PSI s VCT SWOT Analysis

1. PSI�s VCT SWOT Analysis Dvora Joseph HIV/AIDS Service Delivery Manager July 27, 2006

2. PSI VCT SWOT Background: Shifting international focus on VCT has made PSI aware of strengths and weaknesses in VCT delivery Internal & external pressure to adapt & adopt new models of service delivery (such as locally owned or provider initiated CT) Increased competition in VCT worldwide To develop a new strategy we conducted: An e-mail based discussion between local, expatriate and Washington-based PSI staff about PSI�s VCT SWOT Internal data and revenue analysis Developed a SWOT document (reviewed by field) SWOT analysis will be used to develop a strategy for PSI in terms of VCT service delivery

3. Outline of Strengths Social marketing of VCT Franchising and capacity building Widely accessible, affordable services Strong relationships with stakeholders Delivery of high-quality services (counseling & testing)

4. Social Marketing of VCT Marketing: PSI targets groups least likely to test Core competency includes: �Research driven services where there is latent VCT demand� Targeting is evidence-based (i.e. sex workers, mobile populations, youth and couples) PSI VCT countries have shown an increasing % tested and % intending to test Couples: Important target group as research shows that BC is greatest following couples� VCT Numbers: PSI delivers numbers (tested over 460,000 clients in 2005, 10% of # tested with PEPFAR funding in 2005) More people receive care & support (including ART)- in line with public health need, donor and host country priorities India, intent to test among target groups increased significantly from 24% to 61% between 2002 and 2004. In Kenya, only 8% of the adult population had been tested in 2000 which increased to 16% 2003. Ten percent of the adult population in Zimbabwe has been tested at PSI�s New Start centers (2001- 2005). In Zimbabwe specific VCT promotions relating to calendar events such as Mother�s day, Valentine�s Day and World AIDS Day with high media coverage contribute to increases in client flow of 10-20%, where they test over 18,000 clients per month. In Zambia, only 7% of the population had been tested in 2002 which increased to 13% in 2006. Couples: Zimbabwe, South Africa, Zambia and Rwanda see more than 10% of their clients as couples. India, intent to test among target groups increased significantly from 24% to 61% between 2002 and 2004. In Kenya, only 8% of the adult population had been tested in 2000 which increased to 16% 2003. Ten percent of the adult population in Zimbabwe has been tested at PSI�s New Start centers (2001- 2005). In Zimbabwe specific VCT promotions relating to calendar events such as Mother�s day, Valentine�s Day and World AIDS Day with high media coverage contribute to increases in client flow of 10-20%, where they test over 18,000 clients per month. In Zambia, only 7% of the population had been tested in 2002 which increased to 13% in 2006. Couples: Zimbabwe, South Africa, Zambia and Rwanda see more than 10% of their clients as couples.

5. Social Marketing of VCT Possible weaknesses: Competitors can outpace PSI numbers tested through rapid scale-up of routine testing Rapid increase in VCT demand can strain provider capacity

6. Franchising and Capacity BuildingNGO/CBO/FBO and Public Sector Promotes network of quality services under a recognized, respected brand Allows rapid expansion through standardized materials, trainings and protocols Builds capacity with local organizations Cuts PSI�s direct costs Donors looking for less direct service provision, more capacity building for sustainability

7. Widely Accessible, Affordable Services Multiple VCT service delivery models including workplace, outreach & mobile, integrated, stand-alone, and franchised, to increase access to and demand for VCT Services are affordable (price of a beer or coke) or free Mobile programs very successful providing services for hard-to-reach groups PSI�s VCT programs: �Augment and enhance public sector VCT programs by providing a choice and by taking VCT out of the �medical setting�- alleviating pressure off of busy public sector�� VCT Staff Zambia

8. Strong Relationships with Stakeholders Work closely with MOHs, public health sectors, & stakeholders to support VCT growth including: QA, training, policy, M&E PSI respected in VCT implementation, marketing, innovation Often participate in national VCT working committees & other partnerships

9. Delivery of High Quality ServicesCounseling and Testing High Quality Services Focus on high quality counseling to help change risky behavior (for both + and � clients) PSI developed QA, M&E and supervisory guidelines to realistically ensure quality, and guidelines shared with multiple stakeholders to build capacity Use innovative internal and external QA methods Stakeholders are focused on quality and appreciate PSI�s focus on quality (even though some donors are not)

10. Delivery of High Quality Services Client centered targeted services Programs adapt communications and service delivery models to risk group needs In Asian programs, data supports that clinics are addressing highest-risk populations In Zimbabwe, increase in HIV prevalence following access to ART in public sector lead to increased focus on positive prevention in counseling

11. Outline of Weaknesses Post test care and support systems inadequate New paradigm requires changes in stand-alone model Lack of evidence for link between VCT and behavior change Inadequate public health perspective Cost of service delivery

12. Post test care and support (C&S) systems often inadequate PSI lacks C&S capacity, PSI�s role unclear Need to strengthen links between HIV+ clients and C&S More difficult for stand-alone & mobile sites than for integrated & hospital-based models Need for greater focus on post-test services for both + and � clients including post test clubs, counseling, product/service delivery Access to C&S may be improved through enhanced counseling

13. New paradigm requires changes in stand-alone model Efficacy of models Most sites are stand alone or mobile, more effective at reaching target populations However, lower HIV prevalence and fewer clients, than integrated or public health sector- esp. those with routine testing PSI seen as implementing programs and not building capacity �Our model may not be fundable for very long and I think we need to start thinking about how PSI would �do HIV testing� aside from the way we do it now.� � PSI/Lesotho

14. New paradigm requires changes in stand-alone model PSI�s management of franchise partners Partners often technically & financially dependent on PSI Competitor�s implementation within public & private sector is seen as less dependent & more sustainable PSI directly managed programs more successful in terms of numbers tested and quality than franchise programs, but also more expensive and not well supported by donors

15. Most PSI VCT sites are stand alone, directly managed sites with 11 of 15 country programs running their own sites (and 31% of clients tested in these sites). But, Myanmar is the only country that has only stand alone, directly managed sites. 10 of 15 country programs have mobile activities, that tested 25% of the total number of clients, ranging from a high of 64% in Mali to a low of 1% in Namibia (where their Miliraty VCT program was launched in April 06). Integrated sites see 31% of clients in 6 countries. Mozambique makes up the bulk of this, testing over 53,000 clietnts in 2006 alone. PSI works with franchised services in 8 countries, making up 13% of cilents in 2006.Most PSI VCT sites are stand alone, directly managed sites with 11 of 15 country programs running their own sites (and 31% of clients tested in these sites). But, Myanmar is the only country that has only stand alone, directly managed sites. 10 of 15 country programs have mobile activities, that tested 25% of the total number of clients, ranging from a high of 64% in Mali to a low of 1% in Namibia (where their Miliraty VCT program was launched in April 06). Integrated sites see 31% of clients in 6 countries. Mozambique makes up the bulk of this, testing over 53,000 clietnts in 2006 alone. PSI works with franchised services in 8 countries, making up 13% of cilents in 2006.

16. New paradigm requires changes in stand-alone model Client anonymity PSI VCT programs have emphasized client anonymity Anonymity might contribute � rather than alleviate � stigma Treating HIV as other diseases may more effectively combat stigma Anonymity can also impede referral tracking and BC monitoring

17. Lack of evidence for link between VCT and behavior change Little evidence supports link between VCT and BC for negative clients Need for longitudinal research on PSI VCT programs, Zimbabwe to launch this year Consider quality counseling important, but expensive & time consuming If VCT does not prevent primary HIV transmission, what is PSI�s role in VCT service delivery? �We need to develop a program for BC for HIV negatives- a post-test workshop, or support groups and then do a study with a control group�� VCT staff Zambia

18. Loss of Public Health Perspective Programs overly focused on donor concerns Controversy over whether PSI is donor- or health impact-driven Who are our clients? Donors or low income and vulnerable? Focus should be on public health perspective: increase numbers, reach vulnerable and at-risk groups and link with care and support Need to change with situations or country demands, but not overly focus on donors

19. Cost of Service Delivery The cost of PSI�s VCT programs is high when compared to other HIV prevention programs (such as condom social marketing). The average unit cost for PSI�s VCT programs was $47/client in 2005, ranging from $12 in Benin to $230 in South Africa. The cost decreased marginally from $49/client in 2004. As programs receive increased funding for VCT implementation and as new programs launch activities, the service delivery costs are not expected to decrease in the near future. PSI needs to develop more cost effective service delivery models. However, this tends to conflict with our mission of serving the most vulnerable as it tends to be costly to reach out to these groups (e.g. mobile VCT, demand creation through social marketing and stand alone directly managed sites).The cost of PSI�s VCT programs is high when compared to other HIV prevention programs (such as condom social marketing). The average unit cost for PSI�s VCT programs was $47/client in 2005, ranging from $12 in Benin to $230 in South Africa. The cost decreased marginally from $49/client in 2004. As programs receive increased funding for VCT implementation and as new programs launch activities, the service delivery costs are not expected to decrease in the near future. PSI needs to develop more cost effective service delivery models. However, this tends to conflict with our mission of serving the most vulnerable as it tends to be costly to reach out to these groups (e.g. mobile VCT, demand creation through social marketing and stand alone directly managed sites).

20. Cost of Service Delivery VCT programs expensive compared to other interventions (e.g., condom social marketing) Cost has marginally decreased, but not expected to decrease further Need to develop more cost effective models, without sacrificing quality or service for vulnerable groups

21. Outline of Opportunities Increases in donor support for C&T and C&S Increasing partnerships New technologies Expand social marketing of VCT and targeted service delivery Integrating other services & products Research

22. Increases in donor funding for �innovative� C&T and C&S PEPFAR increasing funding for C&T and other care initiatives Increased European donor funding for VCT Tap into increased donor interest in HIV, especially treatment VCT is seen as a blockage to initiating treatment: PSI suited to increasing access to & demand for VCT PSI is an innovator of VCT delivery: mobile, community based VCT, workplace services, military/prisoner focused, etc.

23. Post Test Services PSI can improve capacity for C&S services when it provides an effective channel for BC Can provide support services and referrals for those who test positive Prevention for positives an important opportunity with significant donor interest C&S sites can be useful points to sell HIV-related products such as condoms, bednets, SWS, FP and TB DOTS

24. Post test services, cont. �Post test clubs are very important because, if well designed, they will result in sustained behavior change that is also supported by pre- and post-test counseling. Because we offer quality services, clients feel confident in seeking more information from us through PTCs �� VCT Staff Namibia

25. Provider Initiated C&T PSI can play a role in awareness and demand creation, TA for scale up, and capacity building/training Can complement PSI programs and boost numbers Botswana implemented successfully: Launched a comprehensive media campaign reaching general population increased # on treatment, reduced stigma PSI�s strength is social marketing of services includes HIV services such as provider initiated C&T

26. �We shouldn't discount the health impact of testing someone in a medical setting with little or no counseling where ART is available. Prolonging someone's life by testing them, even with minimal or no counseling, and getting them into an ART program is serious life-saving health impact at low cost.� � VCT staff South Africa

27. Increasing partnerships to support PSI programs and mission Increasing numbers while maintaining quality: strong partnerships are key Increased franchising of VCT services can increase access and build partner capacity �PSI should take up the role of training, supervision of health care providers in provider initiated testing. With PSI's assistance the services at these centers could be considerably improved. PSI has demonstrated capacity to implement quality VCT programs, design standard HIV testing protocols and implement them, and ensure the quality of services through skilled monitoring and supervision�� VCT staff Zimbabwe

28. Involvement in New Technologies New technologies in HIV testing and care can make it easier to offer these services Mobile & whole blood CD4 cell count machines Saliva based testing Easier, less expensive rapid tests

29. Expand social marketing of VCT and targeted service delivery PSI�s role in marketing of VCT often underappreciated Reach clients less likely to test in health care setting and more likely to change behavior (e.g. mobile populations, couples) Increase workplace testing programs Improve targeting of couples, HIV positive

30. Integrating Other Health Services and Products Integrate FP services, TB prevention & screening, STI treatment, malaria treatment/prevention, etc. to increase health impact Take advantage of strengths and reputation in product marketing to target needed products and services to PLWHA PSI is involved in the delivery and marketing of products that can benefit PLHA, including multivitamins, STI treatment, TB DOTS, SWS, family planning (FP) and malaria prevention and treatment. In some countries the TB/HIV co-infection rate is as high as 50-90%. Combining TB and HIV programs helps maximize health impact. Prevention of TB among HIV+ clients through Isoniazide Preventative Therapy (IPT) is another area that is often overlooked. In 2005, 17.5 million women were HIV-infected, most of reproductive age, and most through heterosexual contact. In 2003, 13% of new HIV infections occurred among children, in the majority of the cases through MTCT. FP represents the most effective method of PMTCT through prevention of unintended pregnancies in HIV infected women. FP counseling and service provision can be integrated into VCT sites for additional health impact and prevention of HIV and VCT can similarly be integrated into FP clinics to increase access to VCT, as Zimbabwe will do this year.PSI is involved in the delivery and marketing of products that can benefit PLHA, including multivitamins, STI treatment, TB DOTS, SWS, family planning (FP) and malaria prevention and treatment. In some countries the TB/HIV co-infection rate is as high as 50-90%. Combining TB and HIV programs helps maximize health impact. Prevention of TB among HIV+ clients through Isoniazide Preventative Therapy (IPT) is another area that is often overlooked. In 2005, 17.5 million women were HIV-infected, most of reproductive age, and most through heterosexual contact. In 2003, 13% of new HIV infections occurred among children, in the majority of the cases through MTCT. FP represents the most effective method of PMTCT through prevention of unintended pregnancies in HIV infected women. FP counseling and service provision can be integrated into VCT sites for additional health impact and prevention of HIV and VCT can similarly be integrated into FP clinics to increase access to VCT, as Zimbabwe will do this year.

31. Research Is there a link between VCT and BC? Can critical number tested in communities change community norms and risk behavior? BC impact of post test clubs?

32. Outline of Threats Donor focus on numbers More local control, focus on sustainability VCT as part of care continuum Competition Lack of evidence of link between VCT and BC

33. Focus on Numbers Increased push for universal testing in high prevalence countries Strain on health systems from increased demand for testing Less emphasis on quality Focus on process indicators over health impact (i.e. # trained over CAAs or DALYs) Ethical questions of physician authority: can people consent, when they don�t think they can refuse their physician?

34. Local control and sustainability PSI increasingly focused on local ownership of VCT in response to donor pressure to give up control of service delivery, often at the expense of quality or even numbers of clients tested At times PSI programs are forced to create �exit plans� for ourselves when one of our main visions is �long term commitment to the people we serve.� PSI becoming a capacity builder, not a service provider �The Paradigm shift is inevitable, but how still remains a question for us all, and remember the buzz word is "an indigenous response" to scaling up CT, and thus sustainability should be at the center of our focus �� VCT Staff Swaziland

35. Other threats PEPFAR classifies VCT as part of care continuum, PSI considers VCT as prevention intervention (focused on primary vs. secondary prevention)- also an opportunity? More players receiving funding for VCT (FHI, AED, URC), more willing to embrace donors� preferred approaches If VCT and BC link is not supported, what is the future of VCT service delivery in PSI?

36. Cross-cutting issues: Local vs. direct control over service delivery PSI�s future role in service delivery: sub out to others, franchise, work with public sector, build local capacity? Post test care and support & PSI�s role Focus on provider initiated or medicalized CT Communications: branded vs. generic Cost of service delivery Internal support of VCT

37. Strategy decisions: Considering PSI�s current mission: PSI deploys commercial marketing strategies to promote health products, services and other types of healthy behavior that enable low income and other vulnerable people to lead healthier lives. What is the strategy for VCT implementation?

38. Strategy questions: What is our goal in VCT service delivery? What are strategies to meet this goal? What kind of funding do we need? What do we need more of? Less of? What are the pros and cons?

39. Discussion & Questions�..