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1 Effectiveness of PEPFAR-Funded Community Outreach HIV Prevention Programs in Vietnam: Key Findings November 6, 2008 Dr. Lora Sabin Center for International.

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Presentation on theme: "1 Effectiveness of PEPFAR-Funded Community Outreach HIV Prevention Programs in Vietnam: Key Findings November 6, 2008 Dr. Lora Sabin Center for International."— Presentation transcript:

1 1 Effectiveness of PEPFAR-Funded Community Outreach HIV Prevention Programs in Vietnam: Key Findings November 6, 2008 Dr. Lora Sabin Center for International Health and Development Department of International Health Boston University School of Public Health

2 2 Evaluation Team Members and Affiliations Boston University School of Public Health Lora Sabin, MA, PhD Mary Bachman DeSilva, MS, ScD Davidson H. Hamer, MD Taryn Vian, M.Sc. Danielle Lawrence, MPH Kelly McCoy, MPH Jordan Tuchman, MPH Ho Chi Minh City Statistical Office Le Thi Thanh Loan, PhD Abt Associates Inc. Theodore Hammett, PhD Funding provided by: PEPFAR/USAID: Country Research Activity GHS-A Additional acknowledgments: Ahmar Hashmi, Jen Beard, Wayland Bergman, Bill MacLeod, Matt Fox, Don Thea, Jill Costello, Jon Simon, and Deirdre Pierotti

3 3 Background Vietnam’s 2004-National Strategic Plan focus:Vietnam’s 2004-National Strategic Plan focus: VCT, ART, harm reduction,VCT, ART, harm reduction, Harm reduction programs include community outreach programs that aim to:Harm reduction programs include community outreach programs that aim to: Distribute info about HIV transmission, prevention, and care among most at-risk populations (MARPs)Distribute info about HIV transmission, prevention, and care among most at-risk populations (MARPs) Reduce risky behaviors, increase safe behaviors relating to drug use and sexual practicesReduce risky behaviors, increase safe behaviors relating to drug use and sexual practices Promote use of VCT, STI, social, and other available support servicesPromote use of VCT, STI, social, and other available support services Outreach programs employ 2 approaches:Outreach programs employ 2 approaches: Peer educators (PE) and Health Educators (HE) Peer educators (PE) and Health Educators (HE)

4 4 Public Health Evaluation of PEPFAR- supported HIV/AIDS Outreach and Referral Programs Family Health InternationalFamily Health International CDC LIFEGAPCDC LIFEGAP Médecins du MondeMédecins du Monde CARE InternationalCARE International

5 5 1.Are outreach workers well prepared to deliver services among MARPs? 2. Are outreach workers identifying and communicating well with clients? Primary Research Questions HE and PEs in Hoang Mai, Hanoi 3. Is this BCC intervention effective in changing behavior?

6 6 Design & Methods 1.Review of program information 2.Qualitative: 223 in-depth interviews with outreach workers, MARPs, other key informants (6 provinces) 3.Quantitative: Cross-sectional survey of 2,222 MARPs & 272 PEs/HEs (4 provinces) Qualitative and quantitative methods: PE demonstrating needle cleaning

7 7 Study Population “Intervention” – contact with PE or HE in last six months“Intervention” – contact with PE or HE in last six months “Control” – no contact with PE or HE in last six months“Control” – no contact with PE or HE in last six months Snowball sampling to identify both populationsSnowball sampling to identify both populations

8 8 Methodology: Limitations Cross-sectional survey: cause and effect cannot be inferred between Intervention and Control groupsCross-sectional survey: cause and effect cannot be inferred between Intervention and Control groups Possible social desirability biasPossible social desirability bias Differences between PEs and HEs not relevant to all programsDifferences between PEs and HEs not relevant to all programs Sample sizes of MARP groups different from sizes of MARP groups in Vietnam overallSample sizes of MARP groups different from sizes of MARP groups in Vietnam overall Potential bias from snowball sampling approachPotential bias from snowball sampling approach

9 9 HP: CDC/LG, FHI QN: CDC/LG, FHI, CARE HC: All 4 programs HN: All 4 programs HP: CDC/LG, FHI QN: CDC/LG, FHI, CARE HC: All 4 programs AG: CDC/LG, FHI, CARE CT: CDC/LG, FHI, CARE

10 10 Evaluation Findings

11 11 Characteristics of MARP Respondents Few differences in demographic characteristics:Few differences in demographic characteristics: 58% female58% female Mean age ~29 yearsMean age ~29 years About 1/3 had a high school education or higherAbout 1/3 had a high school education or higher Some differences in previous behaviors between Intervention group (Int) and Control group (Con)Some differences in previous behaviors between Intervention group (Int) and Control group (Con) 22% of Int vs 16% of Con had tested + for HIV22% of Int vs 16% of Con had tested + for HIV 13% of Int vs 6% of Con had had sex with HIV+ person13% of Int vs 6% of Con had had sex with HIV+ person 24% of Int vs 15% of Con had had sex with an IDU24% of Int vs 15% of Con had had sex with an IDU Among MSM:Among MSM: 14% of Int vs 23% of Con had ever bought sex14% of Int vs 23% of Con had ever bought sex 31% of Int vs 40% of Con had ever sold sex31% of Int vs 40% of Con had ever sold sex

12 12 Research Question 1: How prepared are outreach workers? Training and skillsTraining and skills Knowledge and qualificationsKnowledge and qualifications SuppliesSupplies Supervision and supportSupervision and support Financial supportFinancial support

13 13 Training & Skills Most PEs/HEs felt training was appropriate and adequate preparation for jobMost PEs/HEs felt training was appropriate and adequate preparation for job Before I knew about these topics only through friends, but now [my] knowledge is more scientific and concrete. (PE in Hanoi)Before I knew about these topics only through friends, but now [my] knowledge is more scientific and concrete. (PE in Hanoi) Thanks to the course, I am more daring; I’m not afraid of going to the establishments to talk anymore. (PE in Hai Phong)Thanks to the course, I am more daring; I’m not afraid of going to the establishments to talk anymore. (PE in Hai Phong) [PEs] should be trained more to be more experienced and knowledgeable to work. (PE in An Giang)[PEs] should be trained more to be more experienced and knowledgeable to work. (PE in An Giang)

14 14 Training & Skills >90% of PEs and HEs received pre-service training, 95% received refresher training>90% of PEs and HEs received pre-service training, 95% received refresher training >95% of outreach workers had covered key topics of HIV transmission, prevention through safe sex/safe injection, demonstration of correct condom use, negotiation & outreach skills>95% of outreach workers had covered key topics of HIV transmission, prevention through safe sex/safe injection, demonstration of correct condom use, negotiation & outreach skills 13% PEs and 26% HEs had not received infection control training13% PEs and 26% HEs had not received infection control training PEs mentioned wanting more training related to antiretroviral therapy (ART)PEs mentioned wanting more training related to antiretroviral therapy (ART)

15 15 Knowledge about HIV

16 16 PE/HE Knowledge Gaps 8% did not know that HIV can be transmitted through breastfeeding8% did not know that HIV can be transmitted through breastfeeding Only 55% knew that withdrawal during sex is not an effective method for preventing HIV infectionOnly 55% knew that withdrawal during sex is not an effective method for preventing HIV infection 13% thought that not touching someone who is HIV+ is an effective prevention method13% thought that not touching someone who is HIV+ is an effective prevention method Nearly 20% did not know there is no cure for HIV/AIDSNearly 20% did not know there is no cure for HIV/AIDS 24% did not know that ART improves immune functioning24% did not know that ART improves immune functioning 60% did not know that the purpose of ART is to treat HIV/AIDS60% did not know that the purpose of ART is to treat HIV/AIDS

17 17 Supplies Sometimes inadequate (PE, MARP)Sometimes inadequate (PE, MARP) More safety items needed (PE)More safety items needed (PE) I’m not satisfied with the lack of some aids…there should be alcohol, distilled water, condoms, and it’s really good to have injection syringes and needles. (PE in Hai Phong)I’m not satisfied with the lack of some aids…there should be alcohol, distilled water, condoms, and it’s really good to have injection syringes and needles. (PE in Hai Phong) Without access to sterile injection equipment people like us can spread disease all over the society. (CSW in Hanoi)Without access to sterile injection equipment people like us can spread disease all over the society. (CSW in Hanoi)

18 18 What type of support have you received?

19 19 Perceptions of Community Support

20 20 Supervision and Support Now, we are still rushed by the police when approaching gathering spots. Sometimes I am even assaulted…We are even captured by the police even though we wear uniform and badges. (PE in Hai Phong)Now, we are still rushed by the police when approaching gathering spots. Sometimes I am even assaulted…We are even captured by the police even though we wear uniform and badges. (PE in Hai Phong) At present, the police are not quite clear about our job... The police ask us to inform them before approaching any particular places, but we refuse as we have to keep our customers’ secret. (PE in HCMC)At present, the police are not quite clear about our job... The police ask us to inform them before approaching any particular places, but we refuse as we have to keep our customers’ secret. (PE in HCMC)

21 21 Financial Support Some workers dissatisfied with salaries (mean reported salaries: PEs = 900,000; HEs = 2,300,000 VND/mo)Some workers dissatisfied with salaries (mean reported salaries: PEs = 900,000; HEs = 2,300,000 VND/mo) …some outreach workers work at bars, massage parlors, discotheques and at that time the fees are especially high. At the moment we haven’t got the financial support when approaching those areas. (HE in Hanoi)…some outreach workers work at bars, massage parlors, discotheques and at that time the fees are especially high. At the moment we haven’t got the financial support when approaching those areas. (HE in Hanoi) If the workers here just thought of the salary, it’s possible that nobody would do this job…Our salary is quite poor… not enough to support our life. (PE in Hai Phong)If the workers here just thought of the salary, it’s possible that nobody would do this job…Our salary is quite poor… not enough to support our life. (PE in Hai Phong)

22 22 Research Question 2: How well do outreach workers identify and communicate with clients? Contacts between outreach workers and MARP clientsContacts between outreach workers and MARP clients Approaches used by outreach workersApproaches used by outreach workers Services provided to MARP clientsServices provided to MARP clients

23 23 % of PE and HE who reported contact with each client group in last month

24 24 PE/HE Contacts by Client Group

25 25 PEs/HEs use a variety of approaches to reach clients

26 26 Specific approaches Used by PEs and HEs Specific tactics: humor, scare tactics, friendly and polite demeanor, emphasizing risks to family membersSpecific tactics: humor, scare tactics, friendly and polite demeanor, emphasizing risks to family members PEs/HEs said that approaching street CSWs (SSWs) is much easier than establishment-based CSWs (KSWs)PEs/HEs said that approaching street CSWs (SSWs) is much easier than establishment-based CSWs (KSWs) For MSM, hot spots and introductions are keyFor MSM, hot spots and introductions are key MARPs said best approaches are: making clients feel comfortable, using personal connections, being reliableMARPs said best approaches are: making clients feel comfortable, using personal connections, being reliable

27 27 How PEs and HEs talk to clients It depends on each customer. For example, at the railway, the ice-breaker is: Where did you buy the “goods”? Is it good? Who did you buy it from?... I show them that I’m in their circle. Then I step-by- step turn to some anecdotes [and] lead them to my purpose, [which] is to talk about HIV. (PE in Hai Phong)It depends on each customer. For example, at the railway, the ice-breaker is: Where did you buy the “goods”? Is it good? Who did you buy it from?... I show them that I’m in their circle. Then I step-by- step turn to some anecdotes [and] lead them to my purpose, [which] is to talk about HIV. (PE in Hai Phong) We go to the women’s gathering places ourselves to make friends … Sometimes I even bring my child along. Sometimes I tell a lie that used to be a sex worker. (PE in Hanoi)We go to the women’s gathering places ourselves to make friends … Sometimes I even bring my child along. Sometimes I tell a lie that used to be a sex worker. (PE in Hanoi) Continuous rain softens the hardest soil. We can’t see it right away. They change their habits step by step. (PE in Quang Ninh)Continuous rain softens the hardest soil. We can’t see it right away. They change their habits step by step. (PE in Quang Ninh)

28 28 Services Provided by PEs and HEs Provincial variability in contacts per monthProvincial variability in contacts per month Hai Phong: 50 total/12 new; An Giang: 25 total/8 newHai Phong: 50 total/12 new; An Giang: 25 total/8 new Rising trend in number of clients per month in the past 6 months: +81% in Hai Phong; +57% in HCMCRising trend in number of clients per month in the past 6 months: +81% in Hai Phong; +57% in HCMC 95% tell IDUs that sharing injection equipment is unsafe95% tell IDUs that sharing injection equipment is unsafe 30% able to name unsafe sources30% able to name unsafe sources 31% tell where to obtain bleach31% tell where to obtain bleach 93% provided VCT referrals in previous month93% provided VCT referrals in previous month 62% to STI clinics62% to STI clinics 36% for ART36% for ART 33% to TB clinics33% to TB clinics

29 29 Conversations Reported by MARPs Possible secondary benefit: Intervention MARPs had more discussions about safe sex (98% v 45%) & safe injection (69% v 27%) in previous 6 months A. Discussions about safe sex B. Discussions about safe injection

30 30 Research Question 3: How effective is the behavior change communication? Knowledge, attitudes, and beliefsKnowledge, attitudes, and beliefs Risk behaviorsRisk behaviors Referral service usage and perceived riskReferral service usage and perceived risk Qualitative information on program strengths and weaknessesQualitative information on program strengths and weaknesses

31 31 Effectiveness of BCC: MARP Knowledge

32 32 Knowledge Gaps Among MARPs TransmissionTransmission 28% (24% Int, 32% Con) did not know that HIV can be transmitted through breastfeeding28% (24% Int, 32% Con) did not know that HIV can be transmitted through breastfeeding PreventionPrevention 65% (both Int/Con) said that withdrawal during sex is an effective method of HIV prevention65% (both Int/Con) said that withdrawal during sex is an effective method of HIV prevention 27% (24% Int, 30% Con) said that not touching someone who is HIV+ is an effective prevention method27% (24% Int, 30% Con) said that not touching someone who is HIV+ is an effective prevention method Treatment – main area of knowledge weaknessTreatment – main area of knowledge weakness 25% (both Int/Con) did not know there is no cure for HIV25% (both Int/Con) did not know there is no cure for HIV 66% (56% Int, 76% Con) did not know that ART improves immune functioning66% (56% Int, 76% Con) did not know that ART improves immune functioning 60% did not know that the purpose of ART is to treat HIV60% did not know that the purpose of ART is to treat HIV

33 33 Changes in MARPs’ Beliefs Changes in beliefs about what was risky behavior and the seriousness of riskChanges in beliefs about what was risky behavior and the seriousness of risk Better understanding of modes of HIV transmissionBetter understanding of modes of HIV transmission New attitudes toward people living with HIVNew attitudes toward people living with HIV Stronger feelings of personal security and self- efficacyStronger feelings of personal security and self- efficacy I changed a lot of my beliefs…I used to underestimate [the risk] and not use condoms, but since talking with him, I know the benefits. (MSM in Hanoi)I changed a lot of my beliefs…I used to underestimate [the risk] and not use condoms, but since talking with him, I know the benefits. (MSM in Hanoi)

34 34 IDUs and Injection Behaviors IDU MARPs (n=703) - reported low-risk injection behaviorsIDU MARPs (n=703) - reported low-risk injection behaviors 97% Intervention / 95% Controls could obtain new needles/syringes when needed97% Intervention / 95% Controls could obtain new needles/syringes when needed 14% in both groups had recently shared needles/syringes14% in both groups had recently shared needles/syringes In IDIs, noted barriers to access sterile equipmentIn IDIs, noted barriers to access sterile equipment No single guaranteed sourceNo single guaranteed source Inconvenience in bad weather, late at nightInconvenience in bad weather, late at night Fear of discovery with equipment by police, familyFear of discovery with equipment by police, family Intervention IDUs - more likely to start or increase cleaning of injection equipmentIntervention IDUs - more likely to start or increase cleaning of injection equipment 71% intervention vs 61% controls 71% intervention vs 61% controls

35 35 IDUs and Injection Behaviors Before meeting [outreach workers], I thought nothing about problems concerning sharing syringes and needles. Now I no longer share syringes or needles with others. (IDU in Hanoi)Before meeting [outreach workers], I thought nothing about problems concerning sharing syringes and needles. Now I no longer share syringes or needles with others. (IDU in Hanoi) We used to share syringes and needles in groups of 4, 5 users. Now we no longer share them as I’ve witnessed many deaths. (IDU in An Giang)We used to share syringes and needles in groups of 4, 5 users. Now we no longer share them as I’ve witnessed many deaths. (IDU in An Giang) I’ve changed a lot, I’ve thought of it a lot…After listening to him, I don’t [share]. I used to use the kits again…Now I wash them with boiling water twice or three times according to the formula. (IDU in Quang Ninh)I’ve changed a lot, I’ve thought of it a lot…After listening to him, I don’t [share]. I used to use the kits again…Now I wash them with boiling water twice or three times according to the formula. (IDU in Quang Ninh)

36 36 Sexual Behaviors: Condom Use Sexually active MARPs (n=1623) reported on condom use in the last 6 months:Sexually active MARPs (n=1623) reported on condom use in the last 6 months: 37% always used condoms37% always used condoms 29% with primary partner29% with primary partner 43% with casual partner43% with casual partner 63% with sex clients63% with sex clients 34% usually used condoms34% usually used condoms 29% never/occasionally used29% never/occasionally used CLEARLY substantial room for improvementCLEARLY substantial room for improvement

37 37 Sexual Behaviors Higher condom use reported by intervention MARPsHigher condom use reported by intervention MARPs …but lots of room for change…but lots of room for change

38 38 Sexual Behaviors I changed a lot of my beliefs…I used to underestimate [the risk] and not use condoms, but since talking with him, I know the benefits. (MSM in Hanoi)I changed a lot of my beliefs…I used to underestimate [the risk] and not use condoms, but since talking with him, I know the benefits. (MSM in Hanoi) After talking, I know how to protect myself. When I have sexual relations, I use condoms even with my lover. I’ve taught my boyfriend to use [condoms]. (CSW in Hai Phong)After talking, I know how to protect myself. When I have sexual relations, I use condoms even with my lover. I’ve taught my boyfriend to use [condoms]. (CSW in Hai Phong) She convinced [me] so I understand that when I am in a hard situation earning money as a prostitute, I have to use condoms, have blood test….I also learned how to use condoms in the right way. (CSW in HCMC)She convinced [me] so I understand that when I am in a hard situation earning money as a prostitute, I have to use condoms, have blood test….I also learned how to use condoms in the right way. (CSW in HCMC)

39 39 Referral Service Usage & Perceived Risk Intervention group more likely than controls to seek HIV testingIntervention group more likely than controls to seek HIV testing 76% of intervention group vs. 46% of controls were tested76% of intervention group vs. 46% of controls were tested 78% vs. 33% sought pre-test counseling78% vs. 33% sought pre-test counseling Among tested, 81% vs. 61% sought post-test counselingAmong tested, 81% vs. 61% sought post-test counseling MARPs reported low perceived risk of infectionMARPs reported low perceived risk of infection Less than 1/4 see high riskLess than 1/4 see high risk Reasons: always use condom, never use drugsReasons: always use condom, never use drugs

40 40 Referral Service Usage & Perceived Risk In IDIs, MARPs described mixed experiences with referrals:In IDIs, MARPs described mixed experiences with referrals: Positive: provided for free, make them feel more secure, friendly staff, short wait timesPositive: provided for free, make them feel more secure, friendly staff, short wait times Negative: unkind/unfriendly staff, unhelpful counselingNegative: unkind/unfriendly staff, unhelpful counseling Illustrative statements by IDI respondents:Illustrative statements by IDI respondents: The way they greeted us really offended us. [The receptionist’s] manner was very hierarchical, and she shouted and scolded us. (CSW in Hanoi)The way they greeted us really offended us. [The receptionist’s] manner was very hierarchical, and she shouted and scolded us. (CSW in Hanoi) It’s a waste of medicine to treat an addict like him. (PE in Hai Phong retelling what a doctor told him, while motioning toward an IDU)It’s a waste of medicine to treat an addict like him. (PE in Hai Phong retelling what a doctor told him, while motioning toward an IDU)

41 41 Perceived Program Strengths Intervention MARPs rated most services very or mostly useful; >95% for:Intervention MARPs rated most services very or mostly useful; >95% for: InformationInformation Demonstration of condom use, injection cleaning methodsDemonstration of condom use, injection cleaning methods HIV transmission/prevention knowledgeHIV transmission/prevention knowledge >95% said PEs/HEs are trustworthy>95% said PEs/HEs are trustworthy 72% would “absolutely” urge friends to talk to PEs/HEs72% would “absolutely” urge friends to talk to PEs/HEs About half of MARPs could not distinguish PEs v HEsAbout half of MARPs could not distinguish PEs v HEs Of those who could: HEs seen as more knowledgeable, PEs as more practical, available, and able to help change behaviorOf those who could: HEs seen as more knowledgeable, PEs as more practical, available, and able to help change behavior

42 42 Perceived Program Strengths At first I was also shy as I didn’t know what they were like, but when we were closer to each other, I really liked talking to them. (CSW in Hanoi)At first I was also shy as I didn’t know what they were like, but when we were closer to each other, I really liked talking to them. (CSW in Hanoi) …just like friends talking with each other. (MSM in HCMC, on his relationship with a PE)…just like friends talking with each other. (MSM in HCMC, on his relationship with a PE) [Talking with PEs is] beneficial as they bring us information to prevent HIV…. (IDU in Hai Phong)[Talking with PEs is] beneficial as they bring us information to prevent HIV…. (IDU in Hai Phong) I’ve met health educators and I find them really enthusiastic. They all answered every question of mine. … I see peers more often, so I like them more…. I ask the health educators the questions which peers can’t answer. (MSM in Hanoi)I’ve met health educators and I find them really enthusiastic. They all answered every question of mine. … I see peers more often, so I like them more…. I ask the health educators the questions which peers can’t answer. (MSM in Hanoi)

43 43 Challenges in Providing Services 83% PEs/HEs reported difficulties in approaching clients83% PEs/HEs reported difficulties in approaching clients 53% had encountered violent clients53% had encountered violent clients Lack of client cooperation due to fear, police interference, time conflictsLack of client cooperation due to fear, police interference, time conflicts MARPs: some PEs apathetic or too preachy:MARPs: some PEs apathetic or too preachy: Most PEs working here are not enthusiastic. They just work to receive salary. (MSM in HCMC)Most PEs working here are not enthusiastic. They just work to receive salary. (MSM in HCMC) He [PE] communicates with me but sometimes talks so much that it makes me feel a headache…. he keeps preaching. Even on doing this and that for prevention; such a headache…. (IDU in Quang Ninh)He [PE] communicates with me but sometimes talks so much that it makes me feel a headache…. he keeps preaching. Even on doing this and that for prevention; such a headache…. (IDU in Quang Ninh)

44 44 Challenges in Providing Services Challenges in Providing Services 3/4 of control MARPs had not heard of programs3/4 of control MARPs had not heard of programs Of those who had, main reasons no contact: inconvenient time, location, not sure how to contact, feel uncomfortableOf those who had, main reasons no contact: inconvenient time, location, not sure how to contact, feel uncomfortable 1/4 expressed interest in talking to a PE1/4 expressed interest in talking to a PE Qualitative data highlight fears of MARPs and potential need for more PEs:Qualitative data highlight fears of MARPs and potential need for more PEs: I recommend an increase in the number of PE to outreach drug users…If so, there will be a decrease in the number of drug users. (IDU in Hai Phong) I recommend an increase in the number of PE to outreach drug users…If so, there will be a decrease in the number of drug users. (IDU in Hai Phong) Outreach workers need to work better. To make the unaware people go [to clinic] for examination; or they should chat to those people. (CSW in An Giang)Outreach workers need to work better. To make the unaware people go [to clinic] for examination; or they should chat to those people. (CSW in An Giang)

45 45 Social Discrimination Social Discrimination The biggest problem is the prejudices from the community. Many people do not know anything about MSM’s feelings, and they [think they] are sick and debauched people. (HE in Hanoi)The biggest problem is the prejudices from the community. Many people do not know anything about MSM’s feelings, and they [think they] are sick and debauched people. (HE in Hanoi) The police even beat us if they catch us delivering condoms outside the street. I have been beaten by a club. They don’t even want to know what we do, just chase us. (PE in Hai Phong)The police even beat us if they catch us delivering condoms outside the street. I have been beaten by a club. They don’t even want to know what we do, just chase us. (PE in Hai Phong) The obstacles are from the [establishment] owners; they don’t welcome us. They deny that they have prostitutes inside…if the local government and other unions support us a bit in our job, the program will be more effective. (PE in An Giang)The obstacles are from the [establishment] owners; they don’t welcome us. They deny that they have prostitutes inside…if the local government and other unions support us a bit in our job, the program will be more effective. (PE in An Giang)

46 46 Key Informants on Program Strengths Why are programs effective?Why are programs effective? Proven ability of PEs/HEs to reach clients who need servicesProven ability of PEs/HEs to reach clients who need services Comprehensive in scope, with broad supportComprehensive in scope, with broad support Tight/strict management, stable budgetsTight/strict management, stable budgets Well-trained staffWell-trained staff Rise in number of people accessing VCT and other servicesRise in number of people accessing VCT and other services Improvement in knowledge/awareness of MARPsImprovement in knowledge/awareness of MARPs Reduction in risky behaviors of MARPsReduction in risky behaviors of MARPs

47 47 Key Informants on Program Weaknesses Challenges:Challenges: Policy conflictsPolicy conflicts Inability to distribute sterile needles/syringesInability to distribute sterile needles/syringes Turnover, mediocre PE performance, low salariesTurnover, mediocre PE performance, low salaries Geographic coverageGeographic coverage Little coordination between PEPFAR-funded and other outreach programsLittle coordination between PEPFAR-funded and other outreach programs But views varied on whether this is a major issueBut views varied on whether this is a major issue  These views generally shared by PEs/HEs and MARPs

48 48 Summary 1.Outreach workers generally well prepared  But some areas need improvement. 2.Outreach workers use many effective strategies to identify and communicate with MARPs  Yet social stigma still makes it difficult to access clients. 3.Tension between “peers” and being a role model 4.Job satisfaction high, but there are issues:  Inadequate supplies  Weak community support  Low compensation

49 49 Summary 5.Possible “ripple effect” seems to be important benefit of the outreach programs 6.Data on contacts/worker raise questions about data quality and possible market saturation in some areas 7.Programs appear to have increased knowledge among MARPs, but knowledge on treatment is low, among both MARPs and outreach workers 8.Effectiveness of programs is suggested by differences in intervention v control: condom use, HIV testing

50 50 Summary 9.Little reported needle sharing, but intervention group more likely to start or increase cleaning of injection equipment 10. Although there are differences between PEs and HEs, a combination of both PEs and HEs appears most effective for service provision PE and HE model appears to work wellPE and HE model appears to work well 11. There is a need for greater coordination between PEPFAR-funded programs and other programs

51 51 Thank you!


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