Evaluation of HIV Prevention Programs in Vietnam: Key Findings June 2008

1. Evaluation of HIV Prevention Programs in Vietnam:Key FindingsJune 2008 Dr. Davidson Hamer Center for International Health and Development Department of International Health Boston University School of Public Health

2. Evaluation Team Members and Affiliations Boston University School of Public Health Lora Sabin, MA, PhD Mary Bachman DeSilva, MS, ScD Davidson H. Hamer, MD Taryn Vian, M.Sc. Danielle Lawrence, MPH Kelly McCoy, MPH Jordan Tuchman, MPH Ho Chi Minh City Statistical Office Le Thi Thanh Loan, PhD Abt Associates Inc. Theodore Hammett, PhD Funding provided by: PEPFAR/USAID: 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, and Deirdre Pierotti

3. Presentation Outline • Background • Evaluation questions • Methodology and limitations • Findings • Summary • Recommendations

4. Background • Vietnam’s 2004-National Strategic Plan focus: • VCT, ART, harm reduction, other best practices • Harm reduction programs include community outreachprograms that aim to: • Distribute information 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 and • Health educators

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

6. Design & Methods 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) PE demonstrating needle cleaning

7. 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

8. Methodology: Limitations • Cross-sectional survey: cause and effect cannot be inferredbetween Intervention and Control groups • Possible social desirability bias • Differences between PEs and HEs not relevant to all programs • Sample sizes of MARP groups different from sizes of MARP groups in Vietnam overall • Potential bias from snowball sampling approach

9. QN: CDC/LG, FHI, CARE QN: CDC/LG, FHI, CARE HN: All 4 programs HP: CDC/LG, FHI HP: CDC/LG, FHI AG: CDC/LG, FHI, CARE HC: All 4 programs HC: All 4 programs CT: CDC/LG, FHI, CARE

10. EvaluationFindings

11. Characteristics of MARP Respondents • Few differences in demographic characteristics: • 58% female • Mean age ~29 years • About 1/3 had a high school education or higher • Some differences in previous behaviors between Intervention group (Int) and Control group (Con) • 22% of Int vs 16% of Con had tested + for HIV • 13% of Int vs 6% of Con had had sex with HIV+ person • 24% of Int vs 15% of Con had had sex with an IDU • Among MSM: • 14% of Int vs 23% of Con had ever bought sex • 31% of Int vs 40% of Con had ever sold sex

12. Research Question 1: How prepared are outreach workers? • Training and skills • Knowledge and qualifications • Supplies • Supervision and support • Financial support

13. Training & Skills • Most PEs/HEs felt training was appropriate and adequate preparation for job • Before I knew about these topics only through friends, but now [my] knowledge is more scientific and concrete.(PE in Hanoi) • Thanks to the course, I am more daring; I’m not afraid of going to the establishments to talk anymore.(PE in Hai Phong) • [PEs] should be trained more to be more experienced and knowledgeable to work.(PE in An Giang)

14. Training & Skills • >90% of PEs and HEs received pre-service training, 95% received refresher training • >95% of outreach workers had covered key topics of HIV transmission, prevention through safe sex/safe injection, demonstration of correct condom use, negotiation & outreach skills • 13% PEs and 26% HEs had not received infection control training • PEs mentioned wanting more training related to antiretroviral therapy (ART)

15. Knowledge about HIV

16. PE/HE Knowledge Gaps • 8% did not know that HIV can be transmitted through breastfeeding • Only 55% knew that withdrawal during sex is not an effective method for preventing HIV infection • 13% thought that not touching someone who is HIV+ is an effective prevention method • Nearly 20% did not know there is no cure for HIV/AIDS • 24% did not know that ART improves immune functioning • 60% did not know that the purpose of ART is to treat HIV/AIDS.

17. Supplies • Sometimes inadequate (PE, MARP) • More safety items needed (PE) • I’m not satisfied with the lack of some aids…there should be alcohol, distilled water, condoms, and it’s really good to have injection syringes and needles. (PE in Hai Phong) • Without access to sterile injection equipment people like us can spread disease all over the society. (CSW in Hanoi)

18. What type of support have you received?

19. Perceptions of Community Support

20. Supervision and Support • Now, we are still rushed by the police when approaching gathering spots. Sometimes I am even assaulted…We are even captured by the police even though we wear uniform and badges. (PE in Hai Phong) • At present, the police are not quite clear about our job. .. The police ask us to inform them before approaching any particular places, but we refuse as we have to keep our customers’ secret. (PE in HCMC)

21. Financial Support • Some workers dissatisfied with salaries (mean reported salaries: PEs = 900,000; HEs = 2,300,000 VND/mo) • …some outreach workers work at bars, massage parlors, discotheques and at that time the fees are especially high. At the moment we haven’t got the financial support when approaching those areas.(HE in Hanoi) • If the workers here just thought of the salary, it’s possible that nobody would do this job…Our salary is quite poor… not enough to support our life.(PE in Hai Phong)

22. Research Question 2:How well do outreach workers identify and communicate with clients? • Services provided by outreach workers • Approaches used by outreach workers • Perceived strengths of programs • Challenges encountered in providing services

23. % of PE and HE who reported contact with each client group in last month

24. PE/HE Contacts by Client Group

25. Services Provided by PEs and HEs • Provincial variability in contacts per month • Hai Phong: 50 total/12 new; An Giang: 25 total/8 new • Rising trend in number of clients per month in the past 6 months: +81% in Hai Phong; +57% in HCMC • 95% tell IDUs that sharing injection equipment is unsafe • 30% able to name unsafe sources • 31% tell where to obtain bleach • 93% provided VCT referrals in previous month • 62% to STI clinics • 36% for ART • 33% to TB clinics

26. Conversations Reported by MARPs Possible secondary benefit: 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

27. PEs/HEs use a variety of approaches to reach clients PEs/HEs that reach CSWs (n=161)

28. Approaches Used by PEs and HEs • Specific tactics: humor, scare tactics, friendly and polite demeanor, emphasizing risks to family members • PEs/HEs said that approaching street CSWs (SSWs) is much easier than establishment-based CSWs (KSWs) • For MSM, hot spots and introductions are key • MARPs said best approaches are: making clients feel comfortable, using personal connections, being reliable

29. How PEs and HEs talk to clients • It depends on each customer. For example, at the railway, the ice-breaker is: Where did you buy the “goods”? Is it good? Who did you buy it from?... I show them that I’m in their circle. Then I step-by-step turn to some anecdotes [and] lead them to my purpose, [which] is to talk about HIV. (PE in Hai Phong) • We go to the women’s gathering places ourselves to make friends … Sometimes I even bring my child along. Sometimes I tell a lie that used to be a sex worker.(PE in Hanoi) • Continuous rain softens the hardest soil. We can’t see it right away. They change their habits step by step. (PE in Quang Ninh)

30. Perceived Program Strengths • Intervention MARPs rated most services very or mostly useful; >95% for: • Information • Demonstration of condom use, injection cleaning methods • HIV transmission/prevention knowledge • >95% said PEs/HEs are trustworthy • 72% would “absolutely” urge friends to talk to PEs/HEs • About half of MARPs could not distinguish PEs v HEs • Of those who could: HEs seen as more knowledgeable, PEs as more practical, available, and able to help change behavior

31. Perceived Program Strengths • At first I was also shy as I didn’t know what they were like, but when we were closer to each other, I really liked talking to them.(CSW in Hanoi) • …just like friends talking with each other.(MSM in HCMC, on his relationship with a PE) • [Talking with PEs is] beneficial as they bring us information to prevent HIV….(IDU in Hai Phong) • I’ve met health educators and I find them really enthusiastic. They all answered every question of mine. … I see peers more often, so I like them more…. I ask the health educators the questions which peers can’t answer.(MSM in Hanoi)

32. Challenges in Providing Services • 83% PEs/HEs reported difficulties in approaching clients • 53% had encountered violent clients • Lack of client cooperation due to fear, police interference, time conflicts • MARPs: some PEs apathetic or too preachy: • Most PEs working here are not enthusiastic. They just work to receive salary. (MSM in HCMC) • He [PE] communicates with me but sometimes talks so much that it makes me feel a headache…. he keeps preaching. Even on doing this and that for prevention; such a headache….(IDU in Quang Ninh)

33. Challenges in Providing Services • 3/4 of control MARPs had not heard of programs • Of those who had, main reasons no contact: inconvenient time, location, not sure how to contact, feel uncomfortable • 1/4 expressed interest in talking to a PE • Qualitative data highlight fears of MARPs and potential need for more PEs: • I recommend an increase in the number of PE to outreach drug users…If so, there will be a decrease in the number of drug users.(IDU in Hai Phong) • Outreach workers need to work better. To make the unaware people go [to clinic] for examination; or they should chat to those people.(CSW in An Giang)

34. Social Discrimination • The biggest problem is the prejudices from the community. Many people do not know anything about MSM’s feelings, and they [think they] are sick and debauched people.(HE in Hanoi) • The police even beat us if they catch us delivering condoms outside the street. I have been beaten by a club. They don’t even want to know what we do, just chase us.(PE in Hai Phong) • The obstacles are from the [establishment] owners; they don’t welcome us. They deny that they have prostitutes inside…if the local government and other unions support us a bit in our job, the program will be more effective. (PE in An Giang)

35. Research Question 3:How effective is the behavior change communication? • Knowledge, attitudes, and beliefs • Risk behaviors • Referral service usage and perceived risk • Qualitative information on program strengths and weaknesses

36. Effectiveness of BCC: MARP Knowledge

37. Knowledge Gaps Among MARPs • Transmission • 28% (24% Int, 32% Con) did not know that HIV can be transmitted through breastfeeding • Prevention • 65% (both Int/Con) said that withdrawal during sex is an effective method of HIV prevention • 27% (24% Int, 30% Con) said that not touching someone who is HIV+ is an effective prevention method • Treatment – main area of knowledge weakness • 25% (both Int/Con) did not know there is no cure for HIV • 66% (56% Int, 76% Con) did not know that ART improves immune functioning • 60% did not know that the purpose of ART is to treat HIV

38. Changes in MARPs’ Beliefs • Changes in beliefs about what was risky behavior and the seriousness of risk • Better understanding of modes of HIV transmission • New attitudes toward people living with HIV • Stronger feelings of personal security and self-efficacy • I changed a lot of my beliefs…I used to underestimate [the risk] and not use condoms, but since talking with him, I know the benefits. (MSM in Hanoi)

39. IDUs and Injection Behaviors • IDU MARPs (n=703) - reported low-risk injection behaviors • 97% Intervention / 95% Controls could obtain new needles/syringes when needed • 14% in both groups had recently shared needles/syringes • In IDIs, noted barriers to access sterile equipment • No single guaranteed source • Inconvenience in bad weather, late at night • Fear of discovery with equipment by police, family • Intervention IDUs - more likely to start or increase cleaning of injection equipment • 71% intervention vs 61% controls

40. IDUs and Injection Behaviors • Before meeting [outreach workers], I thought nothing about problems concerning sharing syringes and needles. Now I no longer share syringes or needles with others. (IDU in Hanoi) • We used to share syringes and needles in groups of 4, 5 users. Now we no longer share them as I’ve witnessed many deaths.(IDU in An Giang) • I’ve changed a lot, I’ve thought of it a lot…After listening to him, I don’t [share]. I used to use the kits again…Now I wash them with boiling water twice or three times according to the formula. (IDU in Quang Ninh)

41. Sexual Behaviors: Condom Use • Sexually active MARPs (n=1623) reported on condom use: • 37% always use condoms • 34% usually use condoms • 29% never/occasionally use • CLEARLY substantial room for improvement

42. Sexual Behaviors • Higher condom use reported by intervention MARPs • …but lots of room for change

43. Sexual Behaviors • I changed a lot of my beliefs…I used to underestimate [the risk] and not use condoms, but since talking with him, I know the benefits.(MSM in Hanoi) • After talking, I know how to protect myself. When I have sexual relations, I use condoms even with my lover. I’ve taught my boyfriend to use [condoms].(CSW in Hai Phong) • She convinced [me] so I understand that when I am in a hard situation earning money as a prostitute, I have to use condoms, have blood test….I also learned how to use condoms in the right way.(CSW in HCMC)

44. Referral Service Usage & Perceived Risk • Intervention group more likely than controls to seek HIV testing • 76% of intervention group vs. 46% of controls were tested • 78% vs. 33% sought pre-test counseling • Among tested, 81% vs. 61% sought post-test counseling • MARPs reported low perceived risk of infection • Less than 1/4 see high risk • Reasons: always use condom, never use drugs

45. Referral Service Usage & Perceived Risk • In IDIs, MARPs described mixed experiences with referrals: • Positive: provided for free, make them feel more secure, friendly staff, short wait times • Negative: unkind/unfriendly staff, unhelpful counseling • Illustrative statements by IDI respondents: • The way they greeted us really offended us. [The receptionist’s] manner was very hierarchical, and she shouted and scolded us.(CSW in Hanoi) • It’s a waste of medicine to treat an addict like him.(PE in Hai Phong retelling what a doctor told him, while motioning toward an IDU)

46. Key Informants on Program Strengths • Why are programs effective? • Proven ability of PEs/HEs to reach clients who need services • Rise in number of people accessing VCT and other services • Improvement in knowledge/awareness of MARPs • Reduction in risky behaviors of MARPs • Reduction in HIV incidence • Careful management of programs

47. Key Informants on Program Strengths • Additional strengths: • Comprehensive in scope, with broad support • Tight/strict management, stable budgets • Well-trained staff

48. Key Informants on Program Weaknesses • Challenges: • Policy conflicts • Inability to distribute sterile needles/syringes • Turnover, mediocre PE performance, low salaries • Geographic coverage • Little coordination between PEPFAR-funded and other outreach programs • But views varied on whether this is a major issue • These views generally shared by PEs/HEs and MARPs

49. Summary • Outreach workers generally well prepared • But some areas need improvement. • Outreach workers use many effective strategies to identify and communicate with MARPs • Yet social stigma still makes it difficult to access clients. • Tension between “peers” and being a role model • Job satisfaction high, but there are issues: • Inadequate supplies • Weak community support • Low compensation

50. Summary • Possible “ripple effect” seems to be important benefit of the outreach programs • Data on contacts/worker raise questions about data quality and possible market saturation in some areas • Programs appear to have increased knowledge among MARPs, but knowledge on treatment is low, among both MARPs and outreach workers • Program impact is suggested by differences in intervention v control: condom use, HIV testing