HIV Prevention: New Evidence, New Thinking

Transcription

1 HIV Prevention: New Evidence, New Thinking Background Southern Africa remains at the centre of the global AIDS pandemic. Despite significant investment of financial and technical resources, HIV prevention efforts have not yet achieved the desired results. HIV prevention efforts to date have overwhelmingly focused on reducing individual risk behaviour, and less on structural factors (socio-economic, political, legal, and other contextual factors) that increase vulnerability to HIV. Some national HIV prevention programs are a collection of disconnected interventions without clear linkages, while other programs are all trying to achieve the same prevention targets. At the community level, HIV prevention interventions are often project-driven, largely information based, and promote specific prevention methods that do not take into account the dynamics of the local community and the needs of specific target groups. This results in lost opportunities, such as not using family planning services and other delivery points to include HIV prevention services or addressing the needs of serodiscordant couples. There is limited evidence of systematic training in prevention thinking that uses lessons learned from the past 30 years. Training often covers specific interventions, but does not give the program managers the skills to design and adapt prevention programs that meet the changing needs of different communities. SADC has a unique position in the regional response to the HIV and AIDS pandemic. In terms of the SADC strategic framework on HIV and AIDS the unit is mandated to provide strategic guidance and to inform policy and training approaches across Member States. SADC and BLC approach: In response to this challenge, the Building Local Capacity for Delivery of HIV Services in Southern Africa Project (BLC) and the SADC HIV and AIDS Unit initiated a partnership with the Centre for AIDS Development, Research and Evaluation (CADRE) in July 2012 to build on and adapt an HIV prevention training: HIV Prevention Training: New Evidence, New Thinking for SADC Member States. The training was originally developed with funding from the Swedish International Development Coordination Agency and delivered to representatives of government and civil society organizations (CSOs) in South Africa, Tanzania, and Zimbabwe. The workshop presents a meaningful opportunity for program managers working within government, local and provincial AIDS councils, development agencies, and CSOs to develop their capacity to think strategically about HIV prevention, informed by the latest evidence-based prevention concepts. It is intended to assist in closing the innovation chasm between research results and practice. The program consists of a five-day intensive workshop, presented in modules and based on principles of adult education and experiential learning. It seeks to embed a social ecology and combination prevention approach into the full range of HIV and AIDS responses, including care to orphans and vulnerable children (OVC), support work for people living with HIV, Prevention of Mother-to-Child Transmission (PMTCT), home-based care, and family planning. 1

2 Target Group The target group is managers and leaders of CSOs implementing HIV and AIDS programs, as well as managers and leaders of government health and social services departments and national AIDS councils involved in the design of HIV prevention strategies and interventions. This interactive country workshop bring together national policy makers and implementers at national, provincial, regional and local levels, local AIDS councils, and CSO partners to critically review and rethink their current HIV prevention strategies using the New evidence, New Thinking approach, informed by the latest evidence-informed prevention concepts. It provides an ideal opportunity for countries to conduct a gap analysis of policy intentions vs. implementation at the local level and develop recommendations for improving or aligning country policies, guidelines, training approaches and implementation methodologies to optimize the impact of prevention efforts. Workshop objectives The key objectives of the HIV Prevention: New Evidence, New Thinking approaches are to: Orient participants on key ideas and evidence in current HIV prevention thinking Review and analyze national HIV prevention efforts in light of new/emerging evidence and information (Data interpretation and programming with renewed thinking) Discuss gaps and priorities for improving national and local responses to HIV and AIDS Appreciate the value of combination prevention approaches, and renew HIV prevention thinking based on a sound understanding of the changing nature of the epidemic Strengthen understanding and application of social and behavior change communication and results-based management for effective HIV prevention. The program is oriented along the Theory of Change approach, encouraging participants to reflect on how change happens in HIV prevention in general and within their specific programs (e.g. what role organizations/groups/communities play in a particular context). Participants learn to think critically about interventions, asking questions like what is an intervention like HIV Counselling and Testing (HCT) really good for? What does it achieve?, rather than assuming that an intervention has a particular outcome. They also learn to consider when a targeted approach may be more effective than one that is directed at the general population. This approach builds an understanding of implicit theories of change and how these are operationalized. Participants reflect on their prevention programs core intended outcomes and how these are or can be achieved. Participants learn how to identify the intervention logic of their programs, as well as how the theory of change aligns with national strategic frameworks. What have we learned about HIV prevention needs? Training sessions conducted in South Africa, Tanzania, Zimbabwe, and more recently Swaziland, provide an opportunity to appraise the state of HIV prevention knowledge and practice in the Southern African context. There were several notable differences in the degree of HIV prevention knowledge across countries and organizations, but a number of general conclusions can be drawn: Community prevention interventions are usually project-focused and event-based, and promote specific prevention methods, rather than being consistently applied across time and oriented on the dynamics and risk profiles of specific target groups. There has been little use of communication or social and behavioral change theory, with prevention campaigns being largely information-based. There is little use of multilevel and combination strategies or results-based management principles applied to HIV prevention thinking, and there is little local level collaboration or long-term strategic thinking. Page 2 of 6

3 There is little evidence of systematic training in prevention thinking and learning processes that take practitioners beyond the basic ideas which have been in place for the past 15 years. There is evidence of lost opportunities for HIV prevention; for example, not using family planning services as an opportunity for HIV prevention, and limited work done to address the needs of sero-discordant couples. There is widespread difficulty in grasping some concepts, such as the partial protection offered by male circumcision, the differing HIV prevention needs of specific target groups in generalized epidemics, and the risks of Multiple Concurrent Partnerships (MCP). There has been little diffusion of understanding of new thinking about HIV prevention and little evidence of learning and sharing experiences. In summary, the research points to the need for concerted efforts to translate new evidence about HIV prevention needs and effectiveness into practice. While some national strategic plans may reflect new advances in HIV prevention, there must be a concerted effort by program managers to ensure that such advances are incorporated into program plans and implemented at project and community level. Piloting and implementation the Swaziland Experience Following an in-country needs assessment which included an extensive document review, and consultations and focus group discussions with the Swaziland Prevention Technical Working Group, regional HIV coordinators, and community-based organizations involved in HIV prevention activities, the training material has been revised, updated and utilized for a pilot workshop that was conducted in Swaziland in April In-depth feedback was obtained from the pilot training about the appropriateness of the content, exercises, and areas requiring local data and examples. Members of the SADC HIV and AIDS Unit participated in the training to ensure that it met both local and regional HIV prevention needs. Based on the feedback from the pilot, the training materials are being updated and a training of trainers workshop will be held prior to the rollout to other SADC member states. BLC will also establish an online community of practice with trainers and host regular facilitated discussion groups to share lessons learned and solutions to implementation challenges as well as profile HIV prevention good practices. To ensure that the approach is contextually relevant and meets the needs of SADC member states, BLC with the SADC HIV and AIDS Unit are facilitating a joint planning workshop with selected SADC member states to present the approach and methodology for review and to work closely with the HIV prevention, research and monitoring and evaluation teams from member states to plan the country workshops. In addition a joint BLC, SADC team will meet with executives from the National AIDS Authorities and Health Ministries to obtain buy-in and commitment for the process. BLC will also work with SADC member states to build their capacity to critically analyze available country-specific data using the KYE, KYR approach and socio-ecological lens and present their country data during the in-country HIV prevention workshops. Page 3 of 6

4 Outline of HIV Prevention: New Evidence, New Thinking Program BLOCK 1: KNOW YOUR EPIDEMIC, KNOW YOUR RESPONSE INTRODUCTION Welcome, introductions, workshop objectives, expectations Most significant change exercise An introduction to the training approach and the conceptual framework The program begins with a focus on how change happens. And how change often happens in ways that programmatic thinking often doesn t plan for.. The opening exercise introduces this concept and how the training program aims to guide participants in taking a fresh look at how to create the conditions of change. A conceptual framework is introduced that informs the program, of how knowing the epidemic should guide the response to it and how program managers can adopt outcomes thinking to their programs. MODULE 1: THE BIG PICTURE: EPIDEMIC UPDATE [TAILORED PER COUNTRY] Global and regional prevalence and incidence Types of epidemics Highest incidence, highest prevalence and hotspots Trends Modes of transmission Cost-benefit: scale up of treatment vs new infections The UNAIDS strategic investment framework model Country-specific information: HIV by province; urban and rural; number with HIV; incidence; trends; challenges Analysis of changing epidemic dynamics Key populations Key prevention priorities The first module begins by presenting the need to know your epidemic in order to know how to respond. There is a strong country-specific focus in this module, in addition to presentation of trends in the global epidemic. HIV is a local, specific, and complicated phenomenon. Particular emphasis is on the various modes of transmission and how they contribute to the spread of HIV. Effective program planning requires a firm grasp of the specific drivers of the epidemic in each country and other prevention priorities. What is known about transmission in key populations is also covered, as is the UNAIDS strategic investment framework model. MODULE 2: HOW HIV WORKS: THE DYNAMICS OF TRANSMISSION How the virus works Risk of transmission per MOT Viral load Barriers The body and resistance Genetics ARVs and adherence Condoms and circumcision The second module (day two) focuses on the science of HIV, how important it is to understand and communicate how the virus functions, what methods serve as barriers to transmission, and the various risks of transmission per different modes. The module explores issues such as infectivity and the conditions that increase it and the need to understand that HIV is not something that just happens, but the virology of it. All of these factors impact prevention planning and communication. Page 4 of 6

5 MODULE 3: REVIEWING PREVENTION OPTIONS: KNOW YOUR RESPONSE What do we mean by efficacy and effectiveness? Adherence to HIV prevention technologies Effectiveness of prevention interventions Prevention in the context of different sexual relationships Unidentified opportunities and assets The involvement of CSOs in the response to HIV Block One ends with a module that guides participants to consider the efficacy of different prevention technologies. There is a focus on understanding the difference between efficacy and effectiveness (how well an intervention works) and successful behavioural interventions. Specific interventions are considered, including HCT, condoms, PMTCT, family planning, sexually-transmitted infections (STIs), Post Exposure Prophylaxis, Medical Male Circumcision (MMC), microbicides, abstinence, and Positive Health, Dignity, and Prevention (PHDP). Prevention in the context of concurrent, long-term, and agedisparate relationships is discussed. The basic effect of risk compensation (how personal perceived risk affects behavior) and how this may reduce the effectiveness of condom and MMC interventions is considered. EXERCISE: KYR MATRIX The afternoon of day two ends with an exercise that will inform the rest of the workshop proceedings. In small groups, participants will collectively take responsibility for mapping how well their country s policies and guidelines are fit for purpose in terms of addressing a variety of key HIV prevention priority areas. They will also rate how effective implementation is in that area, how much intelligence is available, whether available assets and linkages have been identified and mobilised, and how well current communication strategies address that particular mode of transmission or driver. This exercise will generate a visual, colour-coded map that clearly indicates where the major gaps are within their national response, to be referred to in the presentations that follow. BLOCK TWO: PLAN YOUR RESPONSE MODULE 4: A SOCIAL ECOLOGY MODEL APPROACH TO PREVENTION PLANNING Understanding the social ecology model and applying it to combination prevention Harmonizing elements around key purposes and outcomes Case example: what are obstacles and enablers to PMTCT? Individual, social network, community and societal barriers and recommendations The next block focuses on prevention strategies and management and how to plan responses that are guided by a social ecology and combination prevention approach. Module 4 presents the guiding principle of this workshop program: social ecology. Participants learn how to apply the model to prevention interventions by using PMTCT as a case study, considering what barriers and enablers to PMTCT exist at individual, social network, community, and societal levels. Participants will develop an understanding of how to see prevention from the different social levels. MODULE 5: COMBINATION PREVENTION What is combination prevention? A comprehensive approach: medical, behavioural, and systemic interventions Why combination prevention? Strategic planning of interventions Program interactions Page 5 of 6

6 Some examples Day 3 continues with a module that introduces the key concept of combination prevention. Participants consider where there are possible opportunities to intervene and make use of different approaches to health promotion. The appropriateness of employing simultaneous and context-specific strategies that are informed by evidence is emphasised in this module. MODULE 6: COMMUNICATION FOR PREVENTION Communicating within a social ecology approach Key communication questions What works? What does not work? Diffusion of innovations Resources for change Social ecology model of communication Harmonizing different elements around key goals The next module (on day four) goes further with the social ecology approach, by applying it to health communication. A number of examples of how to do this are presented, alongside complementary communication objectives. Participants consider how ideas and innovations spread and how that relates to health communication. The targeting of communication messages to individuals, social networks, and the broader society is discussed. MODULE 7: MANAGING FOR OUTCOMES Results-based management (RBM) Find and judge evidence Design your response Plan using a logic model From outputs to outcomes Create conditions for change Managing for change Types of impact Evaluating change achievement of outcomes Strengthening RBM an example Module 7 presents fundamental results-based management concepts, emphasising how to identify an HIV prevention program s logic and theory of change. The module explores how to plan an intervention that is ultimately effective and what steps are needed. The theory of change, how change is created, and how to manage program outputs into outcomes are explored. Planning to create conditions that enable change and evaluate impact are also discussed. WAY FORWARD Summary presentation of key concepts Reviewing the main ideas that have been covered over the previous four days Revisit original most significant change stories Country-led planning of the way forward The last day will begin by reviewing the main concepts that were presented during the workshop. Participants will revisit the original most significant change stories in order to interpret them through the lens of what has been covered in the workshop, emphasizing how change occurred in the practical examples and how this new approach to evidence-based program planning can create space for meaningful change to occur. Reviewing the KYR matrix, national HIV prevention working group members can guide the group in planning for how the priority areas that were identified in the mapping exercise will be addressed in the long-term. Page 6 of 6