M&E of HIV/AIDS prevention
programs
Prof Maretha Visser
Department of Psychology
University of Pretoria
Objectives
•
•
•
•
•
•
•
Why is HIV prevention important?
Different types of HIV prevention
Different levels of prevention
Development of HIV prevention strategies
How will you know if prevention is effective?
Case studies
Barriers to scaling up HIV prevention
Why is HIV prevention important?
• 2004 UNAIDS is requested to develop a global
strategy to intensify HIV prevention
• AIDS epidemic can only be reversed if effective
HIV prevention measures are intensified in
scale and scope – need large scale change to
change epidemic
• Health: no cure, prevention only
• Economy: costly, cannot treat whole
community
Why is M&E of prevention important?
• Need evidence of success to know if
intervention successful and money spent
wisely
• Need evidence to identify best practices, to
scale up good programs and improve
ineffective interventions
Different types of HIV prevention
• Biomedical HIV prevention interventions
• Social and behavioural prevention
interventions
• Structural HIV prevention interventions –
(stigma reduction, gender equality)
• Legal and policy interventions
Different levels of prevention
Prevention: strategies that prevent development
of diseases or interrupt progression of disease
• Primary prevention: reduce exposure or
susceptibility – promote good health; sex
education; protection
• Secondary prevention: early detection and
treatment, reduce risk (treat Sti’s)
• Tertiary prevention: limits disability as result of
disease - ARV
Development of preventive interventions
•
•
•
•
Develop a model of factors to address
Based on the drivers of HIV in community
Needs of the specific target group
Strategies available and relevant
(education/motivation/peer education/skills building)
• Involve all ecological levels in implementation:
individual, peer group, institutional (school/clinic) and
community level (leadership/policy)
• Finding: multilevel, multimodal interventions most
effective
Individual factors
Knowledge about
HIV&AIDS, risk
perception
Interpersonal
influence: social
norms, modelling,
pressures or
support of family
and friends
Intrapersonal: selfesteem, selfefficacy, level of
depression, life
satisfaction
Behavioural
beliefs
Attitude
towards
behaviour
Personal Factors
Normative
beliefs
Subjective
norms
Behavioural
intention
Control
beliefs
Perceived
control
Level of
support:
parents, school,
peer group
Community/cultural climate:
Socio-economic status /safety/stigma/
violence / role models
Contextual Factors
Community infrastructure/public
policy:
Resources: clinics/condoms/services
Support/Barriers of
Healthy Behaviour
How will you know prevention is
effective? Research evidence needed
Biomedical HIV prevention interventions
• Male circumcision (MC) – meta analysis 65% effective
• Highly Active Antiretroviral Therapy (HAART) RCTs on HAART* reported 60%
to 80% reductions in new infections
• Prevention of mother to child transmission (PMTCT) best evidence –
reduce from 35% to 1%
• Condoms (Male and Female) best evidence 90% safe
• Treatment of Sexually Transmitted Infections (STI) limited evidence – 40%
effective
• Microbicides and cervical barriers – some results 30% effective/no evidence
• HIV vaccine – promising evidence in Thailand
Social and behavioural prevention
The goal is to reduce HIV-risk behaviour: (primary &
community wide)
• Increase knowledge
• decrease stigma
• increase access to services
• increase testing rate (intermediate goals)
• delay the onset of sexual intercourse
• reduce the number of sexual partners
• increase condom use
• decrease shared needles or equipment
• reduce or eliminate substance (alcohol) use
(Risk groups) adherence to ARV’s; behaviour change
Social and behavioural prevention
interventions
•
•
•
•
Abstinence-only and ABC interventions
Voluntary Counselling & Testing (VCT)
Stepping Stones counselling intervention
Concurrent sexual partnerships
“Behavioral HIV prevention works. Some
have been pessimistic that it’s possible to
reduce HIV risk behaviors on a large scale,
but this concern is misplaced”
•
Dr. Helene Gayle, co-chair of the Prevention Working Group
Evidence of effective behavioural
prevention
• Best evidence: rigorously evaluated
• Significant effects in reducing risk
• Longitudinal design – 3month follow-up
• 70% retention rate
• Promising evidence: evaluated
•
•
•
•
•
Significant effects in reducing risk
1 month follow-up
60% retention rate
Significant change in more than one outcome
No evidence of critical limitation in design
Social and behavioural prevention interventions
• Abstinence-only and ABC interventions – 13
RCT US, 7 no change in risk- no evidence
• Voluntary Counselling & Testing (VCT)- metaanalysis 11 studies, <68% risky sex for HIV+; 27 studies, no effect for HIV-
• Stepping Stones counselling intervention
(50hours)- men vs control : <partner violence (2 years);
• <transactional sex (I year);
• < problem drinking (1 year); --- promising evidence
• no effect on HIV incidence
• Positive prevention (with HIV+) - < risk behaviour in
pilot study – RCT underway
Structural HIV prevention
interventions
IMAGE intervention with micro-finance for women
and HIV training programme
• RCT in rural Limpopo
• Experience of intimate partner violence (IPV) reduced by
55%.
• No effect on unprotected sex with a non-spousal partner
• No effect on HIV incidence
Communication programmes – Soul City, Love
Life
• No evidence of impact
Evidence-based HIV behavioural
interventions in the US
CDC’s AIDS Prevention Research Synthesis (PRS)
project identified 18 best evidence, theorybased behavioural interventions
demonstrating “best evidence” of efficacy
• for reducing HIV risk;
• targeted at heterosexual men and women,
MSM, Youth, PLWHA and low income
populations, etc.
Case studies
Case study: discussion
1) Which level of HIV prevention needed?
2) Formulate objective of intervention.
3) What intervention strategy can be used.
Suggest one strategy to intervene. For this
strategy, discuss:
• Indicators – various levels
• How measured
• Evaluation design
• Issues involved in intervention and M&E plan
• How will you know if it was successful?
Case study: Southern African community
Risk behaviours: (men and women under 39 years)
multiple partners (44.2% of men and 25% of women);
non-consistent condom use (38% non-consistent use);
alcohol use (36.1% men reported sex when drunk)
Underlying factors:
•
•
•
•
•
Socio-economic situation – poor/for financial gain
Gender roles – women not empowered
Silence about men’s risk behaviour (cultural)
Government taking responsibility – no incentives to stay HIVMedicalization of HIV – medical answer
Case study: Adolescents in schools
Baseline data found:
•
•
•
•
•
•
•
•
•
< HIV knowledge among younger learners
49.4% of boys and 30.5% of girls 16years+ sexually active
7% learners reported sexual debut under15 years old
44% of sexually active report inconsistent condom use
> peer pressure
> gender inequality – different norms for groups
< role models and community support
< socio-economic – money related to prestige
> culture of alcohol abuse
Barriers to scaling up HIV prevention
• Lack of appreciation of prevention: cannot see
immediate results – only long-term
• Lack of resources allocation
(human/financial/training)
• Lack of innovative ideas, difficult to address
societal issues that drive HIV
• Poverty, alcoholism, negative life conditions
more serious (HIV only one life stressor, only
future consequences)
Barriers to scaling up HIV prevention – M&E
• Lack of M&E to identify best practices – keep
on doing same, do not know effect.
• No short term effect
• Research design has to distinguish between
particular intervention and various community
wide campaigns to show effect.
• Need to measure behaviour change or non
occurrence of behaviour
Difficulty in M&E to determine cause
of change
Debate related to what bring about change – how
can components be separated and tested?
• Uganda: prevalence from 15% to 5%, later sexual
debut, less concurrent partners. Why?
• ABC model or addressing gender equality?
• Success because of extensive social mobilisation
at every level + strong political leadership +
empowerment of women + sexual responsibility
of men + observing many people dieing of AIDS
(Murphy, Greene et al., 2006 PLoS Med, 3(9), e379).
Effective change in Zimbabwe
HIV prevalence decrease with 50%. Why?
•
•
•
•
Increased interpersonal conversation about HIV
High exposure to AIDS mortality (die at home)
Understanding of sexual transmission
Deteriorating economic situation – lower income
prevent men from socialising in bars
• Shift in social norms: STI’s became cause of shame
No “Magic Bullet” for HIV
“It is critical to note that there is no “magic
bullet” for HIV prevention. None of the new
prevention methods currently being tested is
likely to be 100 percent effective, and all will
need to be used in combination with existing
prevention approaches if they are to reduce
the global burden of HIV/AIDS.”
Source: Global HIV Prevention Working Group (2008)
Highly active prevention
The AIDS epidemic has taught us to be innovative and to invent,
test and implement new interventions. We now have evidence
of HIV prevention strategies that work!
However, despite our innovation, inventiveness and
compelling evidence of effective strategies, the “killer
virus” is still chasing
and killing us!