MEASURE Evaluation is a global health project funded by USAID to strengthen health information systems in over 25 countries. The project works to improve collection, analysis and use of health data to support decision making. Sharon Weir presented on lessons learned from monitoring and evaluating programs for key populations affected by HIV. She discussed how surveillance can provide more immediate information for programs if distinguished from other monitoring and evaluation activities. The presentation also covered adaptations made to the PLACE method over time to better align with prevention goals and strategically target local HIV epidemics.

1. Key Populations
and the HIV Epidemic
Lessons Learned in M&E and
Future Directions
Sharon S Weir, PhD
MEASURE Evaluation
University of North Carolina
May 11, 2016
USAID Brown Bag Lunch

2. Global, five-year, $180M cooperative agreement
Strategic objective:
To strengthen health information systems – the
capacity to gather, interpret, and use data – so
countries can make better decisions and sustain good
health outcomes over time.
Project overview

3. Improved country capacity to manage health
information systems, resources, and staff
Strengthened collection, analysis, and use of
routine health data
Methods, tools, and approaches improved and
applied to address health information challenges and
gaps
Increased capacity for rigorous evaluation
Phase IV Results Framework

4. Global footprint (more than 25 countries)

5. title
Acknowledgments
MEASURE Evaluation:
• Jess Edwards, Zahra Reynolds, Sarah Hileman, Grace Mulholland,
Becky Wilkes
Global Fund/UNAIDS/WHO
• Jinkou Zhao, Keith Sabin, Txema Calleja
LINKAGES
• Agatha Bula, Jean Lambert Chalachala, Lauren Zalla, William Miller,
Whitney Ewing, Kathy Lancaster, Kate Muessig, Ernest Malenga, country
teams
Collaborations
• MESH Consortium / Gates Foundation / University of West Indies /
University of Manitoba / Makerere University / Enda Santé / FHI360

6. Overview
Shakespeare
NC Bathroom Bill
Star Wars

7. Responsible and timely M&E for action
Shakespeare
The Duke pretends to leave Vienna but disguises himself as a
friar and remains to observe what happens. Claiming to act
against corruption, his deputy Angelo sentences a man to death
for getting his girlfriend pregnant. The man’s sister comes to
plead for mercy for her brother. Angelo agrees to pardon her
brother if she will sleep with him. (Hypocrite!) Eventually the
Duke sheds his disguise, sentences Angelo, frees the brother,
and marries the sister.

8. Responsible and timely M&E for action
Lesson Learned:
Distinctions between
surveillance, monitoring,
evaluation and taking
action are fading.
Surveillance should be
more immediately useful to
programs. Program data
should provide
epidemiologic indicators.
Evaluation
& Action
Surveillance
Monitoring

9. Make PLACE More Useful to Programs
• Mapping Readiness Assessment Tool
• QGIS Plug-In
• Cascade Estimation : prevention and
treatment
• Size estimation – Extrapolation

10. The Mapping Readiness
Assessment Tool
The MRA is a structured guide for
obtaining qualitative input from
stakeholders including key populations
(KPs), healthcare providers, public
officials and law enforcement.
Topics addressed include understanding
the socio-legal environment for KPs,
identifying available services and barriers
to healthcare for KPs, and exploring the
risks of collecting data on KPs.
1. To protect the rights and well-
being of key population
individuals and groups.
2. To adapt the study protocol to the
country context.
3. To ensure data use.
Objectives
“They didn’t consult with us prior to conducting the study, so
we don’t know what they did and we don’t trust the results.”
- Representative of an MSM organization in Haiti

11. IAS ABSTRACT 2016: Minimizing Unintended Risks of HIV-Related Programmatic Mapping
Among Key Populations: Introducing the Mapping Readiness Assessment (MRA)
K. Muessig1, L. Zalla2, E. Emmanuel3, A. Bula4, J. Chapola4, E. Mlenga4, J. Michel3, Y. Estiverne3, M. Herce5, W. Miller2, K. Lancaster2, S. Weir2
Background: Collecting information from key populations, may pose risks even if the purpose is to improve quality
and coverage of health services. Unintended risks can occur through confidentiality breaches, data misuse, or
drawing unwanted attention to hidden populations. The tool engages communities in a comprehensive assessment
of the risks of mapping.
Lessons Learned in South Africa, Haiti, Malawi and Angola: The MRA revealed differential access to services and
exposure to discrimination across KP sub-groups, particularly by socioeconomic class and locale. MRA
implementers learned alternative ways of reaching KPs, such as through social media, in countries where punitive
laws and discrimination limit their public visibility. We documented concerns that targeting KPs for HIV testing
could lead to further stigmatization or violence, by reinforcing the association between sex work and HIV, or
through perceptions that PM implementers are advocating for same-sex marriage or "recruiting" MSM. Action
steps resulting from the MRA included decisions to provide testing to all venue patrons and to alert local leaders
and authorities to PM prior to fieldwork.
Conclusions: MRAs can help governments, program implementers, and civil society engage KPs, protect rights, and
strengthen partnerships to ensure that data collected is ultimately used to improve KP services.

12. QGIS Tool for PLACE
QGIS is free and open-source software
Included in the package are:
1. Geographic data files such as administrative areas, rivers, roads
2. “My Maps” folder—a place to store your own maps
3. “QGIS”—a copy of the GIS software program and the plugin tool
4. “Start QGIS”—a shortcut that will start the Wizard

13. 1
Select
Areas
2
Select
Variable
to Map
3
Select
Points
4
Output
Map

14. QGIS Plug In:
• Tool automatically
puts in the title
(from the first
dialog box), a scale
bar, and a legend.
• It classifies the
districts according
to the Excel file
containing the
priority levels (high,
low, and medium).
• It can classify the
point data which
was contained in
the Excel
spreadsheet with
the GPS locations
and other attribute
data.

15. More responsive to programs

16. PLACE Malawi: Female sex worker HIV care cascade identified by
social mobilizer during spot verification (PLACE Form B)
0%
20%
40%
60%
80%
100%
Ever tested Tested within
prior 11 months
Ever told HIV-
infected
HIV testing history among FSW (n=361)
ALSO PREVENTION
CASCADE

17. • Interviewers facilitated linkage to care.
34 people with problems
accessing ART identified
during site visits April 16-28
• Escorted to lighthouse where she was given
one month emergency supply.
• Provider promised to follow up with Kawale
H/C.
Stopped taking medication.
She was afraid to go back to
the hospital after losing her
booklet
• Escorted to lighthouse where she was
restarted on medication as a transfer in.
Stopped taking medication
because her husband took
away her booklet and they
are now divorced. She
reported she was buying
ARVs from friends.
Lilongwe,
Malawi

18. title
Size estimation
Review
Revise
Extrapolate
R & R in Guyana
MESH

19. Choices. Labels. Stigma. Access.
NC Bathroom Bill

20. Labels.
NC Bathroom Bill
678
•Ever
had
sex
648 • 50+
231
•Exchanged
sex for
cash/gifts
148 • 26+
678 female workers at a sample
of venues where people meet
new sexual partners in Liuzhou
China. 50 had a positive rapid
test for syphilis. 24 were not sex
workers.
Number with a
positive rapid
test for syphilis.
• 148 exchanged
sex for cash in
past 4 weeks

21. Star Wars and HIV : A History

22. Jamaica
All parishes
Zimbabwe
Hwange District
Madagascar
7 cities
Zambia
Mongu
Kapiri Mposhi
Angola
Luanda
Tanzania
Magu
Rwanda
All 12 provinces
St. Lucia
Castries
Gros Islet
Anse la Raye
Haiti
Carrefour
Russia
Saratov-Engels
Samara
St. Petersburg
China
Liuzhou
Lesotho
Ficksburg, Maseru, Maputsoe,
Ladybrand, Fouriesburg, Butha
Buthe
South Africa
2 townships in Port Elizabeth
East London
1 Township in Cape Town
Mexico
Chetumal
Ciudad Hidalgo
Uzbekistan
Tashkent
Kyrgyzstan
Osh
Kazakhstan
Karaganda
Almaty
India
Bhubaneswar
Ghana
All 10 regions
Burkina Faso
Banfora
Tenkodogo
Kenya
All 8 provinces
DR Congo
Burundi
Guyana Uganda
Malawi
PLACE story is still a good one.

23. Problem addressed by PLACE has not changed:
Preventing HIV transmission at the local level
2005: “The PLACE method addresses the need for
rapidly available information to strategically target
and monitor local AIDS prevention.”
2016: The PLACE method addresses the need for
rapidly available information to strategically target
and monitor local HIV/AIDS prevention.
.

24. PLACE rationale—Bikini* version
The HIV pandemic is worldwide but transmission occurs in local
epidemics. Prevention should focus in geographic areas where HIV
incidence is highest.
Interrupting HIV transmission requires focusing on people with high
rates of new sexual or needle sharing contacts. Effective prevention
must be tailored to the local epidemic.
The PLACE method identifies venues and events where local
outreach could reach transmission networks and assesses program
coverage among those who need it most.
Note—Bikini version covers the essentials.

25. Causal Model
Underlying Proximate Biological
New HIV
Infections
Determinants Transmission
 Exposure to HIV
 Susceptibility to HIV
 Number of partners
 Lack of condom use
 Anal sex
 Lack of circumcision
Proximate Determinants model still works.

26. What IS new since 2005?
• New and more biomarkers
• New spatial mapping tools and mapping readiness
• New analysis tools
• New indicators including cascade indicators and coverage
indicators for combination prevention
• Adapted to align to 90/90/90 goals
• Adapted to oversample for key populations
• Adapted to obtain size estimates for key populations
• Adapted to extrapolate estimates to areas in the country
not included
• More experience in data use

27. Summary
Shakespeare
NC Bathroom Bill
Star Wars May the verse be with you!

28. MEASURE Evaluation is funded by the U.S. Agency for
International Development (USAID) under terms of Cooperative
Agreement AID-OAA-L-14-00004 and implemented by the
Carolina Population Center, University of North Carolina at
Chapel Hill in partnership with ICF International, John Snow,
Inc., Management Sciences for Health, Palladium, and Tulane
University. The views expressed in this presentation do not
necessarily reflect the views of USAID or the United States
government.
www.measureevaluation.org