hiv programming for idu in surabaya: lessons from the data inputs for an evaluation of talenta ngo...
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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
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.
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
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.
Basic knowledge and risk perception were exceptionally high before any intervention, but that did not seem to dent risky
behaviour (Surabaya BSS, 2002)
100 100
89 90
0
10
20
30
40
50
60
70
80
90
100
Knows HIV Knows sharedneedles spread HIV
Feels at risk for HIV Shared needles inthe last week
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)
54
7
32
29
83
55
21
59
46
0 20 40 60 80 100
Bandung
Surabaya
Jakarta
Feels at risk BECAUSE shares needlesFeels at risk for HIV but shares needles anywayDoesn't feels at risk for HIV, even though shares needles
Talenta reports reaching over 1,100 IDU, averaging about 5 new contacts and 16 total contacts per OW per month
0
50
100
150
200
250
300
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
2002 2003 2004
New contacts Total contacts Individual risk assesment
External consultant arrives,coupon program begins
The contact has not changed basic knowledge or risk perception, which were already high
(Surabaya BSS, 2002 and 2004)
100 100
89
99 99
85
100 100
85
0
10
20
30
40
50
60
70
80
90
100
Knows HIV Knows shared needlesspread HIV
Feels at risk for HIV
2002 (pre intervention) 2004, no outreach (n 343)2004, outreach (n 102)
Outreach has not noticeably changed risky injecting practices. Nine in 10 injectors reached still share needles regularly
(Surabaya BSS, 2002 and 2004)
88
90
90
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2004, met withoutreach workers
2004, no outreach
2002
Shared a needle last week Shared water/setting No risky injecting
What is Talenta reaching people with?
Outreach workers could do a lot more to refer IDU to services and encourage service use
41
30
1714
18
2924
9 9 9
52
9
20
3 50
102
68
82
0
20
40
60
80
100
120
HIV-relatedinformation
Safer injectingpack (has
bleach, notneedles)
Injectorssupport group
Basic health VCT Care andtreatment
Detox/rehabilitation
Nu
mb
ers
of
IDU
in
BS
S w
ho
re
po
rt r
ec
eiv
ing
in
form
ati
on
/se
rvic
es
Contacted by outreach worker Received information
Refered to service Used service
Which of these services make a difference?
“Support groups” to help IDU change behaviourdo not affect risk perception, needle cleaning or needle sharing
(Surabaya BSS, 2002 and 2004)
85
3
9086
15
90
82
17
91
0
10
20
30
40
50
60
70
80
90
100
Feel at risk for HIV Cleaned needles withbleach/alcohol
Shared needles lastweek
2002 (pre intervention)2004, did not participate in user support group (n 434)2004, participated in user support group (n 11)
Needle-free “safe injecting packs” increase use of bleach, but nothing else
(Surabaya BSS, 2002 and 2004)
3
99
90
7
84
91
47
91
85
0
10
20
30
40
50
60
70
80
90
100
Cleaned needles with bleach(of those sharing)
Abcess in last year Shared needles lastweek
Per
cen
t
2002 (pre intervention)2004, did not receive safe behaviour packs (n 377)2004, received safe behaviour packs (n 68)
P <0.001
P > 0.17
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)
84
47
7
92
0
10
20
30
40
50
60
70
80
90
100
Cleaned needles with bleach (of thosereceiving safe injecting packs)
Abcess in last year
Per
cen
t
Uses bleach to clean needles
Does not use bleach to clean needles
P <0.001
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)
9 9
2623
1916
33 30
0
10
20
30
40
50
60
70
80
90
100
Refered to basic health services Used basic health services
% o
f th
ose
wh
o m
et o
utr
each
wo
rker
s re
fere
d t
o
and
usi
ng
ser
vice
s
No abcess Abcess
No history of overdose History of overdose
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)
3.8
3.9
3.9
4
3.5
3.7
0 1 2 3 4 5
Support group
IEC
Contact withoutreach worker
Average number of people in injecting network
Did not participate/receive services Participated/received services
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
Larger networks have less outreach coverage, but no less injecting risk
(BSS Surabaya 2004)
24
57
62
76
99
100
100
92
100
88
83
96
95
90
88
85
16
13
12
12
11
23
0 10 20 30 40 50 60 70 80 90 100
Average number of people in injecting network
Network size % contacted by outreach % sharing needles
A few of those who try to change succeed
A higher % of IDU reached by outreach say they have
tried to change behaviour
58
77
0
10
20
30
40
50
60
70
80
90
100
Has done something to avoid HIV
Pe
rce
nt
tain
g a
cti
on
to
av
oid
H
IV
No outreach Outreach
Those who did try to change behaviour were less likely to share needles, but close to 9 out of 10 still
shared94
87
0
10
20
30
40
50
60
70
80
90
100
Shared a needle last week
% s
har
ing
nee
dle
in la
st w
eek
Did not try to change behaviourTried to change behaviour
P = 0.001
P = 0.02
The steps people say they have taken to avoid HIV often don’t match with their stated behaviour
(BSS Surabaya 2004)
0 50 100 150 200 250 300 350 400
Always use condoms
Do not share setting
Clean needles with bleach
Stop sharing needles
Stop injecting
Number of respondents
Tried and succeeded Tried and failed Did not try
The change is not always in the direction we hope for(BSS Surabaya 2004)
3.8
4.6
3.8
3.7
0 1 2 3 4 5
Avoid sharingneedles
Reduce numberof sharingpartners
Average number of people in injecting network
Say they adopted safer behaviour in this area to avoid HIV Did not change behaviour
Difference significant at 90% level
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)
60
90
0 10 20 30 40 50 60 70 80 90 100
Did not get needle from outreach worker (n=440)Received needle from NGO worker (n = 5)
p=0.03
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)
2924
80
23 21
3540
50
5
24
17
0
10
20
30
40
50
60
70
80
90
100
Married/live inpartner
Girlfriend Sex worker Sold sex Condom withlast sexworker
Condom atlast casual sex
Pe
rce
nt
2002 2004
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)
53
24
56
16
42
23
59
23
0
10
20
30
40
50
60
70
80
90
100
Bought sex in lastyear
Used condom withlast sex worker
Multiple partnerslast year
Condom with lastcasual partner
2004, no outreach (n 343) 2004, outreach (n 102)
p 0.06
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 toSize of sharing networksProportion of population sharing needlesSexual risk behaviour
In Surabaya, Indonesia
Even if the small observed differences were significant, and HIV prevalence were “only” 25%…
Outreach Non-outreach
Av. partners per injection 2.5 2.5
Av. injections per day 1.5 1.6
% injections where needles are shared (min)
44% 55%
% cleaned with bleach or alcohol
19% 13%
Weeks injecting until infected with HIV
10 8
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
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
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
0
100
200
300
400
500
600
700
800
900
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
New contacts per month Total contacts per month New individual risk assessments per month
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)
30
79 80
45
8582
39
81 83
25
100
75
0
10
20
30
40
50
60
70
80
90
100
Recent overdose Recent abcess Shared needles last week
No risk reduction negotiations (n 107)Risk reduction negotiations once (n 104)Risk reduction negotiations 2-5 times (n 182)Risk reduction negotiations >5 times (n 8)
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)
83
79
0 10 20 30 40 50 60 70 80 90 100
Did not get needle from outreach worker (n=244)Received needle from NGO worker (n = 170)
p=0.26
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 injection 3.3 3.0
Av. injections per day 2.4 2.1
% injections where needles are shared (min)
56% 48%
% cleaned with bleach or alcohol
48% 28%
Weeks injecting until infected with HIV
7 6
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
It is hard to avoid the conclusion that it is time for a fresh approach.
What are the options?
Lessons from other countries
In north Bangladesh, participation in a large scale needle exchange programme reduces injecting and sexual risk(Source: Bangladesh MoH)
59
72
90
38
1621 17
51
0102030405060708090
100
Used needle afterother injector last
time
Used needle afterother injector in
the last week
Reported STIsymptom past
year*
Sought medicaltreatment for STI**
Pe
rce
nt
Did not participate in needle exchangeParticipated in needle exchange
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)
Change in injecting risk among all IDUs, 2000 - 2001
61
30
0
10
20
30
40
50
60
70
80
90
100
Per
cen
t sh
arin
g i
n l
ast
mo
nth
April 2000May 2001
Difference in injection risk for those in and out of needle
exchange, May 2001
42
22
0
10
20
30
40
50
60
70
80
90
100
Per
cen
t sh
arin
g i
n l
ast
mo
nth
Does not use NEPUses NEP
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
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.
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.
The 2004 sample may be more educated, but they have less money
Educational level of IDU
08
83
92
12
63
22
0
20
40
60
80
100
Primary orless
SMP SMA Akademi
2002 2004
Distribution of monthly income
0.57
51
42
15
26
38
21
0
20
40
60
80
100
Under150,000
150-300,000
310-600,000
Over600,000
2002 (mean 700,000)2004 (mean 480,000)