1. HIV programming for IDU in Surabaya: lessons from the data Inputs for an evaluation of Talenta NGO ASA Monitoring and Evaluation Team Jakarta, March 2, 2005

2. Overall programme approach “To foster change in social definitions of appropriate behaviour to incorporate risk reduction measures” (Wayne Weibel) Injecting is a social activity that takes place within social networks. If the network does not support norms of safe behaviour, then individuals can’t easily adopt safe behaviours. So our programme targets networks, as well as the individuals in those networks.

3. Implementing the programme ASA trains outreach workers (mostly ex-IDU) Outreach workers (OW) gain access to IDU, and identify their social networks Meeting with key individuals in networks, OW increase HIV awareness and prevention knowledge OW negotiate individual and group risk reduction plans, and monitor progress of those plans. Additional risk reduction measures proposed when IDU feel ready, with a final goal of risk elimination OW promote prevention advocacy, so that IDU themselves argue for safe behaviour with their peers

4. Information we can use to look at Surabaya programme success: Monthly reports by Talenta of clients reached, materials distributed etc BSS data from 2002 (before programme began): 200 IDU, reached through mapping and snowball sampling BSS data from 2004: 445 IDU reached through paid coupons (RDS). 23% have had contact with outreach workers. Network data available.

5. Basic knowledge and risk perception were exceptionally high before any intervention, but that did not seem to dent risky behaviour (Surabaya BSS, 2002)

6. Pre-intervention data show Surabaya IDU actually suffered less of mismatch between risk perception and risky behaviour than IDU in other Indonesian cities (3 city BSS, 2002)

7. Talenta reports reaching over 1,100 IDU, averaging about 5 new contacts and 16 total contacts per OW per month

8. The contact has not changed basic knowledge or risk perception, which were already high (Surabaya BSS, 2002 and 2004)

9. Outreach has not noticeably changed risky injecting practices. Nine in 10 injectors reached still share needles regularly (Surabaya BSS, 2002 and 2004)

10. What is Talenta reaching people with?

11. Outreach workers could do a lot more to refer IDU to services and encourage service use

12. Which of these services make a difference?

13. “Support groups” to help IDU change behaviour do not affect risk perception, needle cleaning or needle sharing (Surabaya BSS, 2002 and 2004)

14. Needle-free “safe injecting packs” increase use of bleach, but nothing else (Surabaya BSS, 2002 and 2004) P <0.001 P > 0.17

15. Which harms are we reducing? The data suggest that cleaning with bleach is not associated with fewer abscesses (Surabaya BSS, 2004, respondents who shared in the last week) P <0.001

16. Those with stated health problems were more likely to have been referred to basic health services by OW. That means two thirds of those with recent problems who were not referred. (BSS Surabaya 2004, those contacted by outreach only)

17. Participation in programmes does not appear to influence the average size of injecting networks. (BSS Surabaya 2004, no differences are significant at the 90% level)

18. Is there evidence that targeting “networks” works? Talenta reports great difficulty in identifying networks No “group risk reduction plans” have been negotiated RDS (“coupon”) method allows us to identify some individuals with strong networks, and look at behaviour within networks

19. Larger networks have less outreach coverage, but no less injecting risk (BSS Surabaya 2004)

20. Grouping the data makes the lack of difference even more visible (BSS Surabaya 2004)

21. A few of those who try to change succeed P = 0.001 P = 0.02

22. The steps people say they have taken to avoid HIV often don’t match with their stated behaviour (BSS Surabaya 2004)

23. The change is not always in the direction we hope for (BSS Surabaya 2004) Difference significant at 90% level

24. Only one thing seems to be significantly related to less injecting risk, but the numbers are so small it’s hard to tell (BSS Surabaya 2004) p=0.03

25. In 2004, Surabaya IDU reported more non-commercial partners but less sex with sex workers compared with 2002. Condom use is unchanged (Surabaya BSS, 2002 and 2004)

26. The programme is probably not responsible for the changes. IDU with outreach contact have virtually the same sexual risk as those with no outreach contact (Surabaya BSS, 2004) p 0.06

27. Preliminary conclusions The network-focused, outreach-based approach, with no needle or methadone provision and few links to services appears to have made no significant difference to  Size of sharing networks  Proportion of population sharing needles  Sexual risk behaviour In Surabaya, Indonesia

28. Even if the small observed differences were significant, and HIV prevalence were “only” 25%… OutreachNon- outreach Av. partners per injection2.5 Av. injections per day1.51.6 % injections where needles are shared (min) 44%55% % cleaned with bleach or alcohol 19%13% Weeks injecting until infected with HIV 108

29. This “best case scenario” of an added two weeks of injecting life before HIV infection has been achieved at a direct cost of: US$ 70 per IDU reached US$ 20 per contact between outreach worker and IDU This does not include the costs of training, or of ASA or FHI IDU support staff, but includes “intangible” activities such as community advocacy

30. These data only represent one site, which is known to have management problems. But they do suggest that the current approach is not suitable in all contexts. Evaluation data from other sites confirm the need for a re-think

31. ASA’s most comprehensive prevention programme Kios Atma Jaya has reached 2,570 IDU; over a quarter have agreed to individual risk assessments and 35 have also participated in group risk assessments

32. Risk behaviour does not differ significantly for clients who have negotiated risk reduction plans and those who have not (Atma Jaya programme evaluation data, 2003/4)

33. Receiving needles from outreach workers makes no difference to reported injecting risk for these IDU. Atma Jaya reports giving an average of 4 needles each (ever!) to around 6% of its clients (Atma Jaya assessment and programme data) p=0.26

34. Uninfected clients of Atma Jaya will inject on average only a few weeks before HIV infection, unless something changes Risk reduction plan No plan Av. partners per injection3.33.0 Av. injections per day2.42.1 % injections where needles are shared (min) 56%48% % cleaned with bleach or alcohol 48%28% Weeks injecting until infected with HIV 76

35. This “best case scenario” of an added week of injecting life before HIV infection has been achieved at a direct cost of: US$ 59 per IDU reached US$ 17 per contact between outreach worker and IDU This includes only the prevention portion of the programme (including advocacy and network building); it does not reflect the cost of care and support activities or of ASA or FHI IDU support staff

36. It is hard to avoid the conclusion that it is time for a fresh approach. What are the options? Lessons from other countries

37. In north Bangladesh, participation in a large scale needle exchange programme reduces injecting and sexual risk (Source: Bangladesh MoH)

38. In Guangxi, China, a needle social marketing programme run through outreach workers showed a significant impact in its first year of operation. (Source: Guangxi CDC)

39. These data suggest that outreach programmes incorporating easy access to sterile needles (a daily concern for IDU) show more results than those focused largely on more indirect approaches such as changing social norms

40. Notes for nerds (Some notes on BSS methodology) The 2002 BSS was conducted by University of Indonesia. The field staff were ex drug users from Surabaya. After participating in the survey they formed “Talenta”, an NGO which has since implemented the ASA programme for IDU in Surabaya The 2004 BSS was implemented by Talenta with supervision and data management by BPS (national statistics office) 2002 BSS: locations where IDUs gather, buy drugs or use drugs were mapped by UI, with approximate population sizes and contact people. All locations were visited by the survey team, IDUs were invited to participate and an appointment was made for an interview at a time and place of their convenience. Participating IDU were also invited to refer other potential respondents to the team. All respondents in both years were male. A handful of females were recruited but are not included in the data sets.

41. More notes for nerds 2004 BSS: a coupon system was used. Locations were mapped as before, and IDUs judged to be well connected and representing a diversity of users were invited to become “seeds”. Each was given two coupons to pass on to other IDUs. Respondents had to present at a single fixed site for interview. They were paid a small fee for their own participation and for each of the referrals who participated. The 2004 data reported here represents the first 445 respondents, and is biased towards those “new” to outreach workers. Data should not be used to calculate programme coverage. The different recruitment methods may have led to differences in the representativeness of the samples. The two final slides compare demographic and injecting characteristics The 2004 questionnaire was more complex and comprehensive than that used in 2002, where measures of network size were not possible. Definitions of needle sharing are not exactly equivalent between the two surveys.

42. The 2004 sample may be more educated, but they have less money