Why Develop a Taxonomy of HIV Be

							                 Why Develop a Taxonomy
          of HIV Behavioural Prevention Activities,
           and Why Specify Quality, Intensity and
                        Coverage?
                    Barbara O. de Zalduondo, Anindya Chatterjee,
                       Richard Delate and Terhi Aaltonen and the
                      Prevention Reference Group Content Team
                   Department of Policy Evidence and Partnerships
                                      UNAIDS

UNAIDS
November 7, 2010
Overview

• The challenge: why are we calling a UNAIDS Prevention Reference
  Group meeting on this topic? What do we hope to achieve together?

• Why are we calling a meeting on this now?


• Why did we propose to focus on the 5 activities/interventions, as
  opposed to many others?

• Some definitions of our own – please see flip chart page
    “activity, “intervention,” “measure” or “programme”
    Critical element
    Quality
    Standards
UNAIDS
November 7, 2010
Why is UNAIDS calling this Reference
Group meeting on HIV prevention?


• 4.3 million new infections in 2006 (3.6-6.6 million)**
       Coverage of prevention measures is incredibly low; must be
        scaled up
        e.g. In 2005, only 20% of the people most at risk and most in need of
            HIV prevention services, world wide, were getting them.*
            e.g., 9% of men who have sex with men worldwide received HIV
            prevention services (from 4% in Eastern Europe to 24% in Latin
            America).*
       Results of prevention activities have often been inadequate
            e.g Botswana - only about one in three young people aged 15–24 both
            correctly identified ways of preventing the sexual transmission of HIV and
            rejected major misconceptions about HIV transmission.**


UNAIDS
November 7, 2010
To improve prevention impact
(decreased HIV incidence) countries
could require:
• More effort/investment in prevention
  (Eye-dropper problem)

• Better planned and allocated prevention activities

• Better implementation

• All of the above
                            How to tell?
UNAIDS
November 7, 2010
to Do Better – advising countries that are
spending prevention effort in ways unlikely
to impact new infections
Figure 1 Mismatch between funding and HIV epidemiology
observed in a west African country



               100%

                   80%

                   60%

                   40%

                   20%

                   0%
                               Sex workers                            General population

                   HIV rate    Share of infections involving                Share of funding



                                                                                               12
UNAIDS                   Source: Courtesy of World Bank MAP, (2005)
November 7, 2010
Programme evaluation and comparison should
complement prevention research.
Can we compare:

                                                                      Reduced
                                                                    New Infections

  Design/Mix of
  Prev. Actions                                                     Reduced risk
     to meet
                        +                                            behaviour
  current needs                                                   Changed KABP and
                                                                    more enabling
                                                                     environment
                    Adapted to
                   local settings
                                      +    Implemented
                                             Correctly
                                    (“faithfully”) and to Scale    Effective
                                                                  Prevention

UNAIDS
November 7, 2010
“Comprehensive prevention” – from UNAIDS
policy position paper to operational definitions


e.g. UNAIDS Resource Needs Model –
   19 “types” in 2005                  •   Prevention programmes for people
                                           living with HIV
• Mass media
                                       •   Special populations
• Community mobilization
                                       •   Condom social marketing
• Voluntary counseling and testing
                                       •   Public and commercial sector
• Youth in school                          condom provision
• Youth out of school                  •   Improving STI management
• Programmes focused on sex workers    •   Prevention of mother-to-child
   and their clients                       transmission
• Programmes focused on MSM            •   Blood safety
• Harm reduction programmes for IDUs   •   Post-exposure prophylaxis
• Workplace interventions              •   Safe medical injections
                                       •   Universal precautions
                                                  And now, Male circumcision

UNAIDS
November 7, 2010
To build prevention knowledge, and to offer
guidance on prevention planning we need:


1) Clear terminology for each prevention activity – at operational level
   What exactly do we mean by “focus on young people” – or - “school-based
       education?” What are the critical ingredients?

       When we analyze the outcomes of several “school-based education” activities,
         how do we know we are comparing the same things?

2) Information on scaling each one: how much? how much will/should it cost?
   The answers depend on definitions of quality, intensity and coverage

3) Information about the most effective mix of programmatic and policy actions.
    cf. UNAIDS policy position paper: Intensifying HIV prevention
    (7 principles, 10 programmatic actions, and 11 policy actions)



UNAIDS
November 7, 2010
Quality – a value in every health and
development field. Definitions vary in
specificity and generality

Quality management methods, continuous quality improvement etc. are
  widely available. They all entail:
• building technical consensus on the terms and definitions (Mike Sweat’s
  presentation=
    establishing consensus on critical elements
• establishing agreement on the criteria or dimensions of quality (Nancy
  Padian’s presentation)
• specific methodology – what content, goal, method, intensity, etc. –
  which can be costed.

Specifications of quality, intensity and coverage need to be gathered, made
  explicit, and cited, for behavioural interventions, just as they are for
  clinical services. We will be discussing a framework for guiding this.

UNAIDS
November 7, 2010
Testing the framework against SELECTED
prevention actions:


We are developing a model/framework to assist countries and expert
  organizations

We do not expect to arrive at the answers – only to establish the need, and
  to define the processes that will follow this meeting

We selected a few prevention actions because in this initial meeting, time is
  short.
The choice was made in order:
• to illustrate the diverse kinds of prevention interventions
• to focus on areas where international guidelines have not been
  established or widely publicized


UNAIDS
November 7, 2010
Why raise these issues now?


• 4.3 million new infections....

• Global Resource Needs estimation process
    Using best available “legacy categories,” definitions and cost data
    UNAIDS and World Bank are training people to gather cost and
     expenditure data
    Laying the groundwork to provide more and better data for the 2009
     estimates

• The need for behavioural prevention will go on for the next generation –
  so it is time to strengthen the foundation of prevention science.
    Because of the urgency of responding to HIV, we have been in too
      much of a hurry .... for 25 years
      As a result, we are still working with legacy categories and ad hoc
      definitions that make it difficult to build knowledge.
UNAIDS
November 7, 2010
Challenges of terminology



Quality (discussed earlier)

Activity/Measure/Intervention
   An input, activity, or component of an HIV prevention programme that is
   designed and managed as a unit to achieve a specific outcome or result.

Critical components/core elements
   Elements, steps or features that are necessary to the effectiveness of an HIV
   prevention activity/intervention/measure

Standards
    “something established by authority, custom, or general consent as a model or
        example”*
   “something set up and established by authority as a rule for the measure of
        quantity, weight, extent, value, or quality*


UNAIDS             * Source: Merriam-Webster’s Online Dictionary
November 7, 2010
In Sum: UNAIDS seeks your advice and
recommendations for a 2 year plan to clarify
building blocks of prevention science:

       First 12 months:
        an agreed taxonomy (“list,” with definitions) of HIV
         prevention activities/interventions that are used and
         combined in successful national HIV programmes
        an approach to defining minimum standards for each
         prevention activity, including the behavioural ones, to
         permit realistic costing and budgeting for HIV prevention
       Longer term (now through 2008?):
        a process, or series of activities, to engage key
         stakeholders to translate the agreed terminology and
         standards into practice, at country and global levels

UNAIDS
November 7, 2010