The Essential Package

1. The Essential Package Paul Williams United Nations Office on Drugs and Crime Vienna Master Class, Yalta September 2007

2. From the ‘Comprehensive’ to the ‘Essential’ Package: Core service coverage indicators

3. “The position paper is grounded in a number of essential principles crucial to the success of any effective HIV prevention effort.” 1 July 2005

4. 3. Preventing transmission of HIV through injecting drug use • Full range of treatment options (notably ST) • Implementation of harm reduction measures (through among others… - peer outreach - NSP) • VCT – new - PICT • Prevention of sexual transmission (including condoms and STI treatment) • Access to primary health care • Access to ARVs The comprehensive package (vers. 1)

5. Operationalising the package at field level • IEC • Condoms • ST • NSP • VCT • ARVs • STIs • ADAS The comprehensive package (vers. 2)

6. June 2006 • UNODC convened a meeting of ~ 39 international experts in Vienna – charged with reviewing the Comprehensive Package, with respect to resource poor, developing and in-transition countries

7. June 2006 • UNODC convened a meeting of ~ 39 international experts in Vienna – charged with reviewing the Comprehensive Package, with respect to resource poor, developing and in-transition countries • Also charged with identifying which elements of the CP were “ Essential” and which ones were “added value” .

8. Essential Comprehensive • IEC • Condoms • ST • NSP • VCT • ARVs • STIs • ADAS • ST • NSP • VCT • ARVs

9. Essential Measuring the EP Comprehensive • IEC • Condoms • ST • NSP • VCT • ARVs • STIs • ADAS • ST • NSP • VCT • ARVs • ~Condoms~ • ST • NSP • VCT • ARVs

10. Essential Measuring the EP Comprehensive • IEC • Condoms • ST • NSP • VCT • ARVs • STIs • ADAS • ST • NSP • VCT • ARVs • ~Condoms~ • ST • NSP • VCT • ARVs • ~STIs~

11. Essential THE TWO GUIDING PRINCIPLES • ST • NSP • VCT • ARVs 1) While the Comprehensive Package provides optimal results, without at least the Essential Package of measures, efforts will fail

12. Essential THE TWO GUIDING PRINCIPLES • ST • NSP • VCT • ARVs 2) Even if we do implement the Comprehensive Package, we should make sure we at least measure the Essential Package

13. Impact, Coverage, Quality Coverage Quality Impact ~Timing~

14. Impact ONLY TWO INDICATORS MATTER Reduction in incidence

15. Impact ONLY TWO INDICATORS MATTER Reduction in incidence Survival (following diagnosis)

16. Quality • Generally, Measured at the technical level • Standards…(e.g. WHO guidelines)

17. Quality • Generally, Measured at the technical level • Standards…(e.g. WHO guidelines) • Certification (e.g. min. of 3 years training)

18. Quality • Generally, Measured at the technical level • Standards…(e.g. WHO guidelines) • Certification (e.g. min. of 3 years training) • Using proven effective medications etc.

19. Quality Rarely is “client satisfaction”, “gender sensitivity”, “acceptance by neighbourhood”, “level of social disruption/crime associated with facility” etc. measured as “QUALITY” indicators

20. Impact, Coverage, Quality WHAT IF WE COULD USE COVERAGE AS A PROXY FOR MEASURING PROGRESS IN “PROGRAMME ROLLOUT” to prevent transmission by injecting?

21. Impact, Coverage, Quality WHAT IF WE COULD USE COVERAGE AS A PROXY FOR MEASURING PROGRESS IN “PROGRAMME ROLLOUT” to prevent transmission by injecting? And ignore for the time being, quality (which is poorly measured in any event), and impact (which might take years to become evident)

22. Impact, Coverage, Quality WHAT IF WE COULD USE COVERAGE AS A PROXY FOR MEASURING PROGRESS IN “PROGRAMME ROLLOUT” to prevent transmission by injecting? And ignore for the time being, quality (which is poorly measured in any event), and impact (which might take years to become evident) Also puts every country on equal reporting footing – don’t need sophisticated M&E system to track

23. Increase in specificity Evaluation Framework (n=1) (n=3) (n=12) (n=30) (n=60+) (n=150+)

24. So – objective was CORE INDICATORS Challenge: 5 core indicators across each of the three service areas: • ST (methadone, buprenorphine) • NSP • Diagnosis and treatment + three summary indicators = total of 18 core indicators And computations should be available continuously from routine data that are collected at service sites

25. First, look to existing indicators UNGASS Eight candidate indicators

26. 4. Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy

27. 4. Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy • Not specific to IDU – (but could arrange for such a breakdown, though not required)

28. 4. Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy • Not specific to IDU – (but could arrange for such a breakdown, though not required) • Where IDU not driving epidemic, could have high % of non-IDU in receipt, and v.low, or no IDU receiving = (still) high % as a result

29. 4. Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy • Not specific to IDU – (but could arrange for such a breakdown, though not required) • Where IDU not driving epidemic, could have high % of non-IDU in receipt, and v.low, or no IDU receiving = (still) high % as a result • Therefore, can hide discrimination against IDU, or ignore the potential for an IDU “breakout”

30. 7. Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know their results

31. 7. Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know their results • Not specific to IDU (but could arrange for such a breakdown, though not required)

32. 7. Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know their results • Not specific to IDU (but could arrange for such a breakdown, though not required) • Measurement by survey (and we know how difficult IDU are to reach) – not from actual service provision data

33. 7. Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know their results • Not specific to IDU (but could arrange for such a breakdown, though not required) • Measurement by survey (and we know how difficult IDU are to reach) – not from actual service provision data • Computation is “Number tested and know results”/total tested

34. 7. Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know their results • Not specific to IDU (but could arrange for such a breakdown, though not required) • Measurement by survey (and we know how difficult IDU are to reach) – not from actual service provision data • Computation is “Number tested and know results”/total tested • So a country might have done just 10 tests of whom 9 knew their results (=90%), and another 100,000 tests, of whom 90,000 knew their results (also = 90%); but both are ranked equally in performance

35. 8. Percentage of most at risk populations who received an HIV test in the last 12 months and who know their results

36. 8. Percentage of most at risk populations who received an HIV test in the last 12 months and who know their results • Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach)

37. 8. Percentage of most at risk populations who received an HIV test in the last 12 months and who know their results • Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach) • Computation is answers to qns (a) tested? And b) got results?

38. 8. Percentage of most at risk populations who received an HIV test in the last 12 months and who know their results • Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach) • Computation is answers to qns (a) tested? And b) got results? • Same result problems (3/4 returns the same result of 75,000/100,000)

39. 8. Percentage of most at risk populations who received an HIV test in the last 12 months and who know their results • Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach) • Computation is answers to qns (a) tested? And b) got results? • Same result problems (3/4 returns the same result of 75,000/100,000) • PLUS, for both this and #7 – nothing in the indicator “requires” voluntary, confidential counselling

40. 9. Percentage of most at risk populations with HIV prevention programmes

41. 9. Percentage of most at risk populations with HIV prevention programmes • Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach)

42. 9. Percentage of most at risk populations with HIV prevention programmes • Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach) • Computation is individual and sum of answers to qns (a) know where to go for an HIV test? b) last 12 months given condoms [by IDU service]? And c) given sterile needle and syringes [by IDU service]?

43. 9. Percentage of most at risk populations with HIV prevention programmes • Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach) • Computation is individual and sum of answers to qns (a) know where to go for an HIV test? b) last 12 months given condoms [by IDU service]? And c) given sterile needle and syringes [by IDU service]? • 1 x condom; 1 x N&S is treated equally as 100 condoms and say, 300 needles and syringes

44. 14. Percentage of most at risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission

45. 14. Percentage of most at risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission • Proxy for IEC coverage, but not specific to transmission by the injection route – important, but outside the scope of our intention

46. 14. Percentage of most at risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission • Proxy for IEC coverage, but not specific to transmission by the injection route – important, but outside the scope of our intention • PLUS – measures knowledge, not actual behavior change

47. 20. Percentage of injecting drug users reporting the use of a condom the last time they had sexual intercourse

48. 20. Percentage of injecting drug users reporting the use of a condom the last time they had sexual intercourse • Proxy for IEC coverage, but not specific to transmission by the injection route – important, but outside the scope of our intention – nonetheless, we think about this one

49. 20. Percentage of injecting drug users reporting the use of a condom the last time they had sexual intercourse • Proxy for IEC coverage, but not specific to transmission by the injection route – important, but outside the scope of our intention – nonetheless, we think about this one • Measures actual behavior change, so good – another reason to think about it

50. 20. Percentage of injecting drug users reporting the use of a condom the last time they had sexual intercourse • Proxy for IEC coverage, but not specific to transmission by the injection route – important, but outside the scope of our intention – nonetheless, we think about this one • Measures actual behavior change, so good – another reason to think about it • But, only applies to countries where injecting is an established mode – why not all countries?