Effectiveness of PEPFAR-Funded Community Outreach HIV Prevention Programs in Vietnam: Preliminary Findings June 6, 2008

Dr. Jonathon Simon Center for International Health and Development (CIHD) Department of International Health Boston University School of Public Health (BUSPH)

For the Evaluation team:

Dr. Lora Sabin Dr. Mary Bachman DeSilva Dr. Davidson H. Hamer Ms. Taryn Vian Ms. Danielle Lawrence Ms. Kelly McCoy Mr. Jordan Tuchman

CIHD, BUSPH

Dr. Le Thi Thanh Loan

HCM City Statistical Office

Dr. Theodore Hammett

Abt Associates Inc.

Dr. Duong Quoc Trong

Vietnam Administration of AIDS Control (VAAC) 1

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) 2

Public Health Evaluation of PEPFAR-supported HIV/AIDS Outreach and Referral Programs

• • • •

Family Health International CDC LIFEGAP M édecins du Monde CARE International

3

Primary Research Questions

HE and PEs in Hoang Mai, Hanoi 1. Are outreach workers well prepared to deliver services among MARPs?

2. Are outreach workers identifying and communicating well with clients?

3. Is this BCC intervention effective in changing behavior?

4

Overview of Evaluation Design

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)



Here we report on findings from cross-sectional MARP survey relating to program effectiveness

5

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

6

Findings: Characteristics of respondents

• • • • • Few demographic differences across groups: Slightly over 1/2 were female (~58%) Mean age was just under 30 years (~29 years) About 1/3 had a high school education or higher • • • • • • Some differences in previous behaviors between Intervention group (Int)

vs.

Control group (Con) 22% of Int

vs.

16% of Con reported tested + for HIV 24% of Int

vs.

15% of Con reported sex with an IDU Among MSM: 14% of Int

vs.

23% of Con reported ever bought sex 31% of Int

vs.

40% of Con reported ever sold sex Unknown social desirability bias 7

Effectiveness of BCC: Knowledge

• • • • • Over 90% of all MARPs had good knowledge of transmission (answered correctly 75% of questions) Over 70% had good knowledge of prevention Only 24% had good knowledge of treatment (ART) In all 3 areas, intervention population knew slightly more compared to control population Major knowledge gaps • Transmission: having unprotected oral sex/anal sex, mosquito bite, breastfeeding • Prevention: practicing withdrawal, condom use during oral sex/anal sex, not touching a PLWHA, not kissing • Treatment: existence of HIV cure, purpose of ART 8

Effectiveness of BCC: Risk behaviors IDUs and injection behaviors

• • IDU MARPs (n=703) reported injection behaviors • Most (96%) could obtain new needles/syringes when needed • • 14% had recently shared needles/syringes 36% had used a previously used needle at last injection (within last 6 months) Intervention IDUs more likely to report starting or increased cleaning of injection equipment • 71% Intervention

vs.

61% controls 9

Effectiveness of BCC: Reported Condom use

• Reported condom use among respondents • • 37% always use condoms 34% usually use condoms • Higher condom use reported by all intervention MARPs • • • More likely to always use condoms (40%

vs.

34%) More likely to always carry condoms (50%

vs.

42%) Unclear what impact, if any, on transmission dynamics 10

Effectiveness of BCC: Referral service usage and perceived risk

• Intervention group more likely to seek HIV testing • • 76% of intervention

vs.

46% of controls were tested Among tested, 81%

vs.

61% sought post-test counseling • MARPs reported low perceived risk of infection • • Less than 1/4 see themselves as at high risk Reasons provided: • • always use condom, never share needle or syringe 11

Communication about safe sex and safe injection

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 B. Discussions about safe injection 100% 100% 80% Intervention Control 80% Intervention Control 60% 60% 40% 40% 20% 20% 0% PEs Friends Sex partners HEs

Who has talked to you?

Other 0% PEs Friends Sex partners HEs

Who has talked to you?

Other 12

Views of MARP clients on outreach programs and workers

• • • Intervention MARPs rated most services very or mostly useful; >95% for: • Information on: transmission, safe sex, safe needle disposal, HIV testing • Demonstration of condom use, injection cleaning methods • HIV transmission/prevention knowledge was most useful >95% said PEs/HEs are trustworthy 72% would “absolutely” urge friends to talk to PEs/HEs 13

Challenges in providing services

• • • 73% of control MARPs (n=799) had not heard of outreach programs Of those who had (27%, n=322), main reasons why no contact: • • • • • inconvenient time (52%) don’t know how to contact (44%) inconvenient location (34%) do not feel comfortable (30%) worried about police (24%) 25% expressed interest in talking to an outreach worker 14

• • • • • •

Summary

PHE data suggests that outreach programs have been somewhat effective in increasing HIV transmission, prevention, and treatment knowledge Important knowledge gaps remain —especially related to HIV prevention and treatment Further program impact is suggested by differences in intervention v control: condom use, HIV testing “Ripple effect” seems to be important benefit of the outreach programs No evidence of impact regarding needle sharing Challenges remain in reaching MARPs in current program areas 15

Recommendations for program improvement

• • • Improve commodity supplies (condoms) and overcome constraint on distribution of needles Develop targeted quality improvement approaches to overcoming specific barriers to • • accessing clients: Inconvenient time, location of outreach activities Easier ways of contacting outreach workers Collaborate more closely with key community members: police, establishment owners 16

Thank you!

Funding provided by: USAID/Hanoi, Country Research Activity GHS-A-00-03-00020 Additional acknowledgments: Ahmar Hashmi, Jen Beard, Wayland Bergman, Bill MacLeod, Matt Fox, Don Thea, Jill Costello, Jon Simon, Deirdre Pierotti

17

Several detailed slides follow, if useful

18

Surprises during implementation

• • • • Related to data collection: Ease of recruiting “control” participants for quantitative survey Quality of interviewing by local qualitative researchers • • Related to findings: Wide variability across implementing programs, provinces Generally low needle sharing, high access to clean needles/syringes 19

What we would NOT do again

• • Wait so long for IRB approval from a single domestic institution 

Next time, we would simultaneously seek approval from relevant institutions to reduce potential delay

Assume local researchers are sufficiently trained for qualitative data collection 

Next time, we would conduct our own training of all qualitative data collectors to ensure that they are equipped with adequate preparation and skills

20

What we WOULD do again

• • Partner with an experienced in-country research group, even if the group does not have extensive HIV/AIDS-related experience 

Lesson: a strong track record collecting and managing data may be more useful than HIV/AIDS related research experience

Devote considerable time on data collection tools, in collaboration with in-country partner 

Lesson: developing confidence and familiarity with the tools is critical to later use

21

Background

• • • • HIV/AIDS epidemic • • Nationwide adult HIV prevalence in Vietnam: 0.5% Most-at-risk populations (MARPs): IDU, CSW, MSM 2004-National Strategic Plan focus: • VCT, ART,

harm reduction

, other best practices Vietnam is PEPFAR focus country since 2004, supporting interventions including community outreach 2006: BU asked to evaluate outreach interventions in order to provide evidence for program improvements 22

Overview of community outreach programs

•

Community outreach programs are an important component of harm reduction activities that aim to:

• Distribute information about HIV transmission, prevention, and care among at-risk populations • Reduce risky behaviors, increase safe behaviors relating to drug use and sexual practices • Promote use of VCT, STI, social, and other available support services 

Goal: to reduce risk of HIV transmission and STI prevalence among most at-risk populations

23

PEPFAR-funded community outreach programs

• • • Programs implemented in 38 provinces Focus provinces: Hanoi, Hai Phong, Quang Ninh, Ho Chi Minh City, An Giang, and Can Tho • In these 6 provinces - an estimated 116,641 IDUs and 40,495 CSWs Programs employ two approaches: a peer education approach and a health educator approach 24

Methodology: limitations

• • • Design used a cross-sectional survey, not a randomized controlled trial, so cause and effect cannot be inferred • Respondents may have provided overly positive information, biasing findings (“social desirability” bias) The sample sizes of MARP groups is somewhat different than the sizes of MARP groups in Vietnam overall Snowball approach might have resulted in a potential bias of the final samples 

Limitations are important, but we do not believe they affect findings in a meaningful way

25

Findings: MARP Demographics

Characteristic

Geographic location, N Hà Noi HCM Hai Phòng An Giang Age in years, mean (SD) Gender, % male % female % other Education, highest level completed % Primary school or no formal education Secondary school (grade 6-9) High school or higher Employed full time, % Main daily activity Construction/farming/petty job Salaried job Sex worker Entertainment employee Student, housework, other Unemployed Ever been tested for HIV and received a positive test result (n=751 intervention and 466 control individuals ever tested

and

received their results) Intervention group (N=1,101) Control group (N=1,121) 400 397 154 150 29.6 (8.0) 38.3 58.8 2.9 24.3 43.2 32.4 52.9 20.1 12.6 35.9 9.5 12.9 9.0 21.8 410 405 156 150 28.5 (8.0)*** Control group slightly younger, less likely to know status, or be HIV+. 40.3 57.4 2.3 28.4 39.3 32.3 51.3 20.3 16.2 31.9 8.1 13.4 10.0 15.5** 26

MARP Demographics: Risk Behaviors, Intervention vs.. Control

Characteristic

Intervention group

All respondents(n)

Ever had sex 1 with someone infected with HIV with someone who had hepatitis with a man who has sex with men with someone who injects drugs

Injecting drug users (n)

last 6 months Ever injected drugs: 2 with someone infected with HIV 1,101 13.1% 7.1% 19.8% 24.1% 298 Ever admitted to an 06 center (drug rehabilitation center) 40.9% Ever had trouble with police due to drug using behavior? 52.7% Used non-injectable drugs for non-medical purposes in 23.5% 26.9%

Commercial sex workers (n)

Ever admitted to an 05 center (re-education center) Ever had trouble with police because of commercial sex work

Men who have sex with men (n)

Ever used injectable drugs for non-medical purposes Ever gave someone money, drugs, or goods for sex in last 6 months Ever received money, drugs, or goods for sex 603 16.1% 41.6% 200 8.0% 14.0% 30.5% Control group 1,121 5.6%*** 3.5%*** 20.4% 14.6%*** 307 34.2% 44.0%** 20.9% 20.5%** 609 7.6%*** 28.1%*** 208 9.1% 23.1%** Control group lower risk 40.1%** 27

Effectiveness of BCC: Knowledge of Intervention v Control groups

Transmission knowledge: % respondents who gave correct answers Route of transmission (correct answer)

Injections with used needles (yes) Sharing other injecting equipment & solutions (yes) Shaking hands with a person infected w HIV (no) Having unprotected vaginal sex (yes) Having unprotected anal sex (yes) Hugging a person infected w HIV (no) Having sex with a person infected w HIV (yes) Having unprotected oral sex (yes) Contact with infected blood (yes) Sharing toilet with a person infected w HIV (no) Transfusion of blood/blood products (yes) Perinatally, from mother to child (yes) Sharing eating utensils w a person infected (no) Sharing food w a person infected (no)

Intervention (%)

Through breastfeeding (yes) Mosquito bites (no) *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

99 92 95 99 92 94 99 72 96 92 92 94 93 93 75 76

Control (%)

97** 90* 92** 97** 85*** 91** 97 61*** 93** 87** 89** 88*** 90** 90** 66*** 68** 28

Effectiveness of BCC: Knowledge of Intervention v Control groups

Prevention knowledge: % respondents who gave correct answers Prevention strategy (correct answer)

Abstaining from sex (yes) One partner/staying faithful (yes) Not having sex with sex workers (yes) Not kissing (no) Limiting number of sexual partners (yes) Not having sex with IDUs (yes) Use condoms during vaginal sex (yes) Use condoms during oral sex (yes) Use condoms during anal sex (yes) Practicing withdrawal (no) Not using drugs (yes) Not injecting drugs (yes) Not breastfeeding (yes) Disposing of used needles properly (yes) Not touching someone who is HIV-positive (no) Avoiding mosquito bites (no) Protection from traditional healer (no)

Intervention (%)

*significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

68 93 73 93 76 75 68 90 87 71 84 91 99 82 92 36 85

Control (%)

68 88 87 71 81 91 99 75*** 85** 35 84 92 67** 89** 70** 66*** 66 29

Effectiveness of BCC: Knowledge of Intervention v Control groups HIV treatment knowledge: % respondents who gave correct answers Statement (correct answer)

HIV/AIDS makes it difficult to fight other infections (true) There is a treatment for HIV/AIDS (true) ART improves immune functioning (true) Purpose of ART is to treat HIV/AIDS (true) Purpose of ART is to provide vitamin supplements (false) Purpose of ART is to decrease risk of passing on disease (false) If you take ART for a few months, you will be cured (false) Once you take ART you can use condoms less often (false) *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

Intervention (%)

91 74 44 34 17 25 49 51

Control (%)

85*** 75 24*** 18*** 8*** 14*** 28*** 29*** 30

Effectiveness of BCC: Risk behaviors IDUs and injection behaviors

Behaviors reported by respondents who had used heroin in last 6 months Behavior Injection frequency (n=703)

Less than daily Once a day 2-3 times daily 4+ times daily

Can access clean needles any time needed (n=703)

Yes No

Have shared injection equipment in last 6 months (n=701)

Yes No

Used a previously-used needle last time injecting in last 6 months (n=93)

Yes No

Frequency of washing or cleaning needles if previously used by someone else (n=92)

Always Most of the time Occasionally Never *no differences were statistically different at the p=0.05 level

Intervention N %

114 76 156 12 32 21 44 3 348 10 97 3 50 306 17 29 14 9 10 13 14 86 37 63 30 20 22 28

Control

136 56 146 7 328 17 50 295 17 30 8 4 12 22 39 16 42 2 95 5 14 86 36 64 17 9 26 48 31

Effectiveness of BCC: Risk behaviors Sexual behaviors

Behaviors reported by all respondents Behavior Ever used condom (n=2,221)

Yes No

Intervention N %

1045 56 95 5

Frequency of condom use (n=2,050)

Occasionally (1-25%) About half the time (26-74%) Usually (75-99%) Always (100%)

Time to get a condom, when needed (n=2,030)

Always carry them Under 15 min. 15-60 min. Over 1 hour

Use of condoms/female condoms last time had sex with commercial sex client (n=1,383)

Yes No

Use of condoms/female condoms with primary partner in last 6 mo. (n=1,415)

Never Occasionally (1-25%) About half the time (26-74%) Usually (75-99%) Always (100%) 143 118 361 421 519 451 61 1 643 39 170 112 62 148 245 94 6 23 15 8 20 33 *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

14 11 35 40 50 44 6 0

Control N

1008 112

%

90 10 205 126 332 344 418 505 75 0 20 13 33 34 42 51 8 0 *** *** ** 608 93 204 138 62 108 166 87 13 30 20 9 16 24 *** *** 32

Effectiveness of BCC: Referral service uptake

HIV testing and counseling behaviors reported by all respondents Behavior Intervention

N

Had HIV pre-test counseling

Yes 859 No 238 Total 1,097

Ever been tested for HIV

Yes No 838 262 % 78 2 100 76 24 Total 1,100 100

If tested, had HIV post-test counseling

Yes No 678 156 81 19 100 Total 834

If tested, received HIV test results

Yes 751 No Total 80 831 90 10 100

Control

N 371 747 1,118 517 603 1,120 313 200 513 466 49 515 *significant at p<0.05, **significant at p<0.01, ***significant at p<0.001

% 33 67 100 46 54 100 61 39 100 90 10 100

Total

N % 1,230 985 2,215 1,355 865 56 44 100 61 39 2,220 991 356 1,347 1,217 129 1,346 100 74 26 100 90 10 100 *** *** *** 33