Transcript Document

INTRODUCTION TO HIV SITUATION
AND
NEEDS ASSESSMENT IN PRISONS
7 December 2011
Addis Ababa, ETHIOPIA
Acknowledgements
Dr Fabienne Hariga
Expert - HIV/AIDS Unit, UNODC VIENNA
Dr. Caren Weilandt
Scientific Institute of the German Medical Association (WIAD) Bonn, Germany
Dr. Robert Greifinger
City University of New York, USA
Participants of the Expert Group Meeting
March 2009, Vienna, AUSTRIA
Participants of the Regional Consultation Meeting
09 June 2009, Pretoria, SOUTH AFRICA
Contribution of the experts who sent their comments
Definition of Words
For purposes of this workshop, the terms
• “ prison” will be used refer to:
– Structures build or designed to hold people in conflict with the
law, Correctional facilities, Places of detention, Police holding
cells, Remand centers, etc.
• “Prisoner” will be use to refer to:
– An individual residing in prison (excluding children living with
their incarcerated mothers), Inmate, Remandee, Detainee, etc.
• “Prison settings” will be used to refer to:
–
a prison environment where there are prisoners, prison staff and
to some extend, the surrounding community within the prison
vicinity, e.g. staff quarters.
Defining a SITUATIONAL
Assessment
A snapshot of the 'present' used to plan for
the future.
A situational assessment influences planning in significant
ways by examining the legal and political environment,
stakeholders, the health needs of the population, the
literature and previous evaluations, as well as the overall
vision for the project.
Defining a NEEDS
Assessment
A needs assessment is the process of identifying
performance requirements and the "gap"
between what performance is required and
what presently exists
Situational
and Needs Assessment
• Like all other assessments, situational and needs assessment focuses
on collecting data on community/population
• BUT it also considers the broader social, economic, political and
environmental context affecting community health needs.
• Situational assessment also considers strengths, assets and
capacities, not just problems or needs.
A situational assessment includes, but is not limited to the use of the
following types and sources of information:
• Key facts, trends, and recommendations from the literature;
• Data and analyses obtained from population health assessment and
surveillance;
• Legal and political environments; stakeholder perspectives; and
recommendations based on past experiences, including program
evaluation information
Summary
• As the name suggests, there are two components: a situation
assessment and a needs assessment, BOTH conducted
sequentially, but with a concurrent purpose.
• A situation assessment measures the status quo, while a
needs assessment identifies gaps between the status quo and
an accepted standard or pre-existing goal. The concurrent
purpose is to design, resource, implement and monitor and
evaluate interventions to bridge the identified gaps.
• As it applies to HIV/AIDS, the pre-existing goal might be, for
example, consistency with the National AIDS Action Plan.
Goal And
Objectives
• The goal of the situation and needs assessment is to
complement existing information in the country with
regard to HIV and other communicable diseases.
• The gathering of additional information will allow
governments to set more specific targets for
achieving universal access for prisoners to
comprehensive and evidence-based HIV prevention,
treatment, care and support interventions.
Goal And
Objectives…
The specific objectives of the stepwise approach are to:
• Assess the HIV prevalence (and other diseases of interest where possible) in
the prison population generally, and in sub-groups such as women, people
who use drugs, remand and convicted prisoners, and unauthorised
immigrants;
• Identify specific risk factors which may be associated with the transmission of
bloodborne pathogens and airborne infections, including TB, among prisoners
and staff;
• Assess the level of knowledge, attitudes, behaviours and practices (KABP) on
HIV/TB (hepatitis and other STIs) in all target groups within the prison,
including prison staff;
• Determine the availability of and quality of health services, prison conditions,
associated infrastructure and national policies and legal framework to identify
feasible and appropriate opportunities for improvement;
• Strengthen the information and training for prisoners and prison staff; and
• Provide a baseline for ongoing monitoring and evaluation of the resulting
intervention programmes
A needs assessment
should:
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•
•
•
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Describe needs and available resources;
Document lessons learned;
Be feasible, timely, acceptable and applicable;
Have limited costs and use of resources;
Be accurate enough to provide decision-makers with
information to take appropriate actions;
• Have a dynamic plan of action which can be revised on an “asneeded basis”;
• Use multiple sources of information and methods to help
ensure validity and reliability; and
• Be sustainable and able to be monitored.
A multidisciplinary approach
• The very first activity, prior to conducting a situation and needs
assessment, should be the establishment of a Steering Committee,
defining its role, tasks and responsibilities.
• Involving other stakeholders is critical to the success of situation and
needs assessments. These stakeholders include representatives from the
prison staff (wardens, custodial staff, health service members, and
treatment and prevention delivery staff), prison governors and
management boards, as well as from the prisoners themselves, all key
stakeholders in the criminal justice and health systems, N. Drug
authorities; NGOs, Prisoners, PLWH;Staff association; ombudsman; rep.
from Human Rights association; technical partners, etc
• The role of this committee is to guide and monitor the design and
implementation of the exercise and its involvement will facilitate the
implementation of programme interventions because of the strong
interest among the key institutions and partners. To the extent possible,
consensus among members of the Steering Committee should be
obtained.
Steering Committee Membership
Defining Clear TORs
Step 1: Select a qualified team
and provide training
•
•
•
•
Independency from all Ministries
Well qualified PI and team
Multidisciplinary (including criminologist, Microbiologist)
Skills of Surveyors:
– Ability to do field work, Interviewing skills, Data recording and
management skills, Ability to communicate in a relevant local
language, Non-judgmental attitude .
– Confidentiality (template of a confidentiality agreement is
attached in Annex 3. )
• Training of the surveyors
Step 2: Consider costs and
resources
• develop a comprehensive budget and work plan that
should include personnel time and resources to
conduct the needs assessment.
• The budget should include the cost of each of the ten
steps of the study process.
• reflect in-kind contributions (e.g. rapid tests provided
by a Ministry, transport for the team made available
by a partner).
– Template in Annex 4.
Step 3:Obtain ethics committee
approval
• Protocol developed by PI and reviewed by SC must be
approved by National research ethics committee
– WHO Ethical standards and procedures for research with
human beings.
• National guidelines for ethical research must be met
• Most countries have ethics committees at national and
local levels.
• If not, then university/teaching hospitals
• If not, then establish an ad hoc committee
Ethical considerations
And Ethical Clearance
• All research involving human participants must be conducted in an
ethical manner which respects the dignity, safety and rights of
participants, and recognises the safety, security and responsibilities of
research team members.
• The guiding ethical consideration in serological and behavioural
situation and needs assessments is to ensure that the basic human
rights of individuals are not violated in the course of the assessment.
– Meeting human rights principles and minimum rules for the
treatment of prisoners.
– Respects the dignity, safety and rights of participants
– voluntary, anonymous and confidential
– Informed consent
– Unlinked serorologic test + VCT
– Ethical committee
Step 4: Collect and analyse available
information (secondary data)
• to determine what information is available from
secondary sources ( + reliability and validity
• And identify gaps
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–
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Completeness of the data:
Representativity of the data:
Age of the data:
Limitations of the data source
Sources of secondary data
• Literature review
• Policy documents regarding
drug use and HIV and AIDS
prevention and treatment
• Ministry of Justice or Ministry
of Interior reports
• Penal system reports
• National human rights reports
• Reports by prison inspection
bodies (national or
international)
• Civil Society Organisation
reports
• Arrest data on people using
drugs and sex workers
• Records of training and
qualifications of staff
• Data/information/records
from the medical department
of the prison (e.g. urine test
records, HIV, HBV, HCV, and
TB screening and/or
surveillance data, treatment
records)
• National reports and
strategies on HIV, TB, viral
hepatitis, STIs and risk
behaviour in the general
population
• National guidelines for
prevention and treatment of
HIV, TB, viral hepatitis, and
STIs
Step 5: Collect and analyse the national
framework and prison conditions
(primary and secondary data)
• Analysis of the national framework and prison
conditions
• Analysis of national TB and HIV policies and framework
– Checklist in Annex 5
Sources of data
• Desk top analysis (mainly national legal and policy
framework)
• Key informant interviews (living conditions, food/nutrition,
hygienic conditions, sanitation, access to care, risk behaviours
such as violence and drug use in prisons)
• Prison visits, including interviews with key prison staff and
prisoners (all aspects listed on the checklist, including the
information gathered by desk top analysis)
• Focus group discussions (providing insight on prison realities
and explaining attitudes and behaviour at several levels)
Step 6: Interview staff and prisoners
(primary qualitative data)
• Objectives
– generate descriptive data;
– plan pre-test questionnaires;
– identify possible risks that were not envisioned by the
investigators;
– monitor effectiveness of programmes in operation;
– provide explanations of attitudes and behaviour;
– and generate hypotheses for quantitative collection.
• How:
– Interview and focus groups
Step 7: Survey prison risk behaviour and
ascertain HIV prevalence (primary
quantitative data)
A. Cross-sectional voluntary anonymous survey on
communicable disease and related risk-behaviour
among prisoners
B. HIV testing methodology to determine prevalance
C. Tuberculosis
D. Cross-sectional voluntary anonymous survey on HIV
and related risk-behaviour among prison staff
Cross-sectional voluntary anonymous survey
on communicable disease and related riskbehaviour among prisoners
• KABP survey on HIV, HIV-TB
• Careful field preparation
• Questionnaire:
– Self-administered preferably
– Languages
– A template questionnaire and standard information for the recruitment in Annex 6
and 7.
– Do not avoid sensible questions or questions on unknown behaviours
– Use local “wording” (ex: name of drugs)
• Pretesting
Cross-sectional voluntary anonymous survey
on communicable disease and related riskbehaviour among prisoners (Cont.)
• Sampling methodology (annex 10)
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–
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Depends on the prison system
Pre-sentenced/ houses of arrest/ prisons/ etc.
Women, (children ?)
Random sampling
• Inclusion criteria: All prisoners incarcerated on a given
day, including migrant prisoners who speak the
languages of the instrument.
• Exclusion criteria:
Cross-sectional voluntary anonymous survey on
communicable disease and related riskbehaviour among prisoners (Cont.)
• Recruitment of prisoners
– Information of the objective
– In agreement but independently
– Anonymity and confidentiality
• template for standard oral information for prisoners is attached
in Annex 6.
• Location of data collection and surveyors
• Services provided to prisoners during the survey including VCT
• Keeping data anonymous
B. HIV laboratory testing
methodology
HIV Testing
Technology
Specimens
Advantages
Limitations
Cost[1]
EIA
Serum
Plasma
Dried blood
spots
Oral fluids
Urine
Can be batched: good for >100 specimens
at a time
Can be automated
QA/QC done at national and regional
laboratories: easier to control
May cost per test less than cost per rapid
test
Identifies seroconverters earlier: highly
sensitive, which reduces nonreactive period
Fewer staff required
Not flexible in testing (need minimum
numbers filled for maximum efficiency)
Requires skilled, trained technicians to
perform and read results
Requires >2 hours for results (if need to
run two EIAs, >5 hours)
Requires special equipment
Requires maintenance of equipment
Reagents must be refrigerated
1-2
USD
Rapid Test
Serum
Plasma
Whole blood
Oral fluids
Good for testing 1 to 100 specimens at a
time
Requires minimal equipment and reagents
Can be performed in a clinic (on-site
testing)
Highly skilled staff not required
Very easy to interpret test results
Results in < 45 minutes
Test kits can be stored at room temperature
(increased stability)
Not good for testing >100 specimens at a
time
The QA/QC is performed at multiple
sites: requires more control
 May cost more per individual test than
EIA
Choice of testing strategy may require
multiple specimens
Inter-reader variability may provide
inconsistent results with some assay
formats (e.g., particle agglutination)
Possible breaches in
anonymity/confidentiality
More staff required
Possible false positives
1-3
C. Tuberculosis
• the collection of epidemiological data on the TB
problem, e.g. prevalence, case notification and
mortality rates, population demographics, treatment
outcomes, risk factors etc. from representative prisons
• an examination of structural and administrative aspects
that impact on TB control, e.g. existing health service
provision, management and co-ordination of prisons,
rules and regulations, availability of food,
accommodation, etc.
TB epidemiologic secondary data
• Based on notifications data (laboratory; district hospitals; etc.)
• Try to estimate a prevalence (but problems with denominator)
• If Possible :
• Disaggregated by type:
• total smear positive TB cases /year
• Total RX; Total clinical ass.
• Total non pulmonary TB
• new cases and total re-treatment
TB epidemiologic secondary data
Survey
• Co-morbidity:
– HIV
– malnutrition
• Mortality
• Case fatality rate:
N. deaths/Nr. TB Cases
TB Survey
• Depending on the size:
– Sputum (direct supervision / trained staff)
– RX + sputum
• If 1 sputum positive, need reconfirmation
D. Cross-sectional voluntary
anonymous survey on HIV and related
risk-behaviour among prison staff
• Objective:
– KABP on infectious diseases but also drug use
• Methodology:
–
–
–
–
–
Questionnaire (see annexe 9)
Anonymous, voluntary
Possibly with serologic test
Information (see annexe 8)
Preparation important
Step 8: Analyse and interpret
survey data
• identify populations that are infected with HIV and
describe their key characteristics
• understand the trends and the impact of HIV and AIDS
in a prison system
• identify groups or populations at risk of acquiring or
transmitting HIV and identify prevention needs
• determine the characteristics of HIV-infected persons
and persons engaged in high-risk behaviours
• determine the indicators of risk in the prison population
• describe the distribution of the disease (geographically
and by population)
• identify trends over time, if any
Step 9: Prepare a final report:
Suggested chapters
1. Executive summary with key results, findings, conclusion
and recommendations for further action
2. Contextual assessment of prison settings
3. Healthcare resource assessment
4. Intervention and policy assessment (prison management,
healthcare management, HIV, TB programmes, National AIDS
policies &Programmes, National TB policies & Programmes)
5. Methodology :- Sampling, data collection, etc
6. HIV prevalence and knowledge, attitude and behaviour
assessment in both prisoners and prison staff
7. Gap analysis and identification of needs
8. Discussion of the results (obstacles faced, recommendations
for improvement, etc)
9. Conclusions
10. Recommendations
Step 10: Focus interventions
1. Alternatives to imprisonment
2. Health services equivalent to those in the community:
prevention, curative, reproductive and palliative;
3. Include “prison settings” in national AIDS and
Tuberculosis plans (including monitoring);
4. Preventing of physical and sexual violence
5. Providing safe and appropriate health /dental services
6. Providing comprehensive HIV Prevention, treatment
care and support in prison settings
Providing comprehensive HIV
Prevention, treatment, care and support
Services
• Information on modes of HIV transmission and ways to reduce those risks, on
testing, and treatment; (IEC, Peers-prevention)
• Access to essential prevention commodities: male and female condoms, sterile
injection equipment, and safe tattooing/piercing, shaving equipment;
• Voluntary confidential HIV testing and counselling services;
• Prevention and treatment of sexually transmitted infections;
• Drug dependence treatment, including opioid substitution therapy (OST);
• Provide appropriate diet and nutritional supplements;
• Provide antiretroviral treatments, preventing and treating tuberculosis, other
opportunistic infections and other blood-borne infections such as hepatitis B and C;
• Providing access to reproductive health care services;
• Prevent mother-to-child transmission (PMTCT); and appropriate care to children
• Providing post-exposure prophylaxis (PEP) to people having been exposed to a risk;
• Palliative care and compassionate release for AIDS and terminally ill patients.
• Organise continuity of care at entrance and upon release
Providing comprehensive HIV
Prevention, treatment, care and support
Services
•
•
•
•
•
Encourage and support the participation of prisoners
Prevent stigma and discrimination
Provide a safe environment for prison staff: Universal
precautions, protective equip. ; training; IEC
Include “prisons” in national AIDS plans and national
TB plans
Monitoring and evaluation
Annexure
• 1:Templates of informed consent forms
for prisoner survey participants
• 2:Template of informed consent forms
for focus group participants
• 3:Template of a confidentiality
agreement for assessment team
members
• 4:Template of cost plan for the
assessment
• 5:Checklist for the analysis of the national
framework and the prison conditions
• 6: Template for standard oral
information for prisoners on the survey
• 7:Template for a prisoner questionnaire
• 8:Template for standard information for
prison staff on the survey
• 9:Template for prison staff questionnaire
• 10:Sampling Methodology
Join us….
For an oral abstract presentation
30 Million People Each Year, at Risk for HIV and TB,
Forgotten in Prisons: Collect the Evidence!
HIV/TB Situation and Needs Assessment Toolkit
Room A3: Fasiledes [566]
14:00 – 15:30
Join us….
For an oral abstract
presentation
30 Million People Each
Year, at Risk for HIV and
TB,
Forgotten in Prisons:
Collect the Evidence!
HIV/TB Situation and
Needs Assessment Toolkit
Room A3: Fasiledes
14:00 – 15:30
For a Satellite Session on
HIV Assessments in
Southern African Prisons
•Results of Studies
conducted in Lesotho and
the condom distribution
intervention
•Swaziland
•Zambia
Room B3: Shalla
17:30 – 19:00
The Toolkit: Implementation
• How Zimbabwe
did it
• How Lesotho did it
Thank you
Nthabeleng Motsomi-Moshoeshoe
UNODC-ROSAF
http://www.unodc.org/southernafrica/en/hiv/prison-settings.html
[email protected]
+27 12 432 0875