Transcript Effectiveness of PEPFAR-Funded Community Outreach HIV Prevention Programs in Vietnam: Key Findings November 6, 2008 Dr.

Effectiveness of PEPFAR-Funded
Community Outreach HIV Prevention
Programs in Vietnam:
Key Findings
November 6, 2008
Dr. Lora Sabin
Center for International Health
and Development
Department of International Health
Boston University
School of Public Health
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Evaluation Team Members
and Affiliations
Boston University School of Public Health
Lora Sabin, MA, PhD
Mary Bachman DeSilva, MS, ScD
Davidson H. Hamer, MD
Taryn Vian, M.Sc.
Danielle Lawrence, MPH
Kelly McCoy, MPH
Jordan Tuchman, MPH
Ho Chi Minh City Statistical Office
Le Thi Thanh Loan, PhD
Abt Associates Inc.
Theodore Hammett, PhD
Funding provided by: PEPFAR/USAID: Country Research Activity GHS-A-00-03-00020
Additional acknowledgments: Ahmar Hashmi, Jen Beard, Wayland Bergman, Bill MacLeod,
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Matt Fox, Don Thea, Jill Costello, Jon Simon, and Deirdre Pierotti
Background
• Vietnam’s 2004-National Strategic Plan focus:
• VCT, ART, harm reduction,
• Harm reduction programs include community
outreach programs that aim to:
• Distribute info about HIV transmission, prevention, and
care among most at-risk populations (MARPs)
• Reduce risky behaviors, increase safe behaviors
relating to drug use and sexual practices
• Promote use of VCT, STI, social, and other available
support services
• Outreach programs employ 2 approaches:
Peer educators (PE) and Health Educators (HE)
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Public Health Evaluation of PEPFARsupported HIV/AIDS Outreach and
Referral Programs
•
•
•
•
Family Health International
CDC LIFEGAP
Médecins du Monde
CARE International
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Primary Research Questions
1. Are outreach
workers well
prepared to deliver
services among
MARPs?
2. Are outreach
workers identifying
and communicating
HE and PEs in Hoang Mai, Hanoi
well with clients?
3. Is this BCC intervention effective in changing
behavior?
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Design & Methods
Qualitative and quantitative methods:
1. Review of program information
2. Qualitative:
223 in-depth interviews with
outreach workers, MARPs,
other key informants (6
provinces)
3. Quantitative:
Cross-sectional survey of 2,222
MARPs & 272 PEs/HEs (4
provinces)
PE demonstrating needle cleaning
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Study Population
• “Intervention” – contact with
PE or HE in last six months
• “Control” – no contact with
PE or HE in last six months
• Snowball sampling to
identify both populations
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Methodology: Limitations
• Cross-sectional survey: cause and effect
cannot be inferred between Intervention and
Control groups
• Possible social desirability bias
• Differences between PEs and HEs not
relevant to all programs
• Sample sizes of MARP groups different from
sizes of MARP groups in Vietnam overall
• Potential bias from snowball sampling
approach
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QN:
CDC/LG,
FHI, CARE
HN:
AllCDC/LG,
4
HP:
programs
FHI
QN:
CDC/LG,
FHI, CARE
HP: CDC/LG,
FHI
AG: CDC/LG,
FHI, CARE
HC: All 4
CT: CDC/LG,
programs
FHI, CARE
HC: All 4
programs
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Evaluation
Findings
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Characteristics of MARP
Respondents
•
Few differences in demographic characteristics:
•
•
•
•
58% female
Mean age ~29 years
About 1/3 had a high school education or higher
Some differences in previous behaviors between
Intervention group (Int) and Control group (Con)
•
•
•
•
22% of Int vs 16% of Con had tested + for HIV
13% of Int vs 6% of Con had had sex with HIV+ person
24% of Int vs 15% of Con had had sex with an IDU
Among MSM:
• 14% of Int vs 23% of Con had ever bought sex
• 31% of Int vs 40% of Con had ever sold sex
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Research Question 1:
How prepared are outreach
workers?
•
•
•
•
•
Training and skills
Knowledge and qualifications
Supplies
Supervision and support
Financial support
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Training & Skills
• Most PEs/HEs felt training was appropriate
and adequate preparation for job
• Before I knew about these topics only through
friends, but now [my] knowledge is more
scientific and concrete. (PE in Hanoi)
• Thanks to the course, I am more daring; I’m not
afraid of going to the establishments to talk
anymore. (PE in Hai Phong)
• [PEs] should be trained more to be more
experienced and knowledgeable to work. (PE in An
Giang)
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Training & Skills
• >90% of PEs and HEs received pre-service
training, 95% received refresher training
• >95% of outreach workers had covered key
topics of HIV transmission, prevention through
safe sex/safe injection, demonstration of correct
condom use, negotiation & outreach skills
• 13% PEs and 26% HEs had not received
infection control training
• PEs mentioned wanting more training related to
antiretroviral therapy (ART)
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Knowledge about HIV
Domain and level of knowledge
(score)
Transmission Knowledge (15 Qs)
15 correct
12 or more correct
8 or more correct
Prevention Knowledge (17 Qs)
16 or more correct
12 or more correct
8 or more correct
Treatment Knowledge (8 Qs)
8 correct
6 or more correct
4 or more correct
% PEs & HEs
62
98
100
45
97
99
13
71
82
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PE/HE Knowledge Gaps
• 8% did not know that HIV can be transmitted
through breastfeeding
• Only 55% knew that withdrawal during sex is not an
effective method for preventing HIV infection
• 13% thought that not touching someone who is
HIV+ is an effective prevention method
• Nearly 20% did not know there is no cure for
HIV/AIDS
• 24% did not know that ART improves immune
functioning
• 60% did not know that the purpose of ART is to
treat HIV/AIDS
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Supplies
• Sometimes inadequate (PE, MARP)
• More safety items needed (PE)
• I’m not satisfied with the lack of some
aids…there should be alcohol, distilled water,
condoms, and it’s really good to have injection
syringes and needles. (PE in Hai Phong)
• Without access to sterile injection equipment
people like us can spread disease all over the
society. (CSW in Hanoi)
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What type of support have you received?
100%
PEs
HEs
% reporting having received
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any support
Verbal
encouragement
Training
opportunities
Career
development
opportunities
Financial bonus
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Perceptions of Community Support
100%
Hanoi
Hai Phong
% reporting receiving support from
90%
HCMC
80%
An Giang
70%
60%
50%
40%
30%
20%
10%
0%
Any community
members
Family members
Establishment
managers
Police
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Supervision and Support
• Now, we are still rushed by the police when
approaching gathering spots. Sometimes I am
even assaulted…We are even captured by the
police even though we wear uniform and
badges. (PE in Hai Phong)
• At present, the police are not quite clear about
our job. .. The police ask us to inform them
before approaching any particular places, but
we refuse as we have to keep our customers’
secret. (PE in HCMC)
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Financial Support
• Some workers dissatisfied with salaries
(mean reported salaries: PEs = 900,000;
HEs = 2,300,000 VND/mo)
• …some outreach workers work at bars, massage
parlors, discotheques and at that time the fees are
especially high. At the moment we haven’t got the
financial support when approaching those areas.
(HE in Hanoi)
• If the workers here just thought of the salary, it’s
possible that nobody would do this job…Our salary
is quite poor… not enough to support our life.
(PE in Hai Phong)
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Research Question 2:
How well do outreach workers identify
and communicate with clients?
• Contacts between outreach workers
and MARP clients
• Approaches used by outreach workers
• Services provided to MARP clients
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% of PE and HE who reported contact
with each client group in last month
Client group
CSW
IDU
MSM
Partners of at-risk groups
Clients of CSW
n=272 PE/HE
68%
63%
28%
18%
10%
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PE/HE Contacts by Client Group
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Mean number of contacts in previous month
40
# new clients
# repeat clients
35
30
25
20
15
10
5
0
Any client
IDUs
CSWs
MSM
Type of client
Clients of CSWs
Partners at-risk
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PEs/HEs use a variety of approaches
to reach clients
90
% reporting use of strategy
80
70
60
50
40
30
20
10
0
Visit hot spots
regularly
Obtain referrals from
prior clients
Visit known
establishments
regularly
Obtain referrals from
other acquaintances
Strategy
Visit new
establishments
regularly
Develop maps or
strategies at team
meetings
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Specific approaches Used by
PEs and HEs
• Specific tactics: humor, scare tactics, friendly
and polite demeanor, emphasizing risks to family
members
• PEs/HEs said that approaching street CSWs
(SSWs) is much easier than establishment-based
CSWs (KSWs)
• For MSM, hot spots and introductions are key
• MARPs said best approaches are: making clients
feel comfortable, using personal connections,
being reliable
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How PEs and HEs talk to clients
• It depends on each customer. For example, at the
railway, the ice-breaker is: Where did you buy the
“goods”? Is it good? Who did you buy it from?... I
show them that I’m in their circle. Then I step-bystep turn to some anecdotes [and] lead them to my
purpose, [which] is to talk about HIV. (PE in Hai Phong)
• We go to the women’s gathering places ourselves
to make friends … Sometimes I even bring my child
along. Sometimes I tell a lie that used to be a sex
worker. (PE in Hanoi)
• Continuous rain softens the hardest soil. We can’t
see it right away. They change their habits step by
step. (PE in Quang Ninh)
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Services Provided by
PEs and HEs
• Provincial variability in contacts per month
• Hai Phong: 50 total/12 new; An Giang: 25 total/8 new
• Rising trend in number of clients per month in the past 6
months: +81% in Hai Phong; +57% in HCMC
• 95% tell IDUs that sharing injection equipment is
unsafe
• 30% able to name unsafe sources
• 31% tell where to obtain bleach
• 93% provided VCT referrals in previous month
• 62% to STI clinics
• 36% for ART
• 33% to TB clinics
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Conversations Reported by MARPs
Possible secondary benefit: Intervention MARPs had more
discussions about safe sex (98% v 45%) & safe injection
(69% v 27%) in previous 6 months
A. Discussions about safe sex
100%
Intervention
80%
% of MARP Group
% of MARP Group
100%
B. Discussions about safe injection
Control
60%
40%
20%
0%
Intervention
80%
Control
60%
40%
20%
0%
PEs
Friends
Sex
partners
HEs
Who has talked to you?
Other
PEs
Friends
Sex
partners
HEs
Who has talked to you?
Other
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Research Question 3:
How effective is the behavior
change communication?
• Knowledge, attitudes, and beliefs
• Risk behaviors
• Referral service usage and perceived
risk
• Qualitative information on program
strengths and weaknesses
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Effectiveness of BCC:
MARP Knowledge
Domain and level of knowledge
(score)
Transmission (16 Qs)
15 or more correct
12 or more correct
8 or more correct
Prevention (17 Qs)
16 or more correct
12 or more correct
8 or more correct
Treatment (8 Qs)
8 correct
6 or more correct
4 or more correct
Intervention (%)
Control (%)
62
96
100
44
88
98
18
86
99
14
81
96
4
32
51
1
16
28
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Knowledge Gaps Among MARPs
• Transmission
• 28% (24% Int, 32% Con) did not know that HIV can be
transmitted through breastfeeding
• Prevention
• 65% (both Int/Con) said that withdrawal during sex is an
effective method of HIV prevention
• 27% (24% Int, 30% Con) said that not touching someone
who is HIV+ is an effective prevention method
• Treatment – main area of knowledge weakness
• 25% (both Int/Con) did not know there is no cure for HIV
• 66% (56% Int, 76% Con) did not know that ART improves
immune functioning
• 60% did not know that the purpose of ART is to treat HIV32
Changes in MARPs’ Beliefs
• Changes in beliefs about what was risky behavior
and the seriousness of risk
• Better understanding of modes of HIV transmission
• New attitudes toward people living with HIV
• Stronger feelings of personal security and selfefficacy
• I changed a lot of my beliefs…I used to underestimate [the
risk] and not use condoms, but since talking with him, I know
the benefits. (MSM in Hanoi)
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IDUs and Injection Behaviors
• IDU MARPs (n=703) - reported low-risk injection
behaviors
• 97% Intervention / 95% Controls could obtain new needles/syringes
when needed
• 14% in both groups had recently shared needles/syringes
• In IDIs, noted barriers to access sterile equipment
• No single guaranteed source
• Inconvenience in bad weather, late at night
• Fear of discovery with equipment by police, family
• Intervention IDUs - more likely to start or increase
cleaning of injection equipment
• 71% intervention vs 61% controls
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IDUs and Injection Behaviors
•Before meeting [outreach workers], I thought
nothing about problems concerning sharing
syringes and needles. Now I no longer share
syringes or needles with others. (IDU in Hanoi)
•We used to share syringes and needles in groups
of 4, 5 users. Now we no longer share them as
I’ve witnessed many deaths. (IDU in An Giang)
•I’ve changed a lot, I’ve thought of it a lot…After
listening to him, I don’t [share]. I used to use the
kits again…Now I wash them with boiling water
twice or three times according to the formula.
(IDU in Quang Ninh)
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Sexual Behaviors: Condom Use
• Sexually active MARPs
(n=1623) reported on condom
use in the last 6 months:
• 37% always used condoms
• 29% with primary partner
• 43% with casual partner
• 63% with sex clients
• 34% usually used condoms
• 29% never/occasionally
used
• CLEARLY substantial room
for improvement
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Sexual Behaviors
• Higher condom use reported by intervention
MARPs
IDU
MSM
KSW
SSW
Always carry condoms Always use condoms
Int
Control
Int
Control
32%
22 **
28
18 **
37%
28 *
41
34
52%
44 *
42
34 *
65%
54 **
43
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**p<.01, *p<.05
• …but lots of room for change
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Sexual Behaviors
• I changed a lot of my beliefs…I used to
underestimate [the risk] and not use condoms,
but since talking with him, I know the benefits.
(MSM in Hanoi)
• After talking, I know how to protect myself. When
I have sexual relations, I use condoms even with
my lover. I’ve taught my boyfriend to use
[condoms]. (CSW in Hai Phong)
• She convinced [me] so I understand that when I
am in a hard situation earning money as a
prostitute, I have to use condoms, have blood
test….I also learned how to use condoms in the
right way. (CSW in HCMC)
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Referral Service Usage
& Perceived Risk
• Intervention group more likely than controls to
seek HIV testing
• 76% of intervention group vs. 46% of controls were
tested
• 78% vs. 33% sought pre-test counseling
• Among tested, 81% vs. 61% sought post-test
counseling
• MARPs reported low perceived risk of infection
• Less than 1/4 see high risk
• Reasons: always use condom, never use drugs
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Referral Service Usage
& Perceived Risk
• In IDIs, MARPs described mixed experiences with
referrals:
• Positive: provided for free, make them feel more
secure, friendly staff, short wait times
• Negative: unkind/unfriendly staff, unhelpful counseling
• Illustrative statements by IDI respondents:
• The way they greeted us really offended us. [The
receptionist’s] manner was very hierarchical, and she
shouted and scolded us. (CSW in Hanoi)
• It’s a waste of medicine to treat an addict like him. (PE in
Hai Phong retelling what a doctor told him, while motioning toward an IDU)
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Perceived Program Strengths
• Intervention MARPs rated most services very or
mostly useful; >95% for:
• Information
• Demonstration of condom use, injection cleaning methods
• HIV transmission/prevention knowledge
• >95% said PEs/HEs are trustworthy
• 72% would “absolutely” urge friends to talk to
PEs/HEs
• About half of MARPs could not distinguish PEs v HEs
• Of those who could: HEs seen as more knowledgeable,
PEs as more practical, available, and able to help change
behavior
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Perceived Program Strengths
• At first I was also shy as I didn’t know what they
were like, but when we were closer to each other,
I really liked talking to them. (CSW in Hanoi)
• …just like friends talking with each other. (MSM in
HCMC, on his relationship with a PE)
• [Talking with PEs is] beneficial as they bring us
information to prevent HIV…. (IDU in Hai Phong)
• I’ve met health educators and I find them really
enthusiastic. They all answered every question of
mine. … I see peers more often, so I like them
more…. I ask the health educators the questions
which peers can’t answer. (MSM in Hanoi)
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Challenges in Providing Services
• 83% PEs/HEs reported difficulties in approaching
clients
• 53% had encountered violent clients
• Lack of client cooperation due to fear, police interference,
time conflicts
• MARPs: some PEs apathetic or too preachy:
• Most PEs working here are not enthusiastic. They just
work to receive salary. (MSM in HCMC)
• He [PE] communicates with me but sometimes talks so
much that it makes me feel a headache…. he keeps
preaching. Even on doing this and that for prevention;
such a headache…. (IDU in Quang Ninh)
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Challenges in Providing Services
• 3/4 of control MARPs had not heard of programs
• Of those who had, main reasons no contact: inconvenient
time, location, not sure how to contact, feel uncomfortable
• 1/4 expressed interest in talking to a PE
• Qualitative data highlight fears of MARPs and
potential need for more PEs:
•
I recommend an increase in the number of PE to
outreach drug users…If so, there will be a decrease in the
number of drug users. (IDU in Hai Phong)
• Outreach workers need to work better. To make the
unaware people go [to clinic] for examination; or they
should chat to those people. (CSW in An Giang)
44
Social Discrimination
• The biggest problem is the prejudices from the
community. Many people do not know anything
about MSM’s feelings, and they [think they] are sick
and debauched people. (HE in Hanoi)
• The police even beat us if they catch us delivering
condoms outside the street. I have been beaten by
a club. They don’t even want to know what we do,
just chase us. (PE in Hai Phong)
• The obstacles are from the [establishment] owners;
they don’t welcome us. They deny that they have
prostitutes inside…if the local government and
other unions support us a bit in our job, the
program will be more effective. (PE in An Giang)
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Key Informants on Program Strengths
• Why are programs effective?
• Proven ability of PEs/HEs to reach clients who
need services
• Comprehensive in scope, with broad
support
• Tight/strict management, stable budgets
• Well-trained staff
• Rise in number of people accessing VCT and
other services
• Improvement in knowledge/awareness of
MARPs
• Reduction in risky behaviors of MARPs
46
Key Informants on Program
Weaknesses
• Challenges:
•
•
•
•
Policy conflicts
Inability to distribute sterile needles/syringes
Turnover, mediocre PE performance, low salaries
Geographic coverage
• Little coordination between PEPFAR-funded and
other outreach programs
• But views varied on whether this is a major issue
 These views generally shared by PEs/HEs and MARPs
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Summary
1. Outreach workers generally well prepared
 But some areas need improvement.
2. Outreach workers use many effective strategies
to identify and communicate with MARPs
 Yet social stigma still makes it difficult to access
clients.
3. Tension between “peers” and being a role
model
4. Job satisfaction high, but there are issues:
 Inadequate supplies
 Weak community support
 Low compensation
48
Summary
5. Possible “ripple effect” seems to be important
benefit of the outreach programs
6. Data on contacts/worker raise questions about
data quality and possible market saturation in
some areas
7. Programs appear to have increased knowledge
among MARPs, but knowledge on treatment is
low, among both MARPs and outreach workers
8. Effectiveness of programs is suggested by
differences in intervention v control: condom
use, HIV testing
49
Summary
9. Little reported needle sharing, but intervention
group more likely to start or increase cleaning
of injection equipment
10. Although there are differences between PEs
and HEs, a combination of both PEs and HEs
appears most effective for service provision
• PE and HE model appears to work well
11. There is a need for greater coordination
between PEPFAR-funded programs and other
programs
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Thank you!
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