the essential package paul williams united nations office on drugs and crime vienna master class,...

The Essential Package

Paul WilliamsUnited Nations Office on Drugs and Crime

Vienna

Master Class, YaltaSeptember 2007

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

1 July 2005

“The position paper is grounded in a number of essential principles crucial to the success of any

effective HIV prevention effort.”

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)

Operationalising the package at field level

The comprehensive package (vers. 2)

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

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

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” .

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

•

• • ST

• NSP

• VCT

• ARVs

•

•

Essential

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

•

•

• ST

• NSP

• VCT

• ARVs

•

•

Essential Measuring the EP

•

• ~Condoms~

• ST

• NSP

• VCT

• ARVs

•

•

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

•

•

• ST

• NSP

• VCT

• ARVs

•

•


•

• ~Condoms~

• ST

• NSP

• VCT

• ARVs

• ~STIs~

•

•

• • ST

• NSP

• VCT

• ARVs

•

Essential

THE TWO GUIDING PRINCIPLES

1) While the Comprehensive Package provides optimal results, without at least the Essential Package of measures, efforts will fail

•

• • ST

• NSP

• VCT

• ARVs

•

Essential

THE TWO GUIDING PRINCIPLES

2) Even if we do implement the Comprehensive Package, we should make sure we at least measure the Essential Package

Impact, Coverage, Quality

Impact

Coverage

Quality

~Timing~

Impact

ONLY TWO INDICATORS MATTER

Reduction in incidence

Impact

ONLY TWO INDICATORS MATTER

Reduction in incidence

Survival (following diagnosis)

Quality

Generally, Measured at the technical level

- Standards…(e.g. WHO guidelines)

Quality



- Certification (e.g. min. of 3 years training)

Quality



- Certification (e.g. min. of 3 years training)

- Using proven effective medications etc.

Quality

Rarely is “client satisfaction”, “gender sensitivity”, “acceptance by neighbourhood”, “level of social

disruption/crime associated with facility” etc. measured as “QUALITY” indicators


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)




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

Evaluation Framework

Objective

Principle Outcomes

Key outputs

Activities

Evaluation qns

Performance Indicators

(n=1)

(n=3)

(n=12)

(n=30)

(n=60+)

(n=150+)

Increase in

specificity

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

First, look to existing indicators

UNGASS

Eight candidate indicators

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



• 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”

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

know their results


know their results

• Not specific to IDU (but could arrange for such a breakdown, though not required)


know their results


• Measurement by survey (and we know how difficult IDU are to reach) – not from actual service provision data


know their results


• 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


know their results


• 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

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

results


results

• Measurement by SURVEILLANCE survey (but we know how difficult IDU are to reach)


results


• Computation is answers to qns (a) tested? And b) got results?


results



• Same result problems (3/4 returns the same result of 75,000/100,000)


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

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



• 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]?



• 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

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



• 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

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

intercourse


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


intercourse


• Measures actual behavior change, so good – another reason to think about it


intercourse


• 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?

21. Percentage of injecting drug users reporting the use of sterile injecting equipment the last time they

injected


injected

• Surveillance survey (and we know how difficult IDU are to reach)


injected

• Surveillance survey (and we know how difficult IDU are to reach)

• Proxy for actual coverage by NSP (in addition to knowledge), so why not measure actual coverage

23. Percentage of most at risk populations who are HIV infected

23. Percentage of most at risk populations who are HIV infected

• Very important, not a coverage indicator per se, but will be necessary as a denominator for say, ARV coverage

So, UNGASS summary

• Only two are actual coverage indicators (8 & 9) – but measurement/interpretation problems

So, UNGASS summary

• Only two are actual coverage indicators (8 & 9) – but measurement/interpretation problems

• 1 useful for coverage denominator purposes (23), but it is really an impact indicator (which itself is very good)

What about the Current Ukraine M&E plan

• Uses 7 core indicators from UNGASS, plus 2 “additionals”, including 1 replacement of one UNGASS core

indicator”

Additional # 1

VCT1 -Population requesting an HIV test, receiving a test and receiving test results

Additional # 1


• This is the replacement for UNGASS, not specific to IDU, (but could arrange for such a breakdown, though not required)

Additional # 1


• This is the replacement for UNGASS, not specific to IDU, (but could arrange for such a breakdown, though not required)

• Suffers from the same computational/interpretational problems previously identified

Additional # 2

VUL2 –Percentage of respondents in a survey of injecting drug users who, in response to prompting, identify switching to non-injectable drugs, avoiding sharing injecting equipment, and cleaning injecting

equipment with bleach as methods of preventing HIV transmission

Additional # 2



• (phew – quite a mouthful)

Additional # 2



Survey – community of IDU – good, but how many? representativeness etc.

Additional # 2



Prompting??? hmmm.

Additional # 2



Calculation = all three must be answered correctly, but bleach is a problem

Bleach

• Qn comes from UNAIDS 2000 publication

Bleach

• Qn comes from UNAIDS 2000 publication • WHO and UNODC (soon UNAIDS) no longer recommend bleach

Bleach


• So, someone who is up to date on the withdrawal of recommendation will not identify/report using bleach, just as someone who is not aware, but didn’t use it anyway

Bleach


• So, someone who is up to date on the withdrawal of recommendation will not identify/report using bleach, just as someone who is not aware, but didn’t use it anyway

• So indicator no longer accurate, and a proxy anyway, for actual coverage

Bleach


• So, someone who is up to date on the withdrawal of recommendation will not identify/report using use bleach, just as someone who is not aware, but didn’t use it anyway

• So indicator no longer accurate, and a proxy anyway, for actual coverage

Ukraine SUMMARY

Doesn’t add to what we got from UNGASS

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

Comprehensive

• IEC

• Condoms

• ST

• NSP

• VCT

• ARVs

• STIs

• ADAS

•

•

• ST

• NSP

• VCT

• ARVs

•

•


•

• ~Condoms~

• ST

• NSP

• VCT

• ARVs

• ~STIs~

•

Summary measures

A) Elements (and year of introduction) of the essential package provided to IDU

B) Number and proportion of IDU service sites providing each element of the essential package

C) Number and proportion of IDU covered by each element of the Essential package

Summary measures


First step – provide? y/n

ST NSP VCT ARVs All

x x

Summary measures


Second step – Year of introduction

ST NSP VCT ARVs All

1998 - 2001 2003 -

Summary measures

B) Number and proportion of IDU service sites providing each element of the essential package

Begs the question – what is a “service site”?

And that is where the data dictionary comes in – it provides a guide – distinguishes between “fixed” and “mobile” sites

Summary measures

B) Number and proportion IDU service sites providing each element of the essential package

“proportion” requires knowing how many sites in total (as the denominator)

And this means public, private, ngos etc. So we need to know the sites.

Summary measures


NSP ST VCT ARVs All elements1

Kazakhstan 129 (NAC) 0 (0%) 659 (NAC) 22 (NAC) 0 (0%)

Kyrgyzstan 51 (NAC) 2 (NAC) 14 (NAC) 6 (NAC) 0 (0%)

Tajikistan 26 (NAC) n/a 140 (NAC) 7 (NAC) 0 (0%)

Turkmenistan NEA (NAC) n/a NEA (NAC) NEA (NAC) 0 (0%)

Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

NEA – No estimate available ; NAC – No estimate able to be computed (e.g. denominator missing)

Summary measures



Kazakhstan 129 (NAC) 0 (0%) 659 (NAC) 22 (NAC) 0 (0%)

Kyrgyzstan 51 (NAC) 2 (NAC) 14 (NAC) 6 (NAC) 0 (0%)

Tajikistan 26 (NAC) n/a 140 (NAC) 7 (NAC) 0 (0%)

Turkmenistan NEA (NAC) n/a NEA (NAC) NEA (NAC) 0 (0%)

Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

NEA – No estimate available ; NAC – No estimate able to be computed (e.g. denominator missing)

There are a total of 238 sites.

Summary measures


From the 238 sites, 99% (n=235) provide NSP


Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

Summary measures


From the 238 sites, 98% (n=233) provide VCT


Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

Summary measures


From the 238 sites, 0.4% (n=1) provides ST


Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

Summary measures


From the 238 sites, 0.8% (n=2) sites provide ARVs.


Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

Summary measures


From the 238 sites, no sites provide all elements – nor should they (re. ARVs)


Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

Summary measures



Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

But it does raise the qn – what is the right mix?

The right mix?

Only two sites offering ARVs – not enough


Uzbekistan 235 (99%) 1 (0.4%) 233 (98%) 2 (0.8%) 0 (0%)

Virtually all “Trust Points” offer NSP and VCT – v.good. But are 235 Trust Points enough for 300,000 IDU? Are they in

the right places? Simply by mapping the sites and collecting these data raises more, and appropriate qns!

Only one site offering ST – definitely not enough


• Basic information – yes?

Kazakhstan NEA (NAC) O (0%) 22 248 (NAC) 205 (0.2%) NEA (NAC)

Kyrgyzstan NEA (NAC) 227 (0.9%) NEA (NAC) NEA (NAC) NEA (NAC)

Tajikistan NEA (NAC) 0 (0%) 4 991 (33%) NEA (NAC) NEA (NAC)

Turkmenistan NEA (NAC) 0 (0%) NEA (NAC) NEA (NAC) NEA (NAC)

Uzbekistan NEA (NAC) 152 (0.2%) 10 994 (14%) 482 (0.6%) NEA (NAC)

Azerbaijan 2 724 (0.9%) 90 (<0.1%) 3 568 (1%) 11 (NAC) NEA (NAC)

NSP ST VCT ARVs All elements




Kazakhstan O (0%) 22 248 (NAC) 205 (0.2%)

Kyrgyzstan 227 (0.9%)

Tajikistan 0 (0%) 4 991 (33%)

Turkmenistan 0 (0%) )

Uzbekistan 152 (0.2%) 10 994 (14%) 482 (0.6%)

Azerbaijan 2 724 (0.9%) 90 (<0.1%) 3 568 (1%) 11 (NAC)




Kazakhstan O (0%) 205 (0.2%)

Kyrgyzstan 227 (0.9%)

Tajikistan 0 (0%) 4 991 (33%)

Turkmenistan 0 (0%)

Uzbekistan 152 (0.2%) 10 994 (14%) 482 (0.6%)

Azerbaijan 2 724 (0.9%) 90 (<0.1%) 3 568 (1%)

SKIP AHEAD to other basic indicators

• Result is even worse Number (and

proportion) of IDU who received STI

testing and treatment in the past year.

Number (and proportion) of

functional sites with IEC provision on

[census date]

Number (and proportion) of IDUs

who received IEC materials, at least

once, in the last three months

Kazakhstan NEA (NAC) NEA (NAC) NEA (NAC)

Kyrgyzstan NEA (NAC) NEA (NAC) NEA (NAC)

Tajikistan NEA (NAC) NEA (NAC) NEA (NAC)

Turkmenistan NEA (NAC) NEA (NAC) NEA (NAC)

Uzbekistan NEA (NAC) NEA (NAC) NEA (NAC)

Azerbaijan NEA (NAC) NEA (NAC) NEA (NAC)

A quick cautionary note - KISS

So, even basic information is lacking, not collected, or not regionally/nationally collated/aggregated.


So, even basic information is lacking, not collected, or not regionally, nationally collated/aggregated.

What will it be like for sophisticated, multi-layered indicators requiring multiple sources, various surveys

(e.g.2nd gen)


NSP

1. Number and proportion of IDU in (at least) weekly contact with NSP

2. Average number of needles and syringes provided per weekly client per contact

3. Total number of needles and syringes distributed in past year

4. Average number of condoms provided per (any) client per contact

5. Total number of condoms distributed to IDU in past year

NSP


Begs the qn – how many IDU are there?

Triangulated convergent validity study

Result

Primary research (e.g. surveys)

Desk review – official, surveillance dataKI interviews

NSP


Why at least weekly?

• We wanted to distinguish between “once only” and “occasional” from “regular” – it was regular that we wanted to

measure

NSP


Why at least weekly?

• What does “regular” mean? Why not just impose “weekly” as a proxy (note: WHO uses “monthly”)

NSP


How do we measure “weekly”

Firstly – need to record frequency of IDU contacts

Secondly– need to know uniqueness of contact (are IDU securing N&S from multiple NSPs).

Therefore – need for a unique identifier

NSP

Unique identifier

• First two letters of mother’s first name• First two letters of father’s first name• Gender (single letter M/F or number)

• Year of birth (last two digits).

NSP

Unique identifier

Paul Williams

• First two letters of mother’s first name = JU• First two letters of father’s first name = KE• Gender (single letter M/F or number) = M

• Year of birth (last two digits) = 54

Unique identifier = JUKEM54

NSP

Unique identifier

Not totally duplicate proof

• First two letters of mother’s first name = June vs Judy• First two letters of father’s first name = Ken vs Keely

• Gender (single letter M/F or number) = both M• Year of birth (last two digits) = both born 1954

Therefore “Unique” identifier = JUKEM54 for more than one individual

NSP

Unique identifier

Not useful in all circumstances

IDU who do not know one or more parents

IDU who do not know year of birth

NSP



• Is the optimum number of needles and syringes being distributed?


• Is an “adequate” number being distributed


What does WHO say is an “adequate” number?

NSP



• We can compare the average number with total number


• We can then work out ~regular “take” of total


• We can then work out ~regular “take” of total

• If matches- v.good; if does not, this indicates problems with the service or measurement etc.

NSP




• This was an attempt to compare IDU to non-IDU, however, in retrospect we should have compared

average (to non-IDU) with average (to IDU)




5. Average number of condoms distributed to IDU in past year

Substitution treatment

1. Number and proportion of opioid IDU receiving daily dosing of a) methadone and b) buprenorphine for at least 6 months in the past year

2. Average dose of a) methadone and b) buprenorphine

3. Number and proportion of prison opioid IDU receiving a) methadone and b) buprenorphine on [census date]

4. Average dose of a) methadone and b) buprenorphine provided to prison opioid IDU

5. Number and proportion of opioid IDU enrolled in any form of non- detox drug treatment for at least 30 days in the past year

Diagnosis and treatment

1. Number and proportion of IDU who received VCT in the past year

2. Number and proportion of all persons who received VCT in past year who are IDU

3. Number and proportion of HIV+ IDU who are receiving ARV on [census date]

4. HIV+ persons in receipt of ARVs who are IDU on [census date] as a proportion of all in receipt of ARVs

5. Number and proportion of IDU who received STI testing and treatment in the past year

The way forward

Advocate for (at least) the Essential Package

Implement (at least) the Essential Package

Measure (at least) the Essential Package

Then pick up on any of the other measures of the Comprehensive Package

Questions?

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