M&E Framework for Programmes for
Most-at-Risk Populations
Regional Workshop on the
Monitoring and Evaluation of HIV/AIDS Programs
February 14 – 24, 2011
New Delhi, India
What is a Concentrated Epidemic?
 Epidemics are concentrated if transmission is mostly
confined to individuals with high-risk behaviors and
those in their sexual and drug use networks, and
where protecting these groups would protect society
more broadly
 Epidemics are generalized if transmission occurs
mainly outside vulnerable groups and would continue
despite effective vulnerable group interventions
Who are Most-at-Risk Populations
(MARP)?
 These are sub-populations with elevated levels of
HIV-related risk behavior and where there is potential
for HIV transmission
 Populations may include:
 Female sex workers (FSW)
 Clients of FSW
 Injecting drug users (IDU)
 Men who have sex with men (MSM), including
male sex workers (MSW)
What are HIV-related High-risk
Behaviors?
 Unprotected sex with multiple-partners
 Unprotected sex with a partner who has
multiple partners
 Unprotected anal sex with a male partner
 Sharing injecting equipment
 …occurring in the presence of HIV
Purpose of framework
 A “road map” or logic model for planning appropriate
assessment, monitoring and evaluation in
concentrated and low-level epidemic settings
 Can be used to bring stakeholders together to
compile and analyze data in order to plan more
effective intervention and improve programs
 Can be used as a capacity-building tool to identify
strengths and weaknesses in planning, implementing
and using strategic information at national and subnational levels
Understanding the problem and potential
response:
1. What is the problem?
The Answer
 Describes the nature, magnitude, and course of the overall
HIV epidemic and related sub-epidemics
Data Sources
 HIV prevalence from surveillance
 Estimates of the size of affected MARP populations
 Proportion of infections in MARP and projected course of the
epidemic from modeling
HIV Prevalence in IDU and female sex workers
100
Drug Injectors
Percent HIV-Positive
90
Female sex workers
80
70
68
64
59
55
60
52
47
50
39
40
30
20
10
9
3
3
8
8
0
Guangxi, Mumbai, India
China (2002)
(2002)
Jakarta,
Indonesia
(2003)
Kathmandu
Valley, Nepal
(2003)
Source: AIDS in Asia: Face the Facts. MAP Report 2004
Bangkok,
Thailand
(2003)
Haiphong,
Vietnam
(2002)
Source: Strategizing Interventions among MSM in the Greater Mekong Sub-region (GMR)
CDC-GAP/USAID-RDM/FHI-APD Workshop, 2004
Understanding the problem and potential
response:
2. What are the contributing factors?
The Answer
 Describes determinants of HIV infection and
contributing factors at the structural, community,
and individual level
Data Sources
 Rapid assessments and situation analysis
 Knowledge, attitude, and behavior surveys;
 Epidemiologic studies
Source: PLACE in Central Asia: A regional strategy to focus AIDS prevention in Almaty and Karaganda,
Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 2002
Understanding the problem and potential
response:
3. What interventions are effective?
The Answer
 Identifies appropriate and effective interventions to
address the problem and the sub-populations
affected
Data Sources
 Review of existing information on what
interventions are efficacious and effective
 Operations research, evaluation studies, and other
special studies
Understanding the problem and potential
response:
4. What interventions and resources are
needed?
The Answer
 Identifies the specific interventions and resources
that are needed to mount an effective and
comprehensive response
Data and Sources
 Needs analysis, costing,
 Response analysis including an assessment of
current programming and estimated coverage
Monitoring and evaluating the response:
5. What are programs doing and are they
doing it right?
The Answer

Assesses whether project activities are being
implemented as planned and assesses the value
of what a project or programme has achieved in
relation to its planned activities and objectives.
Data Sources

Routine data from project monitoring systems,
special process evaluations including
assessments of service quality
Yearly Product Retail Sales & Outlets
1,400,000
250,000
Male Condom
1,200,000
Lubricant Sachets
Female Condom
1,000,000
Male Condoms
200,000
150,000
800,000
2,255
600,000
1,926
1,896
400,000
1,171
50,000
890
200,000
100,000
-
2002
Source: PSI Burma, 2007.
2003
2004
2005
2006
Lubricants & Female Condoms
Outlets
Example: Assessing Quality and Use
Use of multiple components of a minimum package of
interventions by FSW project beneficiaries
Percent of FSW
Clients
100
Peer Outreach and
Education
above plus Condoms
80
60
above plus Targeted Media
40
above plus VCT
20
above plus STI
0
Vientiane
Yangon
Gejiu
Source: MEASURE Evaluation & IPSR, 2006
Monitoring and evaluating the response:
6. Are programs being implemented as planned and
are they reaching the target population?
The Answer

Determines whether or not the project is reaching
its target population
 Data Sources

Monitoring of program outputs and estimates of
coverage based on 1) project records
aggregated across partners combined with
estimates of population size or 2) surveys.
Example: Monitoring Coverage
Percentage (%)
Exposure to various types of NGO-related information sources about HIV/AIDS among FSWs
is high and increasing over time, Terai Highway Districts, Nepal, 1998 – 2002.
100
90
80
70
60
50
40
30
20
10
0
87
84.5
98.3
97.3
93.8
90
78.5
83.3
75.8
58.3
58.5
60.3
69
43.8
24
1998
1999
Mass m edia*
Individual-based Com m unication***
Source: FHI Bangkok
2000
2001
2002
Group-based Com m unication**
Source: FHI, BSS
Monitoring and evaluating the response:
7. Are interventions effective?
The Answer

Examines program outcomes (e.g. HIV-related
risk behaviors) and determines whether or not
changes are attributable to interventions
Data Sources

Outcome evaluation studies with control or
comparison groups, operations research, health
services research, formative research, and other
special studies.
Example: Outcome Evaluation
The Sonagachi Project of Calcutta
 Intervention:
 community-based intervention to increase condom use among
sex workers
 Design:
 randomized multiple group community trial conducted over a 15
month period
 Results:
 Condom use increased by 39% in the intervention group
compared to 11% in the control group. Consistent condom use
increased by 25% in the intervention group compared to 16% in
the control group.
Source: Basu, Janaand Rotheram-Borus, 2004
Monitoring and evaluating the response:
8. Are collective efforts impacting the
epidemic?
The Answer
–
Assesses whether or not there are changes in HIV-related risk
behavior and HIV prevalence in the population targeted by
programs, and whether or not these changes are plausibly
linked to overall program effort
Data Sources
–
Monitoring outcomes (e.g. risk behavior) and impact (e.g. HIV
prevalence) using surveys and surveillance, triangulated
analysis
Example: Data Triangulation
7000
100
90
6000
80
5000
70
4000
60
50
3000
40
2000
30
20
1000
0
10
1999
2000
2001
2002
489
2750
252
2032
5809
2582
4187
6191
Condoms distributed
(x10,000)
STI referrals
Intervention contacts
Consistent Condom Use
80.3
HIV prevalence
33.2
0
HIV prevalence and condom use (Percent)
Intervention, referral, condoms (Number)
HIV prevalence among brothel-based sex workers declined in Cambodia
and condom use increased. Over the same period interventions among sex
workers tripled and achieved high coverage
Condoms distributed
(x10,000)
STI referrals
Intervention contacts
Consistent Condom
Use
HIV prevalence
89.8
31.5
28.8
Sources: Cambodia BSS 1999 and 2001, HSS 1999, 2000 and 2002, F HI Cambodia monitoring data for women’s health interventions
Source: FHI Bangkok
Challenges to Collecting Data among
MARP
 Political and/or legal environment may lead to
discrimination, threat of prosecution if
attention is brought to members of the subpopulation
 Stigma may keep populations hidden making
them hard to reach for programs or M&E
Ethical Considerations
 Follow a “do no harm” approach
 Maintain the confidentiality of client
information
 Respect privacy and anonymity
 Informed consent
 Data collection should go hand-in-hand with
programming
MEASURE Evaluation is a MEASURE project funded by the
U.S. Agency for International Development and implemented by
the Carolina Population Center at the University of North Carolina
at Chapel Hill in partnership with Futures Group International,
ICF Macro, John Snow, Inc., Management Sciences for Health,
and Tulane University. Views expressed in this presentation do not
necessarily reflect the views of USAID or the U.S. Government.
MEASURE Evaluation is the USAID Global Health Bureau's
primary vehicle for supporting improvements in monitoring and
evaluation in population, health and nutrition worldwide.