 2002 Ghana HIV Service Provision Assessment and 2002 Uganda HIV Service Provision Assessment
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Percentage of VCT Sites With Selected Inputs for Quality Counseling
2
81
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21
39
2
47
All items
Condoms in facility
Condoms at service site
Stop AIDS poster
Visual aids for HIV/AIDS
Guidelines
Visual and auditory privacy
Source: 2002 Ghana HIV Service Provision Assessment
Percent
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Percentage of VCT Sites With Selected Inputs for Quality Counseling
96
52
65
62
63
78
Trained staff
Trained lab technician
Client register
HIV test kits
Visual aids for VCT
VCT guidelines
Percent
Source: 2002 Uganda HIV Service Provision Assessment
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Illustrative Outcome Indicators
• Percentage of people in the community who know about the VCT services
• Proportion of people counseled and tested who report positive behavior change to avoid HIV infection/transmission
• Proportion of people tested and found to be HIV+ who report positive or negative reactions from others
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HIV testing among women in Zambia
05
101520253035404550556065707580
Urban Rural All
Desires to be tested Knows source of testing Has been tested
Source: 2001 Zambia DHS
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HIV testing among men and women in Zambia
05
1015202530354045505560657075
Men Women
Desires to be tested Knows source of testing Has been tested
Source: 2001 Zambia DHS
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HIV testing experience among sentinel groups in Zambia
0
5
10
15
20
25
30
35
Female sex workers Male long-distance truck drivers
VCTEver tested
Source: BSS, Zambia 2000
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• Multi-center randomized trial: 1995-1997
• Three sites: Kenya (N=1515), Tanzania (N= 1427) & Trinidad (N=1357)
• Randomized to receive VCT (N=2152) or Health Information (N=2141)
• Traced and interviewed at 6 & 12 months
• Cross-over at 6 months so that the original Health Information group now had access to VCT
Multi-centre study Design of the VCT Efficacy Study
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Multi-centre study Unprotected intercourse with non-primary partners decreased significantly more among VCT participants
percent
0
10
20
30
40
HI Males
VCTMales
HIFemales
VCTFemales
Baseline 6 Months 12 Months
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Multi-centre study: Unprotected intercourse with commercial sexual partners decreased significantly more among VCT participants
0
2
4
6
8
10
12
14
HI males
VCT males
HIfemales
VCTfemales
Overall HI
OverallVCT
Baseline
6 months
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HIV Program Impact
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Incidence vs. Prevalence
• Incidence = number of new infections in a time period
susceptible population (HIV negative) in the time period
• Prevalence = number of infected people at a given point in time
total population (HIV negative & HIV positive) at that point in time
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Prevalence, the faucet and sink…
Number of HIV infected people
New HIV Infections
Deaths
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Impacts Indicators
• Prevent new HIV infections– Percentage of young people aged 15-24 who are HIV-infected (UNGASS and
Millennium Development Goal)– Percentage of HIV-infected infants born to HIV-infected mothers (UNGASS)
• Extend and improve life for those already infected with HIV– AIDS incidence and prevalence– Quality of life measures – Case fatality rate for HIV/AIDS– Proportion of mortality attributed to AIDS– General population life expectancy
• Mitigate the social and economic impacts of the epidemic– Gross national product or other economic indicators– Infant and child mortality rates
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Impacts: HIV sero-prevalence among 20-24 year old antenatal women in Uganda: 1990-2001
0
5
10
15
20
25
30
35
40
Nsambya Fort Portal Mbale
1990 1991 1992 1993 1994 1995 1996 1997 19981999 2000 2001
Source: STD/AIDS Control Programme, Ministry of Health, Uganda 2002
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Impacts: HIV prevalence estimates based on ANC sentinel-site surveillance vs. estimates based on population surveys
Estimated HIV Prevalence in General Population Aged 15-49
05
10152025
Kenya Mali SouthAfrica
Zambia
Pe
rce
nta
ge
ANC SurveillancePopulation Survey
Sources: Boerma, et. al. 2003; Central Bureau of Statistics 2004; Republic of Kenya 2001
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SAVVY - Sample Vital Registration with Verbal Autopsy
• A package:– “Sample vital registration” conducted in surveillance
communities– “Verbal autopsy” conducted as an interview with the family of the
deceased to ascertain the likely cause of death
• Purpose is – to provide measurement of vital events when alternative sources
(vital registration) are not available or not complete– To provide information on the cause of death when death
certificates may not be accurate
• May be used to monitor AIDS related deaths, use of health services, etc.