The Essential Package

Paul WilliamsUnited Nations Office on Drugs and Crime

Vienna

Master Class, YaltaSeptember 2007

From the ‘Comprehensive’ to the ‘Essential’ Package: Core service coverage indicators

1 July 2005

“The position paper is grounded in a number of essential principles crucial to the success of any

effective HIV prevention effort.”

3. Preventing transmission of HIV through injecting drug use

• Full range of treatment options (notably ST)

• Implementation of harm reduction measures

(through among others…- peer outreach- NSP)

• VCT – new - PICT

• Prevention of sexual transmission (including condoms and STI treatment)

• Access to primary health care

• Access to ARVs

The comprehensive package (vers. 1)

Operationalising the package at field level

The comprehensive package (vers. 2)

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

June 2006

• UNODC convened a meeting of ~ 39 international experts in Vienna – charged with reviewing the Comprehensive Package, with respect to resource poor, developing and in-transition countries

June 2006

• UNODC convened a meeting of ~ 39 international experts in Vienna – charged with reviewing the Comprehensive Package, with respect to resource poor, developing and in-transition countries

• Also charged with identifying which elements of the CP were “ Essential” and which ones were “added value” .

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

• • ST

• NSP

• VCT

• ARVs

Essential

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

• ST

• NSP

• VCT

• ARVs

Essential Measuring the EP

• ~Condoms~

• ST

• NSP

• VCT

• ARVs

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

• ST

• NSP

• VCT

• ARVs

• ~Condoms~

• ST

• NSP

• VCT

• ARVs

• ~STIs~

• • ST

• NSP

• VCT

• ARVs

Essential

THE TWO GUIDING PRINCIPLES

1) While the Comprehensive Package provides optimal results, without at least the Essential Package of measures, efforts will fail

• • ST

• NSP

• VCT

• ARVs

Essential

THE TWO GUIDING PRINCIPLES

2) Even if we do implement the Comprehensive Package, we should make sure we at least measure the Essential Package

Impact, Coverage, Quality

Impact

Coverage

Quality

~Timing~

Impact

ONLY TWO INDICATORS MATTER

Reduction in incidence

Impact

ONLY TWO INDICATORS MATTER

Reduction in incidence

Survival (following diagnosis)

Quality

Generally, Measured at the technical level

- Standards…(e.g. WHO guidelines)

Quality

- Certification (e.g. min. of 3 years training)

Quality

- Certification (e.g. min. of 3 years training)

- Using proven effective medications etc.

Quality

Rarely is “client satisfaction”, “gender sensitivity”, “acceptance by neighbourhood”, “level of social

disruption/crime associated with facility” etc. measured as “QUALITY” indicators

WHAT IF WE COULD USE COVERAGE AS A PROXY FOR MEASURING PROGRESS IN

“PROGRAMME ROLLOUT” to prevent transmission by injecting?

And ignore for the time being, quality (which is poorly measured in any event), and impact (which

might take years to become evident)

And ignore for the time being, quality (which is poorly measured in any event), and impact (which

might take years to become evident)

Also puts every country on equal reporting footing – don’t need sophisticated M&E system to track

Evaluation Framework

Objective

Principle Outcomes

Key outputs

Activities

Evaluation qns

Performance Indicators

(n=12)

(n=30)

(n=60+)

(n=150+)

Increase in

specificity

So – objective was CORE INDICATORS

Challenge: 5 core indicators across each of the three service areas:

• ST (methadone, buprenorphine)

• NSP

• Diagnosis and treatment

+ three summary indicators = total of 18 core indicators

And computations should be available continuously from routine data that are collected at service sites

First, look to existing indicators

UNGASS

Eight candidate indicators

4. Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy

• Not specific to IDU – (but could arrange for such a breakdown, though not required)

• Where IDU not driving epidemic, could have high % of non-IDU in receipt, and v.low, or no IDU receiving = (still) high % as a result

• Therefore, can hide discrimination against IDU, or ignore the potential for an IDU “breakout”

7. Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who

know their results

• Not specific to IDU (but could arrange for such a breakdown, though not required)

know their results

• Measurement by survey (and we know how difficult IDU are to reach) – not from actual service provision data

know their results

• Measurement by survey (and we know how difficult IDU are to reach) – not from actual service provision data• Computation is “Number tested and know results”/total tested

know their results

• Measurement by survey (and we know how difficult IDU are to reach) – not from actual service provision data• Computation is “Number tested and know results”/total tested

• So a country might have done just 10 tests of whom 9 knew their results (=90%), and another 100,000 tests, of whom 90,000 knew their results (also = 90%); but both are ranked equally in performance

8. Percentage of most at risk populations who received an HIV test in the last 12 months and who know their

results

• Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach)

results

• Computation is answers to qns (a) tested? And b) got results?

results

• Same result problems (3/4 returns the same result of 75,000/100,000)

results

• Same result problems (3/4 returns the same result of 75,000/100,000)

• PLUS, for both this and #7 – nothing in the indicator “requires” voluntary, confidential counselling

9. Percentage of most at risk populations with HIV prevention programmes

• Computation is individual and sum of answers to qns (a) know where to go for an HIV test? b) last 12 months given condoms [by IDU service]? And c) given sterile needle and syringes [by IDU service]?

• 1 x condom; 1 x N&S is treated equally as 100 condoms and say, 300 needles and syringes

14. Percentage of most at risk populations who both correctly identify ways of preventing the sexual

transmission of HIV and who reject major misconceptions about HIV transmission

• Proxy for IEC coverage, but not specific to transmission by the injection route – important, but outside the scope of our intention

• PLUS – measures knowledge, not actual behavior change

20. Percentage of injecting drug users reporting the use of a condom the last time they had sexual

intercourse

• Proxy for IEC coverage, but not specific to transmission by the injection route – important, but outside the scope of our intention – nonetheless, we think about this one

intercourse

• Measures actual behavior change, so good – another reason to think about it

intercourse

• Measures actual behavior change, so good – another reason to think about it

• But, only applies to countries where injecting is an established mode – why not all countries?

21. Percentage of injecting drug users reporting the use of sterile injecting equipment the last time they

injected

• Surveillance survey (and we know how difficult IDU are to reach)

injected

• Surveillance survey (and we know how difficult IDU are to reach)

• Proxy for actual coverage by NSP (in addition to knowledge), so why not measure actual coverage

23. Percentage of most at risk populations who are HIV infected

• Very important, not a coverage indicator per se, but will be necessary as a denominator for say, ARV coverage

So, UNGASS summary

• Only two are actual coverage indicators (8 & 9) – but measurement/interpretation problems

So, UNGASS summary

• Only two are actual coverage indicators (8 & 9) – but measurement/interpretation problems

• 1 useful for coverage denominator purposes (23), but it is really an impact indicator (which itself is very good)

What about the Current Ukraine M&E plan

• Uses 7 core indicators from UNGASS, plus 2 “additionals”, including 1 replacement of one UNGASS core

indicator”

Additional # 1

VCT1 -Population requesting an HIV test, receiving a test and receiving test results

Additional # 1

• This is the replacement for UNGASS, not specific to IDU, (but could arrange for such a breakdown, though not required)

Additional # 1

• This is the replacement for UNGASS, not specific to IDU, (but could arrange for such a breakdown, though not required)

• Suffers from the same computational/interpretational problems previously identified

Additional # 2

VUL2 –Percentage of respondents in a survey of injecting drug users who, in response to prompting, identify switching to non-injectable drugs, avoiding sharing injecting equipment, and cleaning injecting

equipment with bleach as methods of preventing HIV transmission

Additional # 2

• (phew – quite a mouthful)

Additional # 2

Survey – community of IDU – good, but how many? representativeness etc.

Additional # 2

Prompting??? hmmm.

Additional # 2

Calculation = all three must be answered correctly, but bleach is a problem

Bleach

• Qn comes from UNAIDS 2000 publication

Bleach

• Qn comes from UNAIDS 2000 publication • WHO and UNODC (soon UNAIDS) no longer recommend bleach

Bleach

• So, someone who is up to date on the withdrawal of recommendation will not identify/report using bleach, just as someone who is not aware, but didn’t use it anyway

Bleach

• So, someone who is up to date on the withdrawal of recommendation will not identify/report using bleach, just as someone who is not aware, but didn’t use it anyway

• So indicator no longer accurate, and a proxy anyway, for actual coverage

Bleach

• So, someone who is up to date on the withdrawal of recommendation will not identify/report using use bleach, just as someone who is not aware, but didn’t use it anyway

• So indicator no longer accurate, and a proxy anyway, for actual coverage

Ukraine SUMMARY

Doesn’t add to what we got from UNGASS

CORE INDICATORS

Challenge: 5 core indicators across each of the three service areas:

• ST (methadone, buprenorphine)

• NSP

• Diagnosis and treatment

+ three summary indicators = total of 18 core indicators

And computations should be available continuously from routine data that are collected at service sites

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

• ST

• NSP

• VCT

• ARVs

• ~Condoms~

• ST

• NSP

• VCT

• ARVs

• ~STIs~

Summary measures

A) Elements (and year of introduction) of the essential package provided to IDU

B) Number and proportion of IDU service sites providing each element of the essential package

C) Number and proportion of IDU covered by each element of the Essential package

Summary measures

First step – provide? y/n

ST NSP VCT ARVs All

Summary measures

Second step – Year of introduction

ST NSP VCT ARVs All

1998 - 2001 2003 -

Summary measures

B) Number and proportion of IDU service sites providing each element of the essential package

Begs the question – what is a “service site”?

And that is where the data dictionary comes in – it provides a guide – distinguishes between “fixed” and “mobile” sites

Summary measures

B) Number and proportion IDU service sites providing each element of the essential package

“proportion” requires knowing how many sites in total (as the denominator)

And this means public, private, ngos etc. So we need to know the sites.

Summary measures

NSP ST VCT ARVs All elements1

Kazakhstan 129 (NAC) 0 (0%) 659 (NAC) 22 (NAC) 0 (0%)

Kyrgyzstan 51 (NAC) 2 (NAC) 14 (NAC) 6 (NAC) 0 (0%)

Tajikistan 26 (NAC) n/a 140 (NAC) 7 (NAC) 0 (0%)

Turkmenistan NEA (NAC) n/a NEA (NAC) NEA (NAC) 0 (0%)