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Evaluation of PEPFAR-Funded HIV Evaluation of PEPFAR-Funded HIV Prevention Programs in Vietnam:Prevention Programs in Vietnam:

Key resultsKey results

April, 2008April, 2008

Dr. Lora SabinDr. Lora SabinDr. Mary Bachman DeSilvaDr. Mary Bachman DeSilva

Center for International Health and Center for International Health and DevelopmentDevelopment

Department of International HealthDepartment of International Health

Boston University School of Public Boston University School of Public HealthHealth

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PEPFAR Evaluation: study collaboratorsPEPFAR Evaluation: study collaborators

Boston University SPHBoston University SPHLora Sabin, MA, PhDLora Sabin, MA, PhD

Mary Bachman DeSilva, MS, ScDMary Bachman DeSilva, MS, ScDDavidson H. Hamer, MDDavidson H. Hamer, MD

Taryn Vian, M.Sc.Taryn Vian, M.Sc.Danielle Lawrence, MPHDanielle Lawrence, MPH

Kelly McCoy, MPHKelly McCoy, MPHJordan Tuchman, MPHJordan Tuchman, MPH

Ho Chi Minh City Statistical OfficeHo Chi Minh City Statistical OfficeLe Thi Thanh Loan, PhDLe Thi Thanh Loan, PhD

Abt Associates Inc.Abt Associates Inc.Theodore Hammet, PhDTheodore Hammet, PhD

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

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BackgroundBackground

• HIV/AIDS epidemic – Nationwide adult HIV prevalence: 0.5%– Most-at-risk populations: IDU, CSW, MSM

• 2004-National Strategic Plan: focus on VCT, ART, harm reduction, other best practices

• PEPFAR focus country since 2004, supporting many interventions including community outreach

• 2006-BU asked to evaluate outreach interventions

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Overview of Evaluation DesignOverview of Evaluation Design

• Study using quantitative and qualitative Study using quantitative and qualitative methods to assess effectiveness of PEPFAR-methods to assess effectiveness of PEPFAR-funded outreach services provided by funded outreach services provided by community outreach workers (PE and HE) to community outreach workers (PE and HE) to three MARP groups (IDU, CSW, MSM) in six three MARP groups (IDU, CSW, MSM) in six provinces provinces

• Components:Components:– Review of program statisticsReview of program statistics– Cross-sectional survey of PE/HE and MARPCross-sectional survey of PE/HE and MARP– In-depth interviews with outreach workers, MARP In-depth interviews with outreach workers, MARP

informants, other key informantsinformants, other key informants

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1.1. Are outreach Are outreach workers well workers well prepared to deliver prepared to deliver services among services among MARPs?MARPs?

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

3.3. Is BCC effective in Is BCC effective in changing behaviors?changing behaviors?

Primary Research questionsPrimary Research questions

HE and PEs in Hoang Mai, Hanoi

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1.1. Are there differences Are there differences between types of between types of workers (peer workers (peer educators versus educators versus health educators)?health educators)?

2.2. How well do services How well do services harmonize with harmonize with services provided by services provided by other donors and other donors and organizations?organizations?

Secondary Research questionsSecondary Research questions

PE demonstrating needle cleaning

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Quantitative Survey Quantitative Survey SampleSample

• 2,222 MARP, of which2,222 MARP, of which– 1,101 intervention, 1,121 control1,101 intervention, 1,121 control– 1,212 CSW, 605 IDU, 408 MSM1,212 CSW, 605 IDU, 408 MSM– 810 Hà Noi, 802 HCM, 310 Hai Phòng, 810 Hà Noi, 802 HCM, 310 Hai Phòng,

300 An Giang300 An Giang

• 272 outreach workers, of which272 outreach workers, of which– 241 peer educators, 31 health educators241 peer educators, 31 health educators– 86 Hà Noi, 49 HCM, 115 Hai Phòng, 22 86 Hà Noi, 49 HCM, 115 Hai Phòng, 22

An GiangAn Giang

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Qualitative InterviewsQualitative Interviews

• 217 respondents, of which217 respondents, of which– 101 MARP, 76 PE/HEs, 40 Key 101 MARP, 76 PE/HEs, 40 Key

InformantsInformants– 43 Hà Noi, 53 HCM, 42 Hai Phòng, 35 43 Hà Noi, 53 HCM, 42 Hai Phòng, 35

An Giang, 44 Quang NinhAn Giang, 44 Quang Ninh– 100 male, 116 female, 1 other100 male, 116 female, 1 other

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Findings: MARP Findings: MARP DemographicsDemographics

Characteristic Intervention group (N=1,101)

Control group (N=1,121)

Geographic location, N Hà Noi HCM Hai Phòng An Giang

400 397 154 150

410 405 156 150

Age in years, mean (SD) 29.6 (8.0) 28.5 (8.0)*** Gender, % male % female % other

38.3 58.8 2.9

40.3 57.4 2.3

Education, highest level completed % Primary school or no formal education

24.3

28.4

Secondary school (grade 6-9) 43.2 39.3 High school or higher 32.4 32.3 Employed full time, % 52.9 51.3 Main daily activity Construction/farming/petty job Salaried job Sex worker Entertainment employee Student, housework, other Unemployed

20.1 12.6 35.9 9.5 12.9 9.0

20.3 16.2 31.9 8.1 13.4 10.0

Ever been tested for HIV and received a positive test result (n=751 intervention and 466 control individuals ever tested and received their results)

21.8

15.5**

Control group

slightly younger, less likely

to know status and be HIV+.

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MARP Demographics: Risk MARP Demographics: Risk Behaviors, Intervention vs. Behaviors, Intervention vs.

ControlControlCharacteristic Intervention

group Control group

All respondents(n) 1,101 1,121 Ever had sex1 with someone infected with HIV with someone who had hepatitis with a man who has sex with men with someone who injects drugs

13.1% 7.1% 19.8% 24.1%

5.6%*** 3.5%*** 20.4% 14.6%***

Injecting drug users (n) 298 307 Ever admitted to an 06 center (drug rehabilitation center) 40.9% 34.2% Ever had trouble with police due to drug using behavior? 52.7% 44.0%** Used non-injectable drugs for non-medical purposes in last 6 months

23.5%

20.9%

Ever injected drugs: 2 with someone infected with HIV

26.9%

20.5%**

Commercial sex workers (n) 603 609 Ever admitted to an 05 center (re-education center) 16.1% 7.6%*** Ever had trouble with police because of commercial sex work

41.6%

28.1%***

Men who have sex with men (n) 200 208 Ever used injectable drugs for non-medical purposes 8.0% 9.1% Ever gave someone money, drugs, or goods for sex in

last 6 months 14.0% 23.1%**

Ever received money, drugs, or goods for sex 30.5% 40.1%**

Control group lower risk

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PE/HE DemographicsPE/HE DemographicsCharacteristic Peer

educator (n=241)

Health educator (n=31)

Geographic location, N Hà Noi HCM Hai Phòng An Giang

75 41 107 18

11 8 8 4

Age in years, mean (SD) 33.9 (8.8) 31.7 (10.3) Gender, % male % female % other

45.2% 51.9% 2.9%

22.6% 71.0% 6.5%

Education, highest level completed % Primary school or no formal education

4.6%

-

Secondary school (Grade 6-9) 39.8% 6.5% High school 49.4% 25.8% College, university (>12) 6.2% 67.7% Average monthly income [1,000 VND], mean (SD) 1,586

(1024) 2,875 (1941)

Outreach work as main daily activity 46.5% 87.1% Time employed in outreach work Full time 14.5% 90.3% Part time (½ day) 46.1% 9.7% Part time (less than ½ day) 39.4% - Length of time with organization, years (mean, SD) 2.3 (1.8) 2.1 (1.1) Used injectable drugs for non-medical purposes in

last 6 months 5.8%

0.0%

Man who ever had sex with men (n=212) 24.3% 25.0% Ever received money, drugs, or goods for sex in last 6 months (n=213)

6.7% 5.0%

PE more likely to be part-time

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Results: How prepared are Results: How prepared are outreach workers?outreach workers?

• Training and skillsTraining and skills• Knowledge and qualificationsKnowledge and qualifications• Supplies and financial supportSupplies and financial support• SupervisionSupervision

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Preparation: Training & skillsPreparation: Training & skills

• Over 90% of PE and HE received pre-service Over 90% of PE and HE received pre-service training (mean=8 days), 95% received training (mean=8 days), 95% received refresher training (mean= 2 days in last refresher training (mean= 2 days in last mo.)mo.)

• Some differences by program: CARE & Some differences by program: CARE & CDC/LG workers received 4.2 and 6.4 days, CDC/LG workers received 4.2 and 6.4 days, respectively, while FHI & MDM workers respectively, while FHI & MDM workers received 9.0 & 11.5 days, respectively.received 9.0 & 11.5 days, respectively.

• PE/HE felt their training was appropriate, PE/HE felt their training was appropriate, had adequately prepared them for their had adequately prepared them for their workwork

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Preparation: Training & skillsPreparation: Training & skills

• A few gaps: 13% of PE and 26% of A few gaps: 13% of PE and 26% of HE had not received infection HE had not received infection control trainingcontrol training

• More FHI workers said they did More FHI workers said they did not receive training on how to not receive training on how to clean needles & syringes, while clean needles & syringes, while more MdM and CARE workers did more MdM and CARE workers did not receive training in negotiation not receive training in negotiation skills.skills.

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Preparation: Training & SkillsPreparation: Training & Skills

• ““Before I knew about these topics only Before I knew about these topics only through friends, but now [my] knowledge through friends, but now [my] knowledge is more scientific and concrete.”is more scientific and concrete.” PE in HanoiPE in Hanoi

• ““Thanks to knowledge I got from training, Thanks to knowledge I got from training, I can approach the customers more I can approach the customers more easily; I know how to convince them so easily; I know how to convince them so SWs, IDUs, and HIV+ people can benefit SWs, IDUs, and HIV+ people can benefit from services.”from services.” PE in Hai Phong PE in Hai Phong

• ““[My work] is not totally like what is [My work] is not totally like what is presented in books. There are some presented in books. There are some differences in reality. I can apply a part.”differences in reality. I can apply a part.” PE in Hai PhongPE in Hai Phong