SOCIAL MARKETING RESEARCH SERIES. The PSI Dashboard

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1 SOCIAL MARKETING RESEARCH SERIES Uzbekistan (2008): HIV/AIDS TRaC Study among Most at Risk Adolescents (MARA) in Priority Sites Second Round The PSI Dashboard Tashkent, Uzbekistan February 2008 PSI s Core Values Bottom Line Health Impact * Private Sector Speed and Efficiency * Decentralization, Innovation, and Entrepreneurship * Longterm Commitment to the People We Serve

2 Research & Metrics Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C Uzbekistan (2008): HIV/AIDS TRaC Study among Most at Risk Adolescents (MARA) in Priority Sites Second Round PSI Research & Metrics 2008 Population Services International, 2008 Contact Information: Elizaveta Joldasova, M&E Coordinator 33a M. Yakubova St. Tashkent, Uzbekistan Phone: 7 (99871) Fax: 7 (99871) Elizaveta@psi.uz Tracey Tuyen, Regional Program Manager 33a M. Yakubova St. Tashkent, Uzbekistan Phone: 7 (99871) Fax: 7 (99871) ttuyen@psi.uz

3 Table of Contents Summary... 1 Acknowledgements... 1 Background & Research Objectives... 1 Description of Intervention... 1 Methodology... 2 Main Findings... 2 Programatic Recommendations... 3 Monitoring Table I... 4 Monitoring Analysis I... 6 Monitoring Table II... 9 Monitoring Analysis II Monitoring Table III Monitoring Analysis III Programmatic Recommendations Appendix 1: Monitoring Tables with LQAS Numbers Appendix 2: Methodology Appendix 3: Performance Framework for Social Marketing Appendix 4: References

4 Summary Acknowledgements This study was supported by the United Nations Children's Fund (UNICEF) in Uzbekistan. This report represents the work of many individuals. We thank Varja Lipovsek (PSI Senior Researcher) for guidance on the study design and questionnaire. Data collection was conducted by ExpertFikri Research Group Ltd. based in Tashkent, Uzbekistan. The PSI outreach team, Avaz Yusupov, Djalilov Uktam and Abidova Zieda provided valuable fieldwork assistance for both survey rounds. The report was written by Elizaveta Joldasova with help from Leah Hoffman (PSI CAR Regional Program Manager) and Kim Longfield (PSI Senior Researcher). Final thanks go to Komiljon Akhmedov, Jadranka Mimica, and Andro Shilakadze at UNICEF for their support and advocacy for young people who are most at risk for HIV/AIDS in Uzbekistan. Background & Research Objectives PSI conducted surveys in December 2007 and February 2008 among Most AtRisk Adolescents (MARA), such as YSWs (young sex workers) and Y IDUs (young injecting drug users) aged 1018 and Most AtRisk Youth (MARY), such as Y MSM (young males having sex with other males) up to age 24 in six sites of Fergana Valley and the Chilanzar district of Tashkent, Uzbekistan. The objectives of the studies described in this report were to: 1. Obtain data to inform interventions with MARA in Uzbekistan with regard to meeting preset targets and sustainability. 2. Obtain data to monitor key indicators, including behavior change, factors associated with behavior change, and exposure to PSI activities as part of its partnership with UNICEF. Description of Intervention In Uzbekistan, UNICEF worked in partnership with the Ministry of Health (MOH) to improve quality of governmental health services to better meet the needs of high risk young people, including confidentiality, anonymity, and friendliness. PSI/Uzbekistan implemented a UNICEFfunded program targeting MARA aged 1018 years in six sites in the Chilanzar District of Tashkent City. PSI also conducted quarterly trainings and ongoing technical assistance for parallel implementation of IPC (interpersonal communications) by a separatelyfunded partner in Fergana Valley. The outreach work of PSI and its partner in Fergana Valley served two purposes: 1) to deliver targeted behavior change communications and 2) to refer MARA and MARY to YFHS (Youth Friendly Health Services) for core interventions such as STI diagnosis and treatment, and voluntary confidential counseling and HIV testing. It should be noted that outreach work in Tashkent was implemented by trained PSI outreach workers 1

5 recruited among young people, and is still being implemented in Fergana Valley by trained district medical workers. Methodology PSI used its TRaCM strategy (Tracking Results ContinuouslyMonitoring only) with Lot Quality Assurance Sampling (LQAS) for this study. A total of 114 MARA aged 1018 and MARY aged 1924 were recruited from the six target geographic areas of the UNICEF project for each survey round. The December 2007 study was conducted one year after program implementation while the February 2008 study was conducted one month after PSI s implementation had ended in Tashkent city but continued in Fergana Valley. Both studies are compared against preset targets. The followup survey measured changes in indicators over time as well as exposure targets. Main Findings These studies demonstrate that the UNICEFMOHPSI partnership attained high coverage of MARA groups. The 2008 study results show a positive trend in respondents exposure to the YFHS brand, but revealed only moderate proportions of MARA subgroups who report being referred to these services (55% vs. 45% in Tashkent, and 65% in Fergana Valley for both rounds). YSWs used condoms less frequently with their nonpaying partners than with commercial partners, especially in Fergana Valley. Overall, reported consistent condom use and condom use at last sex with non paying partner among YSWs decreased in both survey regions. YMSM s consistent condom use with their male partners increased in both regions and achieved the target level (50% vs. 65% in Tashkent, and 60% vs. 80% in Fergana Valley). YIDUs were found to be less likely to report condom use at last sex with their nonregular partners in Tashkent than in Fergana Valley. Moreover, the second survey results revealed a decrease in YIDUs consistent condom use and condom use at last sex with their regular and nonregular of partners in Tashkent. In Fergana Valley the situation regarding condom use among YIDUs is less worrisome, but still leaves the room for improvement. The survey results demonstrated a slight increase of sharing needle/syringes among YIDUs in Tashkent and Fergana Valley (30% vs. 35% in both regions). In February, the situation regarding 2

6 YIDUs sharing injecting equipment considerably deteriorated in Tashkent. Overall, respondents were more likely to share injecting equipment than to share needles/syringes in both regions. In general, respondents of all target groups in both survey regions showed high interest in being tested for HIV. It should be noted that in Fergana Valley the percentage of YIDUs and YMSM who state that they know their personal HIV status is much higher than the percentage of respondents from these target groups who reported having been tested for HIV. Programmatic Recommendations These studies confirm that it is possible to achieve coverage of MARA with an intensive outreach strategy. However, additional human and financial resources are needed to reach programmatic targets and sustain high coverage over time. Future programs should use an outreach strategy adapted to each group's needs, while emphasizing the priority behaviors to change. The outreach was generally successful and the study results indicated a positive trend in improving perceived availability for condoms. However MARA s selfefficacy regarding condom use and attitudes about condoms demonstrate room for improvement. Program intervention should be continued for YIDUs in Tashkent, where condom use decreased after project completion. In contrast for Fergana Valley where activities continued, reported condom use increased. Program activities should prioritize decreasing the sharing of needles/syringes and other injecting equipment, given increasing rates of these risk behaviors. For YSWs, messages about condom use with nonpaying partners and consistent condom use with clients should be prioritized given that both behaviors decreased over time and fall short of project targets. For YMSM, condom use at last sex with male partners decreased over time, but consistent use increased, likely due to the latter s low baseline levels. Condom use with female partners remains exceptionally low and should also be a priority for programs targeting YMSM. Exposure to the YFHS brand increased most for YMSM, especially through wordofmouth. Work remains to be done to promote YFHS to YIDUs and YSWs, given low coverage for both groups against program targets. One explanation for the discrepancy in wordofmouth promotion could be the different expectations of services among groups: YMSM were less likely to be linked with similar services like trust points and friendly cabinets than YSWs and YIDUs. 3

7 Monitoring Table I: YIDUs aged 1018 Monitoring Table Trends in behaviors, OAM determinants of behaviors and exposure among MARA in six sites in Fergana Valley and Chilanzar district, Tashkent, Uzbekistan, 2007 Risk: YIDUs aged 1018 Behavior: Condom use, sharing of injecting equipment, utilizing YFHS BEHAVIOR/USE INDICATOR Dec 2007 Tashkent Feb 2008 Used a condom at last sex with a regular partner 1 55% 50% 70% Always uses condoms for sex with regular partners 1 55% 40% 70% Used a condom at last sex with a nonregular partner 2 95% 75% 95% Reached Always uses condoms for sex with nonregular partners 2 75% 65% 90% Dec 2007 Fergana Valley Feb 2008 Reached 45% 75% 60% 45% 55% 70% 65% 60% 75% 85% 70% 80% Shared a cap, cotton, drug solution, filters or any other injecting equipment 40% 55% <30% 40% 40% 30% with another person at last injection Shared a needle/syringe with another 30% 35% <30% person at last injection 30% 35% <30% OPPORTUNITY Availability Knows a place where can buy condoms 95% >95% 95% 90% >95% >95% ABILITY Knowledge Was able to cite 3 correct HIV prevention methods 0 <30% 30% % Methods of HIV prevention to abstain from having sex <30% 45% 40% % Methods of HIV prevention to have <30% one faithful uninfected partner 50% 40% Methods of HIV prevention to use condoms consistently >95% 80% 95% 40% <30% 55% 55% 65% 70% Methods of HIV prevention to sniff or smoke drugs, but never inject 0 35% 30% <30% <30% 35% Methods of HIV prevention not sharing needles and other injecting equipment Had no misconceptions about methods of HIV transmission 95% 80% 80% >95% 60% 95% Know a healthy looking person can be HIV positive 90% >95% 95% >95% 90% 95% 55% 50% 70% >95% >95% 95% 4

8 Monitoring Table I: YIDUs aged 1018 Agrees with the statement: HIV can be transmitted through a blood >95% >95% >95% >95% >95% >95% SelfEfficacy Could put on condom in the dark on self or partner 55% 45% 70% MOTIVATION Attitudes Disagrees with the statement: I do not like condoms 75% 80% 90% Intention Intends to use a condom the next time he/she has sex 85% 75% 95% Intends to use a new needle and syringe the next time he/she injects 90% 90% 95% 80% 35% 30% 50% 35% 95% 80% 85% 95% >95% >95% >95% Would like to be tested for HIV 95% 85% 95% >95% >95% >95% Threat Has been tested for HIV 55% 50% 70% 70% 70% 85% Knows personal HIV status 40% 45% 55% 85% 90% 95% EXPOSURE Recognized YFHS logo 50% 40% 65% 40% <30% 55% Has ever seen the title Yoshlarga Do stona Xizmat 45% 40% 60% 50% 65% 65% Was referred to YFHS 50% 45% 65% 65% 65% 80% Has visited YFHS 35% 50% 50% 65% 70% 80% Has recommended friends to use YFHS 60% 40% 75% 60% 80% 75% The correct methods of HIV prevention are defined as: 1. to abstain from having sex; 2. to have one faithful uninfected partner; 3. to use condoms consistently. No misconceptions is defined as responding False to the following statements: 1. HIV can be transmitted from one person to another through a kiss; 2. You can get HIV by sharing the food or same dishes with someone who is infected Indicates a logframe indicator The name of Youth friendly services in Uzbek 1 Among those who reported a regular partner (Tashkent: December, n=16, February, n=15; Fergana: December, n=15, February, n=17) 2 Among those who reported a nonregular partner (Tashkent: December, n=16, February, n=15; Fergana: December, n=13, February, n=15) 5

9 Monitoring Analysis I Monitoring Analysis: Trends in behavior; opportunity, ability, and motivational determinants of behavior; and exposure among YIDU adolescents in Uzbekistan, December 2007February This report presents three monitoring tables, one for each of the target groups. All tables were prepared in accordance with PSI s behavior change framework, and present baseline (December 2007) and follow up (February 2008) data for key behaviors such as needle/syringe sharing and condom use as well as factors thought to be related to target groups opportunity, ability, and motivation to adopt targeted behaviors. Tables present proportions for responses that correspond to the LQAS decision rule table. Tables containing the tallies of responses are located in Appendix 1. More detailed information about the analytical technique is described in the methodology section. In Tashkent, the level of YIDUs condom use at last sex with a regular partner decreased from 55% to 50%. In Fergana Valley, the percentage of YIDUs who reported condom use at last sex with their regular partner was much higher than in the first round (45% vs. 75%) and reached the target level. Reported condom use at last sex with a nonregular partner decreased over time in Tashkent (95% vs. 75%). In Fergana Valley, there was a slight increase in this same behavior across the two survey rounds (70% vs. 75%). Rates of consistent condom use with regular and nonregular partners decreased over time in Tashkent (55% vs. 40%, and 75% vs. 65%, respectively). In Fergana Valley, there was an increase in consistent condom use with both types of partners over time (45% vs. 55% for regular partners and 65% vs. 70% for nonregular partners). In both regions, YIDUs were more likely to share needles/syringes at last injection at followup than at baseline (30% vs. 35% for both regions). In Tashkent, there was also an increase in the sharing of other injecting equipment like caps, cotton, and drug solution at last injection (40% vs. 55%). The equipment sharing rate remained constant in Fergana Valley (40% for both survey rounds). 6

10 Monitoring Analysis I Overall, the vast majority of YIDUs in Tashkent as well as in Fergana Valley stated that they know a place where they can buy condoms. There was no difference between the results of both survey rounds in Tashkent ( 95% for both). In the case of Fergana Valley, perceived availability for condoms increased slightly over time (90% vs. 95%). There was a decrease in the proportion of YIDUs who harbored no misconceptions about methods of HIV transmission in both regions ( 95% vs. 60% in Tashkent, and 55% vs. 50% in Fergana Valley). Overall, the second round results show that respondents were able to cite only one or two correct methods for preventing sexual transmission of HIV. Among all of the knowledge indicators, knowledge about abstinence was lowest in both survey regions. There was improvement in this indicator in Tashkent (<30% vs. 45%) but it remained consistently low in Fergana Valley (<30% for both survey rounds). Knowledge about fidelity increased in Tashkent ( 30% vs. 55%), but decreased in Fergana Valley (40% vs. 30%). On the contrary, the percentage of YIDUs who knew that consistent condom use is a method of HIV prevention decreased in Tashkent ( 95% vs. 80%), but increased slightly in Fergana Valley (55% vs. 65%). The most known method of HIV prevention among YIDUs in both survey regions was avoiding the sharing of needles/syringes and other injecting equipment. While the indicator was high in both regions, there was a slight decrease over time (>95% vs. 80% in Tashkent; >95% vs. 80% in Fergana Valley). In Tashkent, there was an increase in the proportion of YIDU who recognized drug administration through sniffing or smoking rather than injecting as a viable prevention method (<30% vs. 35%); however, knowledge remained consistently low in Fergana Valley (<30% for each survey round). Nearly all YIDUs agreed with the statement that HIV can be transmitted through a blood ( 95% for both survey rounds in each region). Nearly all YIDUs also knew that it is not possible to recognize a person s HIV status by his/her appearance (90% vs. 95% in Tashkent; 95% in Fergana Valley for both study rounds). YIDUs self efficacy for putting a condom on themselves in the dark decreased slightly in Tashkent (80% vs. 75%), but increased and reach the target level in Fergana Valley (70% vs. 90%). At the same time respondents selfefficacy regarding their ability to put a condom on a 7

11 Monitoring Analysis I partner in the dark decreased from 55% to 45% in Tashkent and from 35% to 30% in Fergana Valley. Positive attitudes about condoms improved over time in Tashkent where more YIDUs disagreed with the statement I do not like condoms at followup than at baseline (80% vs. 75%). In Fergana Valley, positive attitudes about condoms decreased over time. Fewer respondents disagreed with the same statement at followup than at baseline (80% vs. 35%). Intentions to adopt safer behavior were better in Fergana Valley than in Tashkent. There was an increase in the proportion of Fergana YIDUs who said that they intend to use a condom the next time they have sex (80% vs.85%). In Tashkent, this same intention decreased over time (85% vs. 75%). Intention to use a new needle and syringe remained consistent across study rounds in both locations, but was higher in Fergana Valley (95% for both survey rounds) than in Tashkent (90% for both survey rounds). Intention to get tested for HIV decreased over time in Tashkent (95% vs. 85%), but remained consistent and nearly universal in Fergana Valley (>95% for both survey rounds). Fewer YIDUs recognized the YFHS logo at followup than at baseline (40% vs. 50%). Exposure levels were lower in Fergana Valley and also decreased (from 40% to <30%). Exposure to the title Yoshlarga Do stona Xizmat decreased over time in Tashkent (45% vs. 40%), but increased and reached the target level in Fergana Valley (50% vs. 65%). The percentage of YIDUs that said they were referred to YFHS by an outreach worker decreased slightly in Tashkent over time (from 50% to 45%), but remained consistent and slightly higher in Fergana Valley (65% for both survey rounds). In both locations, the proportion of respondents who reported visiting YFHS increased over time (35% vs. 50% in Tashkent; 65% vs. 70% in Fergana Valley). Wordofmouth proved a stronger exposure strategy in Fergana Valley than in Tashkent. The proportion of YIDUs who said that they had recommended that a friend use YFHS increased over time in Fergana Valley (60% vs. 80%), but decreased in Tashkent (60% vs. 40%). 8

12 Monitoring Table II: YSWs aged 1018 Monitoring Table Trends in behaviors, OAM determinants of behaviors and exposure among MARA in six sites in Fergana Valley and Chilanzar district in Tashkent City, Uzbekistan, 2007 Risk: YSWs aged 1018 Behavior: Condom use, Utilizing YFHS INDICATORS Tashkent Fergana Valley Dec 2007 Feb 2008 Dec 2007 Feb 2008 reached BEHAVIOR/USE Used a condom at last sex with a paying client (commercial sex >95% >95% 95% 90% 90% 95% partner) Always uses condoms at sex with a paying client (commercial sex >95% >95% 95% 95% 85% 95% partner) Used a condom at last sex with a nonpaying client (regular or casual 95% 50% 95% 65% 50% 95% sex partner) 1 Always uses condoms at sex with a nonpaying client (regular or casual 95% 35% 95% 65% 50% 80% sex partner) 1 OPPORTUNITY Availability Knows a place where to buy condoms >95% >95% 95% 90% >95% 95% ABILITY Knowledge Was able to cite 3 correct HIV % prevention methods 0 <30% 30% The ways of HIV prevention to <30% 0 30% abstain from having sex 0 <30% 30% The ways of HIV prevention to have one faithful uninfected <30% <30% 30% 30% 40% 45% partner The ways of HIV prevention to use 90% >95% 95% >95% >95% 95% condoms consistently Had no misconceptions about ways of HIV transmission >95% 90% 95% 50% 65% 65% Know a healthy looking person >95% 80% 95% can be HIV positive >95% >95% 95% Agrees with the statement: HIV can be transmitted through >95% >95% 95% >95% >95% 95% blood SelfEfficacy Could put on condom in the dark >95% >95% 95% on self or partner >95% 95% 95% MOTIVATION Attitudes Disagrees with the statement: I do 45% 45% 60% not like condoms 50% 55% 65% Intention reached 9

13 Monitoring Table II: YSWs aged 1018 Intend to use condom next time >95% >95% 95% having sex >95% >95% 95% Would like to be tested for HIV 90% 85% 95% >95% >95% 95% Threat Have been tested for HIV 65% >95% 80% >95% 90% 95% Knows personal HIV status 90% >95% 95% >95% 90% 95% EXPOSURE Recognized logotype of YFHS 55% 80% 70% 55% 70% 70% Has ever seen the title 80% 90% 95% Yoshlarga Do stona Xizmat 70% 75% 85% Was referred to YFHS >95% >95% 95% 90% 60% 95% Has visited YFHS 90% >95% 95% 95% 75% 95% Has recommend friends to address 90% 85% 95% to YFHS 85% 80% 95% The correct ways of HIV prevention are defined as: 1. to abstain from having sex; 2. to have one faithful uninfected partner; 3. to use condoms consistently. No misconceptions is defined as responding False to the following statements: 1. HIV can be transmitted from one person to another through a kiss; 2. You can get HIV by sharing the food or same dishes with someone who is infected Indicates the logframe indicator The name of Youth friendly services in Uzbek 1 Among those who reported a nonpaying partner (Tashkent: December, n=19, February, n=19; Fergana: December, n=16, February, n=15) 10

14 Monitoring Analysis II Monitoring Analysis: Trends in behavior; opportunity, ability, and motivational determinants of behavior; and exposure among adolescents involved in commercial sex in Uzbekistan, December 2007 February Overall YSWs were less likely to use condoms with their nonpaying partners than their clients. In Tashkent, there was a decrease in condom use at last sex with a nonpaying partner over time (95% vs. 50%) and consistent condom use with nonpaying partners (95% vs. 35%). Decreases were also detected in Fergana Valley where reported condom use at last sex with a nonpaying partner was 65% at baseline, but only 50% at followup. The same trend was apparent for consistent condom use with nonpaying partners (65% vs. 50%). Condom use at last sex with clients was consistent and high in both survey regions over time (>95% in Tashkent for both survey rounds; 90% in Fergana Valley for both survey rounds). While consistent condom use with clients remained nearly universal in Tashkent over time (>95% for both survey rounds), a decline was apparent in Fergana Valley (95% vs. 85%). By February 2008, perceived availability for condoms was nearly universal in both regions. In Tashkent rates remained high and consistent over time (>95% for both survey rounds). In Fergana Valley perceived availability increased slightly over time (90% vs. 95%). Knowledge about preventing the sexual transmission of HIV was low for all items except condom use. In both regions, less than 30% of YSWs could cite three correct HIV prevention methods. The same holds true for abstinence: less than 30% of respondents cited it as a prevention method in both Tashkent and Fergana Valley. Findings for fidelity were similar in Tashkent (<30% for both survey rounds), but improved slightly over time in Fergana Valley (30% vs. 40%). Knowledge about consistent condom use improved over time in Tashkent and became nearly universal (90% vs. 95%). In Fergana Valley knowledge about consistent condom use was nearly universal and consistent across the study rounds (>95% for both rounds). YSWs in Tashkent were less likely than their counterparts in Fergana Valley to harbor misconceptions about HIV; however, there was a slight decrease in this indicator over time in Tashkent (95% vs. 90%), but some improvement in Fergana Valley (50% vs. 65%). The majority of respondents knew about the asymptomatic nature of HIV. However, there was a decrease in this indicator over time in Tashkent (>95% vs. 80%); the indicator remained nearly universal and 11

15 Monitoring Analysis II consistent over time in Fergana Valley (>95% for both survey rounds). Nearly all respondents agreed with the statement HIV can be transmitted through blood. This indicator remained consistent over time in both survey regions (>95% for both study rounds in both locations). Self efficacy for putting a condom on in the dark was universally high and consistent over time in both Tashkent and Fergana Valley (>95% for both surveys in both locations). Approximately half of YSWs in both target regions still harbor negative attitudes about condoms. The percentage of respondents who disagreed with the statement I do not like condoms did not change over time in Tashkent (45% for both rounds), but increased slightly in Fergana Valley (50% vs. 55%). The intention to use condoms at next sex was nearly universal and consistent in both Tashkent and Fergana Valley (>95% for both survey rounds in both regions). YSWs intention to get tested for HIV was high, but decreased slightly in Tashkent over time (90% vs. 85%). Testing intention was nearly universal and consistent over time in Fergana Valley (>95% for both survey rounds). HIV testing rates increased considerably in Tashkent reaching the target level (from 65% to >95%) and decreased slightly Fergana Valley (from >95% to 90%). Nearly all respondents stated that they know their personal HIV status, with a slight increase in Tashkent (90% vs. 95%) and slight decrease in Fergana Valley (95% vs. 90%) over time. Recognition of the YFHS logo improved over time in both locations (55% vs. 80% in Tashkent; 55% vs. 70% in Fergana Valley). Exposure to the Yoshlarga Do stona Xizmat title also improved over time (80% vs. 90% in Tashkent; 70% vs. 75% in Fergana Valley). The vast majority of respondents in Tashkent reported being referred to YFHS by an outreach worker: this indicator remained consistent over time (>95% for both surveys). However, in Fergana Valley fewer YSWs reported being referred to YFHS over time (90% vs. 60%). There was a slight increase in the proportion of YSWs in Tashkent who visited YFHS, making it nearly universal by February 2008 (90% vs. 95%). There was a decrease in the proportion of Fergana Valley YSWs who reported visiting YFHS (95% vs. 75%). 12

16 Monitoring Table III Monitoring Table Trends in behaviors, OAM determinants of behaviors and exposure among MARA in Fergana Valley and Chilanzar district, Tashkent, Uzbekistan, 2007 Risk: YMSM aged 1024 Behavior: Condom use, sharing of injecting equipment, utilizing YFHS INDICATORS Tashkent Fergana Valley Dec 2007 Feb 2008 BEHAVIOR/USE Used a condom at last sex with a male partner 75% 65% 90% Always uses condoms for sex with a male partner 50% 65% 65% Used a condom at last sex with a female partner 1 45% <30% 60% Always uses condoms for sex with a female partner 1 <30% <30% 35% OPPORTUNITY Availability Knows a place where to buy condoms >95% >95% 95% reached Dec 2007 Feb 2008 reached 70% 75% 85% 60% 80% 75% 55% 50% 70% 50% 50% 65% >95% >95% 95% 14

17 Monitoring Table III ABILITY Knowledge Was able to cite 3 correct HIV 35% <30% 50% prevention methods % The ways of HIV prevention to 55% <30% 65% abstain from having sex 30% <30% 45% The ways of HIV prevention to 60% 80% 75% have one faithful uninfected partner 35% 35% 50% The ways of HIV prevention to 95% 85% 95% use condoms consistently 90% 95% 95% Had no misconceptions about ways of HIV transmission >95% >95% 95% 55% 75% 70% Know a healthy looking person can be HIV positive 85% >95% >95% 75% 95% 90% SelfEfficacy Could put on condom in the dark 90% 85% 95% on himself >95% >95% 95% Could put on condom in the dark 80% 80% 95% on his partner 50% 70% 65% MOTIVATION Attitudes Disagrees with the statement: I do 70% 80% not like condoms 85% 55% 80% 70% Intention Intend to use a condom next time 70% 80% 85% having sex 95% 90% 95% Would like to be tested for HIV 85% 80% >95% 85% >95% 95% Threat Has been tested for HIV >95% >95% 95% 80% 80% 95% Knows personal HIV status 60% 85% 75% >95% >95% >95% EXPOSURE Recognized logotype of YFHS 60% 65% 75% 30% 55% 45% Has ever seen the title 60% >95% 75% Yoshlarga Do stona Xizmat 60% 60% 75% Was referred to YFHS 75% >95% 90% 50% 70% 65% Has visited YFHS 45% >95% 60% 70% 70% 85% Has recommend friends to address 65% 95% 80% to YFHS 40% 70% 55% The correct ways of HIV prevention are defined as: 1. to abstain from having sex; 2. to have one faithful uninfected partner; 3. to use condoms consistently. No misconceptions is defined as responding False to the following statements: 1. HIV can be transmitted from one person to another through a kiss; 2. You can get HIV by sharing the food or same dishes with someone who is infected Indicates the logframe indicator The name of Youth Friendly Health Services in Uzbek 1 Among those who reported a female partner (Tashkent: December, n=10, February, n=6; Fergana: December, n=13, February, n=17) 15

18 Monitoring Analysis III Monitoring Analysis: Trends in behavior; opportunity, ability, and motivational determinants of behavior; and exposure among male adolescents having sex with other men in Uzbekistan, December 2007 February There was an increase over time in the percentage of YMSM who reported consistently using condoms with male partners in Tashkent and Fergana Valley (50% vs. 65% for Tashkent; 60% vs. 80% for Fergana Valley). At the same time, reported condom use at last sex with a male partner decreased in Tashkent (75% vs. 65%) and increased slightly in Fergana Valley (70% vs. 75%). Reported condom use at last sex with female partner considerably decreased in Tashkent (45% vs. <35%) and slightly decreased in Fergana Valley (55% vs. 50%). Consistent condom use remained at the same moderate level in Fergana Valley (50%) and remained at uncountable level in Tashkent (<30%). Nearly all YMSM in Tashkent and Fergana Valley stated that they know a placed where they can buy condoms. Results for both survey rounds were consistent over time in both regions ( 95%). Similar to the other two target groups, YMSM had difficulty citing three correct HIV prevention methods. There was a decrease in this indicator in Tashkent (35% vs. <30%) and no improvement in Fergana Valley (<30% for both survey rounds). YMSM s knowledge about preventing the sexual transmission of HIV was, however, generally better than the other two target groups. While knowledge about abstinence decreased over time in both locations (55% vs. <30% in Tashkent; 30% vs. <30% in Fergana Valley), knowledge about fidelity improved in Tashkent (60% vs. 80%) and remained constant (but low) in Fergana Valley (35% for both study rounds). Knowledge about consistent condom use was very high in both locations, but decreased in Tashkent over time (95% vs. 85%) and increased in Fergana Valley (90% vs. 95%). Results regarding misconceptions about methods of HIV transmission among YMSM are encouraging. The percentage of YMSM who did not report common misconceptions remained consistently high across study rounds in Tashkent ( 95% for both rounds) and increased considerably in Fergana Valley (55% vs. 75%). YMSM in Fergana Valley demonstrated more confidence in their ability to put a condom on themselves in the dark than their counterparts in Tashkent (>95% for both rounds in Fergana Valley; 90% vs. 85% in Tashkent). Self efficacy for putting a condom on a partner in the dark 15

19 Monitoring Analysis III was lower in both locations, but showed an increase over time in Fergana Valley (80% for both rounds in Tashkent; 50% vs. 70% in Fergana Valley). Attitudes about condoms improved over time in both survey regions. More YMSM disagreed with the statement I do not like condoms at followup than at baseline (80% vs. 70% in Tashkent; 80% vs. 55% in Fergana Valley). Intention to use condoms during the next sexual encounter improved in Tashkent over time (70% vs. 80%), but decreased slightly in Fergana Valley (95% vs. 90%). The opposite trend was apparent for HIV testing. Fewer Tashkent YMSM said that they would like to be tested for HIV at followup than at baseline (85% vs. 80%) while more YMSM in Fergana Valley said they would do the same (85% vs. >95%). Ironically, nearly all respondents in Tashkent reported that they had been tested for HIV (>95% for both rounds), but fewer knew their HIV status even though this indicator improved over time (60% vs. 85%). In Fergana Valley, the proportion of Y MSM who said that they had been tested remained constant across study rounds at 80%, but a higher proportion of them (95% for both study rounds) said that they knew their HIV status. Recognition of the YFHS logo was lower for YMSM than it was for YSW, but similar to rates for YIDU. Recognition in Tashkent was moderate and showed slight improvement over time (60% vs. 65%) While lower in Fergana Valley, the improvement in logo recognition over time was more pronounced (30% vs. 55%). Recognition rates for the YFHS title Yoshlarga Do stona Xizmat improved substantially over time in Tashkent (60% vs. >95%), but remained moderate and constant in Fergana Valley (60% for both survey rounds). Rates of referral improved over time in Tashkent, with nearly all YMSM reporting that they had been referred to YFHS by an outreach worker in February 2008 (75% vs. >95%). Rates of referral also showed improvement in Fergana Valley (50% vs. 70%). A similar pattern was seen for visits to YFHS in Tashkent, where visits became nearly universal by the followup survey (45% vs. >95%). The proportion of YMSM in Fergana Valley, who reported visiting YFHS, however, remained constant over time (70% for both rounds). More Tashkent YMSM reported referring their friends to YFHS over time (65% vs. 95%). The same was true of Fergana Valley YMSM (40% vs. 70%). 16

20 Programmatic Recommendations Programmatic Recommendations These studies confirm that it is possible to achieve coverage of MARA with an intensive outreach strategy. However, additional human and financial resources are needed to reach programmatic targets and sustain high coverage over time. Pairing TRaCM results with a Management Information System (MIS) that uses anonymous codes for MARA group members is especially helpful for implementing improvements: results can be used to identify geographic areas where coverage and logframe indicators fall short of benchmarks and indicate where outreach workers must focus their efforts. Overall recognition of YFHS promotion (the logo and title) was reasonably high, but fell short of some project targets. For YIDU, logo and title coverage was better in Fergana Valley than in Tashkent, but the reverse was true for YMSM. For YSW coverage was high in both study regions. Logo and title coverage could be improved with better YFHS promotion, such as distribution informational and educational materials with printed logo of YFHS among MARA and MARY. The success of the referral program varied by target group with YMSM in both study regions appearing to benefit the most. For YIDU project targets for outreach referrals were not met in either region; however, the program was successful in meeting its benchmark for YFHS visits in Tashkent. Interestingly, wordofmouth appears to be effective promotional strategy for YIDU. Future programs should focus on promoting YFHS within IDU peer networks, especially since injecting circles tend to be intimate and distrust of outsiders high. For YSWs in Tashkent, project targets were met for both referrals and visits to YFHS, indicating that the outreach worker referral strategy was successful. In Fergana Valley, however, project benchmarks were not achieved. These results confirm the need for combined referral activities, implemented by trained outreach workers recruited among young people, aged 1824 and trained district medical nurses in Fergana Valley. Declines in wordofmouth referrals among YSWs in February 2008 could be explained by the end of outreach worker escort services or could indicate dissatisfaction with YFHS services. Program should continue escort services for MARA and the trainings for medicine personnel on improvement of YFHS quality. 17

21 Programmatic Recommendations The referral and wordofmouth strategy was most successful for YMSM where project targets were achieved and even surpassed for most indicators. One interpretation of these findings is that YSWs and YIDUs had a higher set of expectations for YFHS services than YMSM because they might have already visited similar services, such as trust points or friendly cabinets. Y MSM, on the other hand, were less likely to be linked with these services, may have had lower expectations of YFHS, and were pleasantly surprised when service quality exceeded their initial expectations. It is recommended to organize educational sessions for clinic personnel to enhance their knowledge about the program, and facilitate their exchange of information on how to better improve quality of care for MARA. The high coverage outreach strategy was generally successful in improving perceived availability for condoms across target groups. All groups, however, would benefit from condom demonstrations and practice putting them on in the dark, especially putting them on a partner. Negative attitudes about condoms should also be improved. Strategies for doing so include educational sessions among MARA with emphasis on consistent condom use as the most reliable method of HIV and STI prevention. The outreach strategy was most successful in improving YIDUs condom use in Fergana Valley where the project continued, demonstrating that the intervention should be continued in both regions. Since other projects targeting YIDUs do not generally address condom use, continuation of PSI s program is especially important. Messages for YIDUs should continue to focus on preventing the sexual transmission of HIV, especially those related to fidelity and abstinence since knowledge about these methods remains very low. YIDU in both regions would benefit from additional promotion for HIV testing. Much work remains for reducing needles/syringe and other injecting equipment sharing, especially since sharing rates are roughly four times higher for YIDU than for older IDU. Programs should refine educational messages regarding safe injecting practice and focus on other injecting equipment with additional information regarding needle sharing. For YFSW, additional efforts are needed for promoting condom use with nonpaying partners. While rates of condom use with clients remains high and nearly universal, condom use with non 18

22 Programmatic Recommendations paying partners falls far short of program benchmarks. Testing should continue to be promoted among YFSW to maintain already high levels of use. For YMSM, condom use should continue to be promoted for male partners and promotion efforts should include messages about condom use with female partners. Similar to YIDUs, Y MSM would benefit from additional information about preventing the sexual transmission of HIV. While they appear to have received the consistent condom use message, knowledge about fidelity and abstinence remains low. Both regions would benefit from additional promotion of HIV testing among YMSM. 19

23 Appendix 1: Monitoring Tables with LQAS Numbers Monitoring Table Trends in behaviors, OAM determinants of behaviors and exposure among MARA in six sites in Fergana Valley and Chilanzar district, Tashkent, Uzbekistan, 2007 Risk Group: YIDUs aged 1018 Behavior: Condom use, sharing of injecting equipment, utilizing YFHS INDICATOR Dec 2007 Tashkent Feb 2008 Reached Dec 2007 Fergana Valley Feb 2008 BEHAVIOR/USE Used a condom at last sex with a regular partner Always uses condoms for sex with regular partners Used a condom at last sex with a nonregular partner Always uses condoms for sex with nonregular partners Shared a cap, cotton, drug solution, filters or any other injecting equipment with another person at last injection Shared a needle/syringe with another person at last injection OPPORTUNITY Availability Knows a place where can buy condoms Reached 20

24 Appendix 1: Monitoring Tables with LQAS Numbers ABILITY Knowledge Was able to cite 3 correct HIV prevention methods Methods of HIV prevention to abstain 2 from having sex Methods of HIV prevention to have one faithful uninfected partner 5 8 Methods of HIV prevention to use condoms consistently Methods of HIV prevention to sniff or smoke drugs, but never inject Methods of HIV prevention not sharing needles and other injecting equipment Had no misconceptions about methods of HIV transmission Know a healthy looking person can be HIV positive Agrees with the statement: HIV can be transmitted through a blood SelfEfficacy Could put on condom in the dark on self or partner MOTIVATION Attitudes Disagrees with the statement: I do not like condoms Intention Intends to use a condom the next time he/she has sex Intends to use a new needle and syringe the next time he/she injects Would like to be tested for HIV Threat Has been tested for HIV Knows personal HIV status EXPOSURE Recognized YFHS logo Has ever seen the title Yoshlarga Do stona Xizmat Was referred to YFHS Has visited YFHS Has recommended friends to use YFHS The correct methods of HIV prevention are defined as: 1. to abstain from having sex; 2. to have one faithful uninfected partner; 3. to use condoms consistently. No misconceptions is defined as responding False to the following statements: 1. HIV can be transmitted from one person to another through a kiss; 2. You can get HIV by sharing the food or same dishes with someone who is infected Indicates a logframe indicator The name of Youth friendly services in Uzbek 21

25 Appendix 1: Monitoring Tables with LQAS Numbers 1 Among those who reported a regular partner (Tashkent: December, n=16, February, n=15; Fergana: December, n=15, February, n=17) 2 Among those who reported a nonregular partner (Tashkent: December, n=16, February, n=15; Fergana: December, n=13, February, n=15) 22

26 Appendix 1: Monitoring Tables with LQAS Numbers Monitoring Table Trends in behaviors, OAM determinants of behaviors and exposure among MARA in six sites in Fergana Valley and Chilanzar district in Tashkent City, Uzbekistan, 2007 Risk Group: YSWs aged 1018 Behavior: Condom use, Utilizing YFHS INDICATORS Tashkent Fergana Valley BEHAVIOR/USE Used a condom at last sex with a paying client (commercial sex partner) Always uses condoms at sex with a paying client (commercial sex partner) Dec 2007 Feb reached Dec 2007 Feb 2008 reached Used a condom at last sex with a nonpaying client (regular or casual sex partner) 1 Always uses condoms at sex with a nonpaying client (regular or casual sex partner) 1 OPPORTUNITY Availability Knows a place where to buy condoms

27 Appendix 1: Monitoring Tables with LQAS Numbers ABILITY Knowledge Was able to cite 3 correct HIV prevention methods The ways of HIV prevention to abstain from having sex The ways of HIV prevention to have one faithful uninfected partner The ways of HIV prevention to use condoms consistently Had no misconceptions about ways of HIV transmission Know a healthy looking person can be HIV positive Agrees with the statement: HIV can be transmitted through blood SelfEfficacy Could put on condom in the dark on self or partner MOTIVATION Attitudes Disagrees with the statement: I do not like condoms Intention Intend to use condom next time having sex Would like to be tested for HIV Threat Have been tested for HIV Knows personal HIV status EXPOSURE Recognized logotype of YFHS Has ever seen the title Yoshlarga Do stona Xizmat Was referred to YFHS Has visited YFHS Has recommend friends to address to YFHS The correct ways of HIV prevention are defined as: 1. to abstain from having sex; 2. to have one faithful uninfected partner; 3. to use condoms consistently. No misconceptions is defined as responding False to the following statements: 1. HIV can be transmitted from one person to another through a kiss; 2. You can get HIV by sharing the food or same dishes with someone who is infected Indicates the logframe indicator The name of Youth friendly services in Uzbek 1 Among those who reported a nonpaying partner (Tashkent: December, n=19, February, n=19; Fergana: December, n=16, February, n=15) 24

28 Appendix 1: Monitoring Tables with LQAS Numbers Monitoring Table Trends in behaviors, OAM determinants of behaviors and exposure among MARA in Fergana Valley and Chilanzar district, Tashkent, Uzbekistan, 2007 Risk Group: YMSM aged 1024 Behavior: Condom use, Utilizing YFHS INDICATORS Tashkent Fergana Valley Dec 2007 Feb 2008 BEHAVIOR/USE Used a condom at last sex with a male partner Always uses condoms for sex with a male partner Used a condom at last sex with a female partner Always uses condoms for sex with a female partner OPPORTUNITY Availability Knows a place where to buy condoms reached Dec 2007 Feb 2008 reached

29 Appendix 1: Monitoring Tables with LQAS Numbers ABILITY Knowledge Was able to cite 3 correct HIV prevention methods The ways of HIV prevention to abstain from having sex The ways of HIV prevention to have one faithful uninfected partner The ways of HIV prevention to use condoms consistently Had no misconceptions about ways of HIV transmission Know a healthy looking person can be HIV positive SelfEfficacy Could put on condom in the dark on himself Could put on condom in the dark on his partner MOTIVATION Attitudes Disagrees with the statement: I do not like condoms Intention Intend to use a condom next time having sex Would like to be tested for HIV Threat Has been tested for HIV Knows personal HIV status EXPOSURE Recognized logotype of YFHS Has ever seen the title Yoshlarga Do stona Xizmat Was referred to YFHS Has visited YFHS Has recommend friends to address to YFHS The correct ways of HIV prevention are defined as: 1. to abstain from having sex; 2. to have one faithful uninfected partner; 3. to use condoms consistently. No misconceptions is defined as responding False to the following statements: 1. HIV can be transmitted from one person to another through a kiss; 2. You can get HIV by sharing the food or same dishes with someone who is infected Indicates the logframe indicator The name of Youth Friendly Health Services in Uzbek 1 Among those who reported a female partner (Tashkent: December, n=10, February, n=6; Fergana: December, n=13, February, n=17) 26

30 Appendix 1: Monitoring Tables with LQAS Numbers Appendix 2 Population characteristics Risk Group: YIDUs aged 1018 INDICATOR Tashkent Fergana Valley Risk Group: YSWs aged 1018 Dec 2007 Feb 2008 Dec 2007 Feb 2008 Age, % 53% 5% 5% Age, % 47% 95% 95% Male 90% 95% 85% 95% Female 10% 5% 15% 5% Knows a place where can buy condoms 95% >95% 95% >95% Has been tested for HIV 55% 50% 70% 70% Knows personal HIV status 40% 45% 85% 90% Reported regular partners 84% 78% 78% 89% Reported nonregular partners 84% 78% 68% 78% INDICATOR Tashkent Fergana Valley Dec 2007 Feb 2008 Dec 2007 Feb 2008 Age, % 15% 0 Age, % 95% 85% 100% Male Female 100% 100% 100% 100% Knows a place where can buy condoms >95% >95% 90% >95% Has been tested for HIV 65% >95% >95% 90% Knows personal HIV status 90% >95% >95% 90% Reported paying partners 100% 100% 100% 100% Reported nonpaying partners 100% 100% 84% 78% Risk Group: YMSM aged 1024 INDICATOR Tashkent Fergana Valley December Feb December Feb Age, % 37% 10% 10% Age, % 63% 90% 90% Knows a place where can buy condoms >95% >95% >95% >95% Has been tested for HIV >95% >95% 80% 80% Knows personal HIV status 60% 85% >95% >95% Reported female partners 52% 32% 68% 89% Reported male partners 100% 100% 100% 100% Sampling by age group and the spread of proportions between two rounds are skewed toward the elder age group due to the sampling methodology not having included requirements to comply with age group distribution given insufficient sample size for assignment of quotas by respondents age and gender. 27

31 Appendix 2: Methodology Methodology Study Design Due to budget constraints, the TRaCM strategy was chosen over a larger TRaC survey with a probability sample among same groups of youth. Although TRaCM studies are best for monitoring exposure, they can also be used to benchmark logframe indicators and prioritize programming efforts by identifying differences in performance between geographic areas. TRaCM studies rely on lot quality assurance sampling (LQAS), which allows results to be quantified for a catchment area, such as highrisk neighborhoods ( hot zones ). A sample of 19 individuals from each target group (YSW, YIDU, and YMSM) was taken from each catchment area to measure variations in behavior, logframe indicators, and levels of exposure. A sample of 19 for each target group is the optimum number of representatives to calculate LQAS monitoring tables and provides an acceptable level of error for making management decisions; at least 92% of the time it correctly identifies supervision areas that have reached their coverage target. It should be noted that LQAS findings can be generalized only to a subsample of the population living in a certain catchment area. Sampling and participants The study population for these surveys was MARA aged 1024 in six sites in Fergana Valley (Baghdad, Kuva, Fergana City/Kirgili, Kuvasai, Margilan, and Kokand) and Chilanzar district of Tashkent city. The target population is defined as adolescents who engage in commercial sex, inject drugs, and/or males who have sex with other males. The target sites were chosen for their high concentrations of YIDUs, YSWs, and YMSM. Among YSWs and YIDUs, the age range of the target population was PSI increased the age range for YMSM to 1824 years in order to achieve the required sample size for this especially difficult to group to reach. Respondents' distribution by regions and gender is presented in Table 1. It should be noted that only in Tashkent was it possible to fulfill the quotas for different categories of respondents stipulated in the contract. The fieldwork team encountered difficulties in selecting the required number of YMSM, living in small towns of the Fergana Valley. Therefore it was decided to shift some of the quota to Fergana City. 26