Dr. Jonathon Simon Center for International Health and Development (CIHD)

1. Effectiveness of PEPFAR-Funded Community Outreach HIV Prevention Programs in Vietnam: Preliminary FindingsJune 6, 2008 Dr. Jonathon Simon Center for International Health and Development (CIHD) Department of International Health Boston University School of Public Health (BUSPH) For the Evaluation team: Dr. Lora Sabin Dr. Mary Bachman DeSilva Dr. Davidson H. Hamer Ms. Taryn Vian Ms. Danielle Lawrence Ms. Kelly McCoy Mr. Jordan Tuchman CIHD, BUSPH Dr. Le Thi Thanh Loan HCM City Statistical Office Dr. Theodore Hammett Abt Associates Inc. Dr. Duong Quoc Trong Vietnam Administration of AIDS Control (VAAC)

2. Background • Vietnam’s 2004-National Strategic Plan focus: • VCT, ART, harm reduction, • Harm reduction programs include community outreachprograms that aim to: • Distribute info about HIV transmission, prevention, and care among most at-risk populations (MARPs) • Reduce risky behaviors, increase safe behaviors relating to drug use and sexual practices • Promote use of VCT, STI, social, and other available support services • Outreach programs employ 2 approaches: Peer educators (PE) and Health Educators (HE)

3. Public Health Evaluation of PEPFAR-supported HIV/AIDS Outreach and Referral Programs • Family Health International • CDC LIFEGAP • Médecins du Monde • CARE International

4. Primary Research Questions 1. Are outreach workers well prepared to deliver services among MARPs? • Are outreach workers identifying and communicating well with clients? HE and PEs in Hoang Mai, Hanoi 3. Is this BCC intervention effective in changing behavior?

5. Overview of Evaluation Design Qualitative and quantitative methods: • Review of program information • Qualitative: 223 in-depth interviews with outreach workers, MARPs, other key informants (6 provinces) • Quantitative: Cross-sectional survey of 2,222 MARPs & 272 PEs/HEs (4 provinces) • Here we report on findings from cross-sectional MARP survey relating to program effectiveness

6. Study Population • “Intervention” – contact with PE or HE in last six months • “Control” – no contact with PE or HE in last six months • Snowball sampling to identify both populations

7. Findings: Characteristics of respondents • Few demographic differences across groups: • Slightly over 1/2 were female (~58%) • Mean age was just under 30 years (~29 years) • About 1/3 had a high school education or higher • Some differences in previous behaviors between Intervention group (Int) vs. Control group (Con) • 22% of Int vs. 16% of Con reported tested + for HIV • 24% of Int vs. 15% of Con reported sex with an IDU • Among MSM: • 14% of Int vs. 23% of Con reported ever bought sex • 31% of Int vs. 40% of Con reported ever sold sex • Unknown social desirability bias

8. Effectiveness of BCC: Knowledge • Over 90% of all MARPs had good knowledge of transmission (answered correctly 75% of questions) • Over 70% had good knowledge of prevention • Only 24% had good knowledge of treatment (ART) • In all 3 areas, intervention population knew slightly more compared to control population • Major knowledge gaps • Transmission: having unprotected oral sex/anal sex, mosquito bite, breastfeeding • Prevention: practicing withdrawal, condom use during oral sex/anal sex, not touching a PLWHA, not kissing • Treatment: existence of HIV cure, purpose of ART

9. Effectiveness of BCC: Risk behaviorsIDUs and injection behaviors • IDU MARPs (n=703) reported injection behaviors • Most (96%) could obtain new needles/syringes when needed • 14% had recently shared needles/syringes • 36% had used a previously used needle at last injection (within last 6 months) • Intervention IDUs more likely to report starting or increased cleaning of injection equipment • 71% Intervention vs. 61% controls

10. Effectiveness of BCC: Reported Condom use • Reported condom use among respondents • 37% always use condoms • 34% usually use condoms • Higher condom use reported by all intervention MARPs • More likely to always use condoms (40% vs. 34%) • More likely to always carry condoms (50% vs. 42%) • Unclear what impact, if any, on transmission dynamics

11. Effectiveness of BCC: Referral service usage and perceived risk • Intervention group more likely to seek HIV testing • 76% of intervention vs. 46% of controls were tested • Among tested, 81% vs. 61% sought post-test counseling • MARPs reported low perceived risk of infection • Less than 1/4 see themselves as at high risk • Reasons provided: • always use condom, • never share needle or syringe

12. Communication about safe sex and safe injection Intervention MARPs had more discussions about safe sex (98% v 45%) & safe injection (69% v 27%) in previous 6 months A. Discussions about safe sex B. Discussions about safe injection

13. Views of MARP clients on outreach programs and workers • Intervention MARPs rated most services very or mostly useful; >95% for: • Information on: transmission, safe sex, safe needle disposal, HIV testing • Demonstration of condom use, injection cleaning methods • HIV transmission/prevention knowledge was most useful • >95% said PEs/HEs are trustworthy • 72% would “absolutely” urge friends to talk to PEs/HEs

14. Challenges in providing services • 73% of control MARPs (n=799) had not heard of outreach programs • Of those who had (27%, n=322), main reasons why no contact: • inconvenient time (52%) • don’t know how to contact (44%) • inconvenient location (34%) • do not feel comfortable (30%) • worried about police (24%) • 25% expressed interest in talking to an outreach worker

15. Summary • PHE data suggests that outreach programs have been somewhat effective in increasing HIV transmission, prevention, and treatment knowledge • Important knowledge gaps remain—especially related to HIV prevention and treatment • Further program impact is suggested by differences in intervention v control: condom use, HIV testing • “Ripple effect” seems to be important benefit of the outreach programs • No evidence of impact regarding needle sharing • Challenges remain in reaching MARPs in current program areas

16. Recommendations for program improvement • Improve commodity supplies (condoms) and overcome constraint on distribution of needles • Develop targeted quality improvement approaches to overcoming specific barriers to accessing clients: • Inconvenient time, location of outreach activities • Easier ways of contacting outreach workers • Collaborate more closely with key community members: police, establishment owners

17. Thank you! Funding provided by: USAID/Hanoi, Country Research Activity GHS-A-00-03-00020 Additional acknowledgments: Ahmar Hashmi, Jen Beard, Wayland Bergman, Bill MacLeod, Matt Fox, Don Thea, Jill Costello, Jon Simon, Deirdre Pierotti

18. Several detailed slides follow, if useful

19. Surprises during implementation • Related to data collection: • Ease of recruiting “control” participants for quantitative survey • Quality of interviewing by local qualitative researchers • Related to findings: • Wide variability across implementing programs, provinces • Generally low needle sharing, high access to clean needles/syringes

20. What we would NOT do again • Wait so long for IRB approval from a single domestic institution • Next time, we would simultaneously seek approval from relevant institutions to reduce potential delay • Assume local researchers are sufficiently trained for qualitative data collection • Next time, we would conduct our own training of all qualitative data collectors to ensure that they are equipped with adequate preparation and skills

21. What we WOULD do again • Partner with an experienced in-country research group, even if the group does not have extensive HIV/AIDS-related experience • Lesson: a strong track record collecting and managing data may be more useful than HIV/AIDS-related research experience • Devote considerable time on data collection tools, in collaboration with in-country partner • Lesson: developing confidence and familiarity with the tools is critical to later use

22. Background • HIV/AIDS epidemic • Nationwide adult HIV prevalence in Vietnam: 0.5% • Most-at-risk populations (MARPs): IDU, CSW, MSM • 2004-National Strategic Plan focus: • VCT, ART, harm reduction, other best practices • Vietnam is PEPFAR focus country since 2004, supporting interventions including community outreach • 2006: BU asked to evaluate outreach interventions in order to provide evidence for program improvements

23. Overview of community outreach programs • Community outreach programs are an important component of harm reduction activities that aim to: • Distribute information about HIV transmission, prevention, and care among at-risk populations • Reduce risky behaviors, increase safe behaviors relating to drug use and sexual practices • Promote use of VCT, STI, social, and other available support services • Goal: to reduce risk of HIV transmission and STI prevalence among most at-risk populations

24. Programs implemented in 38 provinces • Focus provinces: Hanoi, Hai Phong, Quang Ninh, Ho Chi Minh City, An Giang, and Can Tho • In these 6 provinces - an estimated 116,641 IDUs and 40,495 CSWs • Programs employ two approaches: a peer education approach and a health educator approach PEPFAR-funded community outreach programs

25. Methodology: limitations • Design used a cross-sectional survey, not a randomized controlled trial, so cause and effect cannot be inferred • Respondents may have provided overly positive information, biasing findings (“social desirability” bias) • The sample sizes of MARP groups is somewhat different than the sizes of MARP groups in Vietnam overall • Snowball approach might have resulted in a potential bias of the final samples • Limitations are important, but we do not believe they affect findings in a meaningful way

26. Findings: MARP Demographics Control group slightly younger, less likely to know status, or be HIV+.

27. MARP Demographics: Risk Behaviors, Intervention vs.. Control Control group lower risk

28. Effectiveness of BCC: Knowledge of Intervention v Control groups Transmission knowledge: % respondents who gave correct answers *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

29. Effectiveness of BCC: Knowledge of Intervention v Control groups Prevention knowledge: % respondents who gave correct answers *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

30. Effectiveness of BCC: Knowledge of Intervention v Control groups HIV treatment knowledge: % respondents who gave correct answers *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

31. Effectiveness of BCC: Risk behaviorsIDUs and injection behaviors Behaviors reported by respondents who had used heroin in last 6 months *no differences were statistically different at the p=0.05 level

32. Effectiveness of BCC: Risk behaviorsSexual behaviors Behaviors reported by all respondents *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

33. Effectiveness of BCC: Referral service uptake HIV testing and counseling behaviors reported by all respondents *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001