Presented by Sharon Weir for a MEET, AIMEnet, and GEMNet-Health virtual event in July 2014.

1. Operational Guidelines for
Monitoring and Evaluation of HIV
Programmes for Sex Workers, Men
who Have Sex with Men and
Transgender People
July 15, 2014
Sharon Weir and William Miller
University of of North Carolina

2. Purpose of the Guidelines
To provide operational guidance for M&E of
programmes for:
 Female, male and transgender sex workers
 Men who have sex with men
 Transgender people
Guidance at 3 levels:
 National
 Sub-national
 Service-delivery

3. Approach
 3 levels
 From Size estimation to impact
 Involvement of key populations
 Simple checklists, decision trees and examples
 Provide links to relevant tools and resources
 Indicators Illustrative
 Guidelines must be adapted to country context

4. Key Concepts
1. 8 Step Public Health Questions Model
2. Causal Pathway
3. Combination Prevention Programme
4. Programme Impact Pathway
IT’S NOT JUST ABOUT INDICATORS!!

5. Are prevention
programmes
effective?
What activities
are we
implementing?
Are we doing
them right?
What should we
be doing to
reduce HIV
transmission?
2. Measure Determinants
3. Know your response
4. Input monitoring
5. Quality monitoring
6. Monitoring outputs and coverage
7. Outcome monitoring and evaluation
8. Impact monitoring and evaluation
1. Know your epidemic

6. Causal Pathway from
Programmes to Prevention
To illustrate the logic behind indicators and motivate programmes to use indicators
Implement
Combination
Prevention
Programme
Reduce
Biologic
Susceptibility
and/or
Exposure to HIV
Prevent
transmission of
HIV

7. Combination Prevention Programme
Enabling Environment at the Community Level
Package of Individual Level High Quality Health Services
Biomedical Services
• HIV testing and counselling
• Linkage to care, viral load
reduction
• STI screening and treatment
• Psychosocial interventions
• Harm reduction
• HBV Immunization
Behaviour Change
Services
• Condom
Promotion and
Distribution
• Education and
Risk Reduction
Counselling

8. I
M
P
A
C
T
Inputs
Outcomes:
Direct biologic
Outputs/
Coverage
Combination
Prevention
Programme
Outcomes:
Critical enabler
PROGRAM IMPACT PATHWAY

9. Steps 1-3: Plan
What should we be doing to reduce HIV
transmission among key populations?
Step 1
What is the magnitude and geographic distribution of
the HIV epidemic over time among key populations?
1. How many people from each key population
live in the country, each sub-national area and
the local catchment area? How is each
population distributed across sub-national
areas?
2. What information is available about the
extent of HIV infection?

10. What are the baseline estimates of the direct
biologic determinants of HIV transmission and
social enablers?
1. Biologic:What are baseline measures
of key indicators of biologic exposure,
susceptibility and infectiousness?
2. Environment:What are other
individual, community and structural
factors contributing to the epidemic?
Step 2

11. Survey Data on Biologic
Determinants
 Number of sexual partners
 Extent to which partnerships are overlapping
 Number of HIV-discordant partnerships
 Age at first sex
 Use of condoms during vaginal and anal sex
 Use of condom-compatible lubricants during anal sex
 Effective treatment of sexually transmitted infections
 Among people who use drugs: number of injections with
non-sterile needles

12. Critical Enabler Assessment
Structural, community and individual factors that contribute to HIV
transmission risk Barrier Strength
Structural Level Social Enablers
 Stigma and discrimination
 Public health policies and availability of comprehensive HIV
services
 Lack of medical education and training for health professionals in
health care concerns of MSM
 Punitive laws, policies & practices
Social and Community Level Social Enablers
 Social norms, beliefs, and values within communities with regard
to MSM
 Community responses, availability of support in cases of
violence, etc.
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13. How is the Combination Prevention Programme
defined and what are the targets for outputs,
coverage, outcomes and impact?
1. What Combination Prevention Programme of health services and
critical enabler interventions is needed?
2. What are the operational definitions of "a person being reached”
with each service?
3. What sub-populations, sub-areas or setting-specific populations
should be monitored?
4. What services are currently available in each sub-national area?
5. What are the 2-year targets for impact, outcome and coverage
indicators in each sub-national area?
6. Based on the above, what is the national Programme Impact
Pathway?
Step 3

14. Steps 4-6: Monitor
What activities are we
implementing? Are we doing them
right?
Step 4
What resources are needed to meet
targets?
What resources are available?
What is the gap in resources?

15. What services and critical enabler interventions
are currently implemented?With what quality?
1. Are national quality standards
available? Are they updated
regularly?
2. What is the quality of each service
being provided? Are programme
enablers addressed?
Step 5

16. Universal Quality Standards
Standards on involving key populations:
 The populations identified for targeted prevention services are included in needs
assessment, planning, delivery, and evaluation of HIV prevention services
Standards on users’ rights:
 Users are fully informed of the nature and content of the services as well as the
risks and benefits to be expected
 Confidentiality and privacy of users is maintained at all times
 Guarantee of human rights; removal of legal barriers to access prevention and
care
 Access to medical and legal assistance for key populations who experience sexual
coercion or violence

17. Are output targets achieved?What proportion
of key populations receive services?
1. What outputs will be monitored and
aggregated? How will double-counting
of users be avoided?
2. How is service coverage (geographic,
population) calculated and interpreted?
3. What are the trends over time for
outputs, service availability, the enabling
environment, coverage and the HIV
prevention and treatment cascades?
Step 6

18. HIVTesting andTreatment
Cascade
2000
1000
700
500 400 300 200
0
500
1000
1500
2000
2500
NumberofMSM
Stage of Engagement in HIV Care

19. Steps 7-8: Evaluate
Are programmes effective?
Step 7
1. Outcome Monitoring: Are there
changes in biologic determinants of
HIV transmission?Are there changes in
the environment?
2. Outcome Evaluation: Are the changes in
outcomes due to the programme?

20. Is the combination HIV prevention programme
reducing HIV transmission?
1. Has HIV prevalence increased or
decreased in these populations?
2. Did the HIV prevention
programme decrease new
infections?
Step 8

24. Acknowledgements
 Keith Sabin, AllisonCrocket, UNAIDS
 Jenny Butler, Marleen van der Ree, UNFPA
 Abu Abdul-Quader, CDC
 Ludo Bok, UNDP
 AnnetteVerster,WHO
 MaryAnnTorres, ICASO
 MariaAu, USAID
 Sandra Kuzmanovska,Global Fund
 MaryAnnTorres, ICASO
 And many others

25. The research presented here has been supported by the
President’s Emergency Plan for AIDS Relief (PEPFAR)
through the United States Agency for International
Development (USAID) under the terms of MEASURE
Evaluation cooperative agreement GHA-A-00-08-00003-
00. Views expressed are not necessarily those of
PEPFAR, USAID or the United States government.
MEASURE Evaluation is implemented by the Carolina
Population Center at the University of North Carolina at
Chapel Hill in partnership with Futures Group, ICF
International, John Snow, Inc., Management Sciences for
Health, and Tulane University.