1. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Review of the UNAIDS / GAMET Modes of Transmission Process in Five Countries UNAIDS / GAMET Satellite Symposium August 3, 2008 Mark Colvin UNAIDS RST mark@maromi.co.za

2. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Introduction  Briefly discuss methods used and what has been achievd to date.  At this stage of the MoT process any overview can only cover the process issues because there has not yet been time for the synthesis reports to filter into the planning processes of the 5 countries.  However, an evaluation of the impact of the MoT process on policy and practice will be conducted over the next 9 months.

3. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Why was this process undertaken? 1.Varied epidemics between and within countries. 2.Poor analysis of evolving country epidemics leading to poor strategic focus and continued misallocation of responses. 3.Inadequacy of prevalence data in directing attention to evolving priorities for response. 4.Poor understanding of HIV incidence in countries further limits prevention planning efforts. 5.Weak leadership for prevention resulting in lack of coordination, accountability and technical direction for prevention.

4. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS In-Country Heterogeneity: rural/urban variations in Kenya Source: Gouws et al, June 2006Source: National STI & AIDS Control Programme

5. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Emerging evidence 1.Varied epidemics between and within countries. 2.Poor analysis of evolving country epidemics leading to poor strategic focus and continued misallocation of responses. 3.Inadequacy of prevalence data in directing attention to evolving priorities for response. 4.Poor understanding of HIV incidence in countries further limits prevention planning efforts. 5.Weak leadership for prevention resulting in lack of coordination, accountability and technical direction for prevention.

6. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Aim of Modes of Transmission Process  To complement “Know Your Epidemic” efforts – understanding of epidemic and critical analysis of current response  Key objective: Help countries become more systematic in the approach to prevention.  Prioritization & use of strategic information: Establish practice of evidence informed prioritization for prevention strategies and resource allocation.  Evidence-informed Planning and decisions: Translate this knowledge into improved national prevention strategies, plans and budgets.  Strengthening leadership: Formalize a clear national leadership forum for prevention.

7. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS MOT Process June 2007: 1 st Working Group Meeting: UNAIDS, SADC, WB, CDC, UNICEF, UNFPA, HAD Results: -Agreed to undertake process in 6 – 8 countries July 2007: 2 nd Working Group Meeting: UCCs ESA, WCA; HDA Results: - Definition of tools - Country Selection - Costed Workplan October 2007: NAC Directors’ Meeting (Kenya, Lesotho, Mozambique, Swaziland, Uganda) UNAIDS, UNFPA, SADC, WB Results: - Agreement on Country process October to Date: - Formalization of UNAIDS/WB collaboration - 5 country studies - Team recruitment - Country partner orientation - Team Training - Data gathering Target Completion Date: July 20 th 2008

8. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Analytical Components  Epidemiological Review of quality existing survey data: examine trends in general population and specific groups (age, most at risk groups) and describe local factors affecting their risk  Model the incidence based on existing data: establish where next infections likely to occur.  Review of Prevention Response: examine the current national prevention programme and distribution of resources for response.  Review of prevention resource use

9. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Epidemiological Review  Use Existing Data Sources Surveillance, MOH statistics Household surveys Special studies (special populations, qualitative & KAP studies) DHS, Behavioral Surveys Prevention spending, service statistics Published & Grey Literature (national, regional, international) Key Informants  Establish clear quality criteria  Record decisions & select data for inclusion in model  Identify data gaps

10. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS HIV Incidence Model  Spreadsheets analyzing distribution of infections based on major modes of transmission (sexual, IDU, transfusion, injections) will use the current prevalence of HIV infection numbers of individuals with particular exposures, and the rates of these exposures to calculate the expected incidence of HIV infection over the coming year  Analyzes incidence in low risk heterosexual sex and casual sex groups 15 – 24 years, 25+ years and effect of age mixing.

11. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS

12. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Review of Prevention Response  Two Part Tool: What should be done vs What is Being Done  Adapted from “Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access” (UNAIDS 2007)  Part One: 3 checklists for action in hyperendemic contexts: Policy Actions Strategic Information required for a prevention response Programmatic Actions

13. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Review of Prevention Response  Part Two: Assessment of HIV Prevention Programmes to Address Needs of Specific Target Groups Implementers Coverage Programmatic Scope

14. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Bringing it All Together - National Synthesis Report  Where are the new infections occurring and why?  What does behavioural data say about priority target groups? (Who should we be targeting?)  Where should we be reaching them?  What are we doing at the moment, where and with what resources  What is the degree of alignment between what/where we are spending and what we should be doing?

15. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS End of section on methods

16. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS What has been achieved to date?

17. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Overall impression of MoT process  First and foremost, it is apparent from country reports, regional meetings, the recent survey and from informal interactions, that the MoT process has been a worthwhile initiative.  No individual or organization has suggested that the MoT concept or its implementation so far, was seriously flawed.  All those interviewed believed that this process needs to be repeated..

18. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Why has the process been so successful?  Extensive international and in-country consultation  The rationale for the MoT process was well constructed and well motivated  Adequate financial and human resources were committed to the process  Process was driven by in-country Technical and Policy teams rather than only by consultants  Key role played by the NACs  High level expertise and experience in doing synthesis work brought into the process by GAMET

19. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Significant support provided to countries  Support for the MoT process was provided in the following areas: Financial support from UNAIDS and GAMET Provision of Lead Epidemiologists in 4 countries by GAMET and supervision by GAMET In-country and inter country coordination provided by UNAIDS Establishment of Regional Technical Team Regular teleconferences and monthly regional reports Terms of reference for consultants developed Methods guidelines and templates developed Training workshops held in country Limited in-country “mentoring” support

20. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Challenges  Main challenge has been the lack of data – particularly for the model Numbers of people in certain risk groups – MSM, IDU, Sex workers and clients Numbers of partners for the various risk groups Numbers of sex acts per risk group Prevalence of STIs among particular risk group  Lack of readily available expertise in country.  Extent of work required to determine HIV prevention response

21. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) May 17, 2015 UNAIDS Conclusion  This has been a highly successful process and collaboration between UNAIDS, GAMET and all 5 countries.  The glitches that have occurred have been relatively minor in nature and easily addressed in the future.  In particular, I would like to thank Susan Kasedde, Marelize Gorgens and Eleanor Gouws for their incredible commitment to the MoT process and the long hours that each has put in.