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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?.

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M e framework for programmes for most at risk populations

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
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
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
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
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 sub-national levels


Understanding the problem and potential response 1 what is the problem
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
HIV Prevalence in IDU and female sex workers

Source: AIDS in Asia: Face the Facts. MAP Report 2004


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
Understanding the problem and potential response: Mekong Sub-region (GMR)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
Understanding the problem and potential response: AIDS prevention in Almaty and Karaganda, Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 20023. 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
Understanding the problem and potential response: AIDS prevention in Almaty and Karaganda, Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 20024. 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
Monitoring and evaluating the response: AIDS prevention in Almaty and Karaganda, Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 20025. 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


Source: PSI Burma, 2007. AIDS prevention in Almaty and Karaganda, Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 2002


Example assessing quality and use
Example: Assessing Quality and Use AIDS prevention in Almaty and Karaganda, Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 2002

Source: MEASURE Evaluation & IPSR, 2006


Monitoring and evaluating the response: AIDS prevention in Almaty and Karaganda, Kazakhstan; Osh, Krygystan; Tashkent, Uzbekistan. 20026. 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

    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.

    Example: Monitoring Coverage

    Source: FHI, BSS

    Source: FHI Bangkok


    Monitoring and evaluating the response 7 are interventions effective
    Monitoring and evaluating the response: about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998 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
    Example: Outcome Evaluation about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998

    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, JanaandRotheram-Borus, 2004


    Monitoring and evaluating the response 8 are collective efforts impacting the epidemic
    Monitoring and evaluating the response: about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998 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
    Example: Data Triangulation about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998

    Source: FHI Bangkok


    Challenges to collecting data among marp
    Challenges to Collecting Data among MARP about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998

    • Political and/or legal environment may lead to discrimination, threat of prosecution if attention is brought to members of the sub-population

    • Stigma may keep populations hidden making them hard to reach for programs or M&E


    Ethical considerations
    Ethical Considerations about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998

    • 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 about HIV/AIDS among FSWs is high and increasing over time, Terai Highway Districts, Nepal, 1998

    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.


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