Mapping of MARPs, Sri Lanka

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Presentation done at IUSTI, New Delhi 2011

Presentation done at IUSTI, New Delhi 2011

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  • 1. Mapping of MARPs and Strategic Planning Dr. Ajith Karawita MBBS, PGDV, MDNational STD/AIDS Control Programme, Sri Lanka
  • 2. Category Sri LankaLand area (sq km) 62,705Provinces 9Districts 25Grama Niladari Divisions 14,013(GND)Estimated mid yearpopulation 20 million(2005)Population density 313.7(Person per sq km)Average annual growth 1.1rate (1981-2001) 2
  • 3. Understanding the epidemic
  • 4. HIV Epidemic in Sri Lanka • First AIDS case reported (A Foreigner)1986 • First Sri Lankan with HIV reported1987 • First locally acquired HIV infection1989 Prepared by SIM Unit, National STD/AIDS Control Programme, Sri Lanka, 2010.
  • 5. National EstimatesCategory ValueAdult HIV prevalence (15-49) 0.02%Total PLHIV (2009) 3000Male: Female Ratio 2:1Children 35New infections per year 350Total ART need 500 One new infection pre day
  • 6. Reported NumbersHIV cases reported to National STD/AIDS Control Programmeas of 3rd Quarter 2011Cumulative number of HIV cases 1431Cumulative number of AIDS deaths 246Cumulative number of children infected with HIV 52(MTCT)Cumulative number of HIV patients on ART (including 207children)Cumulative number of infected children on ART 11Male: Female ratio 1.4: 1 Two new HIV cases are reported per week
  • 7. Number of new HIV cases reported to National STD/AIDS Control Programme, Sri Lanka as of end December 2010 Total Male Female Linear (Total) 160 137 140 129 119 121 120 102 100 95 91 92 80Count 68 77 69 55 54 65 63 60 60 47 50 54 55 54 42 37 45 44 40 27 30 32 37 37 40 39 23 22 34 26 29 26 24 28 26 31 20 11 13 24 7 19 20 18 20 19 15 12 16 2 3 8 6 10 8 11 8 10 10 0 2 3 3 1 3 0 0 -20 Year
  • 8. Cumulative HIV cases by mode oftransmission as of end December 2010 Hetero 82.5% Homo/Bi 11.3% Perinatal IDU Blood 4.4% 0.6% 0.3%
  • 9. Distribution of HIV cases by age and year2018 200616 200714 200812 2009 201010 2 per. Mov. Avg. (2006) 8 2 per. Mov. Avg. (2007) 6 2 per. Mov. Avg. (2008) 4 2 per. Mov. Avg. (2009) 2 2 per. Mov. Avg. (2010) 0 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+
  • 10. HIV prevalence among female sex workers (FSWs) 2 YEAR MOVING AVERAGEHIV PREVELANCE % 0.20% 0.16% 0.14% 0.13% 0.07% 0% 0% 0% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2009 Source: NSACP /Sentinel Suveillance Data
  • 11. HIV prevalence among MSMHIV PREVELANCE % 0.5% 0.0% 2008 2009 Source: NSACP /Sentinel Suveillance Data
  • 12. HIV prevalence among STD clinic attendees 2 Period Moving AverageHIV PREVELANCE % 0.36% 0.28% 0.2% 0.15% 0.13 % 0.08% 0.09% 0.08% 0.04 % 2000 2001 2002 2003 2004 2005 2006 2007 2009 Source: NSACP /Sentinel Suveillance Data
  • 13. HIV prevalence among TB patients 2 Period Moving AverageHIV PREVELANCE % 0.13 % 0.11% 0.07% 0.06% 0.08% 0.00% 0.00% 0% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2009 Source: NSACP /Sentinel Suveillance Data
  • 14. Epidemic status• Low prevalent country (HIV prevalence in any subgroup is less than 5%)• Truncated type of epidemic in returning migrant workers Target Populations for interventions Most at risk populations (MARPs)
  • 15. High Risk Groups (HRGs)High risk groups Additional populations1. Female sex workers (FSWs) 1. Heterosexual men and2. Men who have sex with women with multiple men (MSM). sexual partners3. STD clinic attendees 2. Prisoners4. Clients of FSWs 3. Populations surrounded by5. Injecting drug users (IDUs) armed conflict 4. Female domestic workers 5. Street children Be careful when naming a group according to the occupation Behaviour is the risk. NOT the occupation
  • 16. Mapping of MARPs in Sri Lanka
  • 17. District profile Colombo A.pura Batticaloa N’Eliya North Western Eastern Central Anuradhapura Location Central province Province Province Province Batticaloa Area 1.08% 10.6% 3.0% 2.6% Mid Year 2,400,000 791,000 523,000 742,000 Population Population 3,581/sq. 118/sq.k 186/sq. 412/sq.k Density km m km mColombo MOH 18 19 14 13 Nuwara Eliya Areas
  • 18. Mapping Methodology Pre- mapping The pre-mapping:Level 1 data Preparatory activities – collation Studying maps, Permission and authorization, Zone demarcations, Organization of research teams, logistics etc.Level 2 data collection Data Spot validation analysis Spot list
  • 19. Typologies of MARPs mapped Female Sex Workers MSM1. Brothel based 1. Nachchi (effeminate males/TG)2. Street based3. House /Shanty based 2. Gays4. Lodge/Hotel based 3. Male Sex Workers (MSWs)5. Massage parlor6. Karaoke bars 4. Beach boys (They are a group7. Night clubs of males (homo, hetero or8. Vehicle based - Vehicle based bisexual) cruising in and around sex workers are those who beach areas, who associate with operate from closed type of tourists as a guide, animator or vehicles (cars, vans etc.) in areas provider of any form of with high demand for sex workers. Usually these vehicles entertainment including provide sex workers to clients insertive or receptive sex and sometimes vehicle space for sex.
  • 20. Spots identified during L1 and L2 interviews by districts and MARPs Number of female sex worker spots Nuwara A.pura Colombo Batticaloa Total Eliya# of spots in L1 626 1429 244 531 2830# of active spots (L2) 311 1066 191 370 1938 Number of MSM spots Nuwara A.pura Colombo Batticaloa Total Eliya# of spots in L1 75 653 118 154 1000# of active spots (L2) 77 652 95 122 946
  • 21. Mapping can generate• Number and distribution of hotspots with its typology• Size estimation of the population concerned according to the – Geographical zones e.g. City/town, district – Type of MARPs – Sub-typologies of MARPs• Size of population according to the pattern they operate – On a usual day, on a peak day, what is the peak working hours etc.• Type of the spot according to the seeking risk or taking risk.• Detail information on a profile of MARPs by variables of interest.
  • 22. Mapping can generate cont.• Extrapolation and generation of district or national estimates by the application of different model approaches i.e. Regression model and percentile approaches.• GIS maps with hot spots• Has many more alternatives and adjustments to answer research questions, or objectives of your project planning and implementation.
  • 23. National Estimates for Sri Lanka National estimate for FSWs 41,285 (33,429 - 49,141) National estimate for MSM 32,796 (25,677-39,915)
  • 24. Anuradhapura District
  • 25. Anuradhapura District – FSW spots
  • 26. Anuradhapura District – FSW spots – Thematic map
  • 27. Anuradhapura District – MSM spots
  • 28. Anuradhapura– MSM spots – Thematic map
  • 29. Colombo District
  • 30. Colombo District – FSW spots
  • 31. Colombo District – FSW spots – Thematic map
  • 32. Colombo District – MSM spots
  • 33. Colombo District – MSM spots – Thematic map
  • 34. Batticaloa District
  • 35. Batticaloa District – FSW spots
  • 36. Batticaloa District – FSW spots – Thematic map
  • 37. Batticaloa District – MSM spots
  • 38. Batticaloa District – MSM spots – Thematic map
  • 39. Nuwara’Eliya District
  • 40. Nuwara Eliya District – FSW spots
  • 41. Nuwara Eliya– FSW spots – Thematic map
  • 42. Nuwara Eliya District – MSM spots
  • 43. Nuwara Eliya – MSM spots – Thematic map
  • 44. Before start interventions1. Geographical area of interventions – MOH areas – VillageGS divisionDS divisionsDistrictsProvincesNational – Pradesiya sabhaUrban councilMunicipal councilElectorate2. Population group – Groups practicing high risk activities (FSW, MSM, STI clinic attendees etc)3. Size of the target population (Denominator) – This is the most difficult part – Most of MARPs are hidden and difficult to reach – Different size estimation methodologies can be used ( from simple head counting to Mapping, Multiplier method, Capture-recapture method etc.)4. Coverage in terms of geography and population – This is easy once the denominators are established
  • 45. General target for behaviour change• 80% coverage of population leading to 60% behaviour change can reverse of the epidemic 60% behaviour Lead to reverse the 80% coverage change epidemic status
  • 46. Use of mapping data for strategic planning• Help in the understanding of the magnitude of the MARPs for interventions.• Provide information for advocacy and creating enabling environment for TIs• Provide information for planning of targeted interventions for MARPs• Provide size of population groups and typologies• Provide denominators for monitoring and evaluation of TIs• Monitoring of MARPs related indicators and at project level, national level and international level.• Help in the strengthening of HIV surveillance in a country
  • 47. Use of mapping data for strategic planning• Mapping data facilitate sampling of MARPs for surveys and studies• Provide information for the generation of HIV estimates by modeling (EPP, Spectrum)• Help in setting coverage for prevention interventions• Resource mobilization• Project proposal development and financial allocations• Miro-planning of interventions for MARPs
  • 48. Conclusion• Number of FSWs and MSM is not easy to estimate with precision since these numbers are live and moving.• However, these estimates are more practical and useful denominators for programme planning, monitoring and evaluation of HIV prevention interventions for MARPs.
  • 49. Acknowledgement to partners of this mapping studyMinistry of Health Sri Lanka Community Strength Development Foundation Sri Lanka Police