7.1. Introduction
Action on the recommendations in these guidelines requires a strategy informed by evidence and appropriate to the local context. Planning, decision-making and monitoring are parts of an ongoing process: Once an evidence-based plan is developed and implemented, it must be monitored and evaluated. The resulting findings then inform revision of the strategy and its implementation ().
The programme planning, implementation and evaluation cycle.
7.1.1. Guiding principles
An effective process for developing and implementing a national or sub-national response to HIV among key populations follows these guiding principles:
An ethical and rights-based approach should inform all decision-making. The planned response to HIV among key populations, and the decision-making process itself, should be non-discriminatory and accountable to the populations it seeks to serve, respecting and upholding their autonomy and rights. Principles of fairness and equity should be followed.
Meaningful participation by affected communities is critical to ensure that the decisions made, the plans formulated and the programmes developed are acceptable to community members, equitable, and responsive to community needs. Representatives from key population constituencies should be involved at all stages from designing the response through its implementation to monitoring and evaluation (M&E) (
1). Successful community empowerment (see
Section 5.3) develops the capacity of community members and organizations to participate in these processes in a meaningful way. Community-led organizations play a crucial role in delivering services that best meet the needs of key populations.
Involvement of all stakeholders. Addressing HIV among key populations requires a multisectoral response. Accordingly, planning of the response needs to involve multiple sectors.
Box 7.1 lists potential stakeholders to include in the planning process.
Coordinated approach. The national HIV programme manager and an appropriate body such as a national HIV/AIDS commission should take responsibility for managing the overall planning process and facilitating stakeholder and community participation. Designating an individual to work specifically on developing and coordinating services and issues related to key populations within the national AIDS commission (or similar peak body) may facilitate this. In large and diverse countries, developing a national programme requires formulating strategies at the local and sub-national levels as well, with guidance and coordination centrally, at the national level.
Openness and transparency. The evidence and rationale for decisions should be publicly available, including information on expected effectiveness and risk and the distribution of health benefits and burdens for different groups.
Evidence-based. Policies, interventions and approaches should be based on sound evidence or experience.
Equity. Programmes should aim to achieve equitable health outcomes across all populations and settings and to promote gender equity.
Efficiency and sustainability. Programmes should seek to deliver effective services most efficiently and to ensure that they are sustainable over the long term.
Potential stakeholders to include in the planning process.
7.2. Understanding the situation
The efficacy of the interventions in the essential package is well proven. Experience in multiple countries has demonstrated the generalizability of these interventions in diverse settings. Local factors do, however, have a bearing on intervention effectiveness and impact. It is critical to understand local epidemic dynamics; the characteristics of the populations affected; the physical, social and political environments that influence risk and vulnerability; the needs of people from key populations and any factors that might enable or hinder efforts to address these needs; and the health systems and community infrastructure. With this information in hand, an evidence-based plan can be developed and implemented.
People from key populations face greater HIV risk than the general population and have specific health-related needs. While many of these risks and needs may be common to people from key populations in different settings, some factors will differ among key populations, and some will be specific to a particular context. Accordingly, for a local response to be appropriate, acceptable and most effective, these risks and needs must be examined locally, and local people from key populations must be consulted and actively involved in the situational analysis.
It is also important to recognize the considerable diversity and varying levels of risk within each key population. Those most at risk are likely to be people who could be considered members of more than one key population; for example, some men who have sex with men may also inject drugs or engage in sex work. Thus, they risk exposure to HIV by several routes. People from key populations may also have other characteristics that could increase their risk or vulnerability or create additional health or welfare needs. For example, people from key populations may be homeless, experience mental health conditions or have other acute or chronic health concerns.
Data should guide the response, but lack of data is not a reason to stop or not initiate a response to HIV among key populations.
Key population size and distribution vary from place to place. To determine the required scale of the response, the appropriate balance among different interventions and where interventions should be targeted, it is important to appreciate the size and distribution of key populations, among other factors (see Box 7.2 and Section 7.3).
Key information required for decision-making and planning.
It is critical that information gathering processes, and the information itself, serve to protect, and not put at risk, the safety and privacy of people from key populations. At all times ethical principles must be observed, and the human rights of people from key populations, protected. In some circumstances, determining population size or mapping key populations can unintentionally endanger community members or subject them to stigma by identifying these populations and where they are located. Such information could also lead to arrest or imprisonment of people from key populations whose behaviour is criminalized. When undertaking information-gathering exercises, it is important to strictly maintain privacy, confidentiality and the security of the information collected. If the safety and the human rights of people from key populations cannot be protected, collection of certain data, such as mapping where people from key populations congregate, is better avoided.
The makeup, characteristics and needs of key populations change over time, as do various contextual and environmental factors. Ongoing M&E will identify changing parameters and make it possible to refine or refocus the response.
A situational analysis will almost certainly identify gaps in knowledge. An agenda for further research can address these gaps.
It is also important, whenever analysing and interpreting data, to evaluate the quality of the data and the presence of any sources of bias.
7.3. Planning and implementing the response
The following are some of the decisions that need to be taken while developing and implementing a national response to HIV among key populations.
Targeting the response
Which key populations and which sub-groups within key populations are most at risk?
Which legislation, policies and guidelines need to be developed or revised?
Implementation
Which interventions need to be implemented, and how should their implementation be prioritized?
Where and at what scale do interventions need to be provided?
1What targets and timelines should be set for the implementation and scale-up of interventions?
How and to what extent should services be decentralized and integrated to provide the best service coverage for key populations?
Which modes of service delivery are most appropriate?
What are the roles and responsibilities of the various stakeholders in implementing the response and achieving the agreed targets?
Resources required
Do the costs of implementing the response outweigh the costs of inaction?
What financial, human and other resources and infrastructure are required to implement the response? What resources are currently available, what additional inputs will be required, and how might these be obtained? What types of health-care and other workers are required, and how will they be recruited and trained? How can task shifting and sharing optimize the use of available human resources and expand service delivery?
How will economies of scale and synergies among HIV interventions and with other health interventions save on costs and improve service provision?
Monitoring and evaluation
Risks, outcomes and impacts
What are potential risks and vulnerabilities of the planned response, and what strategies would mitigate their impact? Risks might include domestic factors such as budget cuts, theft of consumables, attrition of health-care workers, and emergence of drug resistance. External factors could include loss of external financial support, political instability, and natural disasters.
7.4. Monitoring and evaluating the response
A monitoring and evaluation system is needed to assess both structural and health sector components of the response to HIV in key populations. It is critical that these systems are practical, not overly complicated, and that they collect information that is current, useful and readily used.
An M&E system is an essential part of the HIV response for key populations.
WHO and UN partner agencies have developed frameworks for monitoring the response to HIV in the general population and key populations. The following documents described these frameworks:
Each of these frameworks recommends a set of national-level indicators. These indicators assess key factors related to the enabling environment; measure the availability, coverage and quality of specific interventions; and examine their outcome and impact (Box 7.3). The indicators can also be used when preparing proposals or reporting progress to donor organizations.
Indicators for monitoring and evaluating the response.
The following documents provide additional guidance on M&E, including how to undertake assessments at the sub-national level:
The M&E process requires data from a variety of sources, including behavioural and sero-surveillance surveys, programmatic and administrative data, as well as information gathered through reviewing policy documents and legislation and consultation with experts and stakeholders (Box 7.4). The quality and limitations of these data should be assessed and considered when undertaking analysis and interpretation.
7.5. Ongoing planning and development of the response
Setting clear, achievable but ambitious targets is crucial when planning to scale up interventions to meet the objectives of the HIV response. Targets concretely define what a successful national programme or project should achieve within a specified time frame. Targets can be set for both intervention-specific indicators and cross-cutting outcome and impact indicators (Box 7.3).
Intervention and enabling environment indicators reflect the availability, coverage and quality of an intervention or service or assess changes in environmental factors, such as revision of legislation, within a specified timeframe. Targets are set with the aims of achieving reductions in HIV and STI risk sufficient to control the epidemic and ensuring the adequate provision of appropriate treatment and care for those living with HIV or with an STI.
Outcome and impact indicators seek to gauge the impact that interventions have had on outcomes that affect exposure to risk, such as changes in risk behaviours (for example, the percentage of people who use condoms consistently) or on impacts on the course of HIV or STI epidemics (for example, reductions in incidence of HIV or STIs).
Like planning overall, the target-setting process should be collaborative, involving the range of stakeholders. Those setting the targets should consider whether they are realistic and whether data can be practically collected. Targets, in keeping with programme strategies, should be tailored to the local epidemic and what the strategy can realistically achieve with obtainable funding and resources. Modelling can help to identify how different target levels would affect the epidemic.
Baseline assessment. Initial assessment should measure the scale of the current response, assessing the availability, coverage, and quality of current interventions, and appraising current environmental enablers and barriers. This information serves as a baseline for tracking progress. Also, currently available resources and technical capacity must be determined in order to estimate what more is needed and how to scale the intervention appropriately. From this information, realistic, achievable targets can be set and the time frame, specified.
Estimating cost. Estimating the costs associated with implementation is a key step in planning the roll-out. Several costing tools and resources are available. Spectrum, for example, is a suite of models and analytical tools to support decision-making. It comprises several software applications, including AIM (AIDS Impact Model) and Goals (Cost and Impact of HIV Interventions). Most countries already have AIM files prepared as part of their national epidemiological estimates, and so both modules can be rapidly applied. Spectrum can be accessed online at: http://www.unaids.org/en/dataanalysis/datatools/spectrumepp2013/.
OneHealth is a software tool designed to strengthen health system analysis and costing and to develop financing scenarios at the country level. It is specifically designed for low- and middle-income countries. It provides planners with a single framework for planning, costing, impact analysis, budgeting and financing of strategies for all major diseases and health system components. OneHealth can be downloaded free of charge (Futures Institute, 2013) at: http://www.futuresinstitute.org/onehealth.aspx.
UNAIDS has developed The human rights costing tool (HRCT), a flexible tool for costing investments in critical enablers (such as integrated treatment and rights literacy programmes, legal services, stigma and discrimination reduction programmes, and training for health-care workers and law enforcement). This, too, can be downloaded free of charge along with a user guide (2,3) at: http://www.unaids.org/en/media/unaids/contentassets/documents/data-and-analysis/tools/The_Human_Rights_Costing_Tool_v_1_5_May-2012.xlsm and http://www.unaids.org/en/media/unaids/contentassets/documents/document/2012/The_HRCT_User_Guide_FINAL_2012-07-09.pdf
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For ART the WHO Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection (2013) provides information on considerations for implementing and scaling up services in line with key recommendations.
