The Priorities for Local AIDS Control Efforts Method PLACE: An Overview Sharon Weir Carolina Population Center & Department of Epidemiology University of North Carolina, Chapel Hill NC USA Email: sharon weir @unc.edu
PLACE Counties: Past and Present Kazakhstan Karaganda Almaty Russia Kyrgyzstan Saratov-Engels Samara China Uzbekistan Osh Liuzhou St. Petersburg TashkentMexicoChetumalCiudad Hidalgo Burkina Faso India Banfora Bhubaneswar DR Congo Haiti TenkodogoJamaica Carrefour Burundi RwandaAll parishes All 12 provinces Guyana Uganda Kenya All 8 provinces St. Lucia Ghana Tanzania Castries All 10 regions Angola Magu Malawi Gros Islet Luanda Madagascar Anse la Raye Zimbabwe 7 cities Zambia Hwange District Mongu Kapiri Mposhi South Africa Lesotho 2 townships in Port Elizabeth Ficksburg, Maseru, Maputsoe, La East London dybrand, Fouriesburg, Butha 1 Township in Cape Town Buthe
Global Recommendationfor PLACE ―Use innovative methods (PLACE, key informant interviews) to estimate the size and location of relevant key populations by country.‖ Key Population Working Group Presentation to PEPFAR’s Scientific Advisory Board Washington, DC, October 2-3, 2012 Mead Over, Center for Global Development
Problem Addressed by PLACE:Preventing HIV transmission at the locallevel∆ The PLACE method addresses the need for rapidly available information to strategically target and monitor local AIDS prevention.
PLACE Argument∆ The HIV pandemic is worldwide but transmission occurs in local epidemics∆ Prevention should focus in geographic areas where HIV incidence is highest∆ No two local HIV epidemics are the same. Each local HIV epidemic reflects its unique underlying pattern of new and concurrent sexual and needle sharing partnerships. National and provincial data may hide local epidemics.∆ In the absence of empiric data on the geographic distribution of HIV incidence and number of new infections, national stakeholders can thoughtfully interpret available information to identify where HIV incidence is high.
PLACE Argument∆ Interrupting HIV transmission requires focusing on people with high rates of new sexual or needle sharing contacts.∆ Effective prevention among these individuals must be multi- level, using tailored ―combination prevention‖ to reduce their partnership rates, increase testing, treatment, referral and counseling for HIV/STI, and condom use.∆ The PLACE method identifies venues and events where local intervention programs can reach the most important sexual and injecting drug use networks.∆ Although outreach to these places can be expensive, outreach is cost-effective if chains of transmission are broken.
Epidemiologic Model: R= c * B * D∆ In a population where everyone initially is uninfected, the epidemic potential for the population can be defined in terms of the average number of new infections ―R‖ that would be sparked per each infected case over a specific time period after one new infection was randomly seeded into the population.∆ If each infected person infects > 1, the epidemic is increasing. If each infected person infects < 1 person, the epidemic will gradually die. What determines if R is going to be greater than one or less than one? – C The rate of new sexual partnerships. The more new partners an infected person has, the more people will be exposed to the infection. The more partners an uninfected person has, the more likely he or she will be exposed to a partner who is infected. – B The probability of transmission during a contact between an infected and uninfected person. Not using a condom, anal sex, high viral load (due to primary infection for example) and untreated STI increase the probability of transmission. – D How long a person is infectious. In HIV, infectiousness is considered lifelong.∆ PLACE aims to identify those with the highest rates of ―c‖ and reduce their probability of transmission per contact through STD treatment and condom use so that R is reduced.
Theoretical Framework: Proximate Determinants of HIV TransmissionUnderlying Proximate Biological Health Demographicdeterminants determinants determinants outcome outcome New Partner C Rate of Acquisition Contact ofContext Mixing patterns susceptibleSocio-economic Concurrency to infected HIVSocio-cultural Abstinence persons incidenceIntervention Condom use MortalityPrograms Concurrent STI B Efficiency ofCT Risky sexual transmissionSTD control practices per contactCondom Chemotherapy STIpromotion incidence Treatment D Duration of infectivity Boerma JT, Weir SS. Integrating demographic and epidemiologic approaches to research on HIV/AIDS: the proximate determinants framework. Jour Inf Dis 2005;191(Suppl 1):S61-S67.
PLACE Overview∆ Define PLACE strategy to meet country needs and adapt protocol∆ Identify and select priority prevention areas where HIV incidence is high∆ In each area, interview community informants to systematically list verifiable public places where people with high rates of new sexual or needle sharing partnerships meet new partners and could be reached with prevention services.∆ Visit all reported places, assess each for on-site prevention program messages and coverage, and map.∆ Construct a sampling frame of places based on the data and select a representative sample of people at the places during peak attendance hours.∆ Interview these persons re demographics, risk behaviors, and exposure to prevention. If possible, obtain biomarker samples.∆ Use results to describe the place-based population and the characteristics of those with highest partnership rates.∆ Work with local stakeholders to identify actionable gaps in prevention and produce coverage maps.
PLACE Protocol Overview: The 5 Steps 1. Establish a PLACE steering committee 2. In high incidence areas: Identify venues where people meet new partners 3. Visit, characterize, map venues 4. Interview and test venue patrons & workers 5. Use results to improve programs
Step 1: Establish PLACE Steering Committee∆ Convene a meeting of experts and review data and contextual factors to identify areas of country where HIV incidence is likely to be high∆ Adapt protocol to country / Obtain IRB approval – Define package of interventions to be assessed with coverage indicators – Identify key populations for any oversampling – Identify indicators required – Gain support of organizations providing prevention and linkage to care – Identify what testing will be done
Example: Selection of High Incidence Areas in Madagascar∆ The National AIDS Commission identified 7 areas based primarily on contextual information: – Antsiribe: 2nd largest city, transportation crossroads, tourism – Tsiromandidy: Semi-urban, large cattle market – Ilakaka: New sapphire mining area – Morondava: Port city, tourism, hiv prevalence ^ – Fort Dauphin: Port city, mining industry, tourism – Mananjary: Port City, tourism, cultural center – Taolagnaro: Economic center, tourism
District HIV stakeholdersidentified tradingcenters, fishing posts, nightlife hot spots, rapid growthareas, and highwaystopovers at in thisTanzania region.
Step 2: Within High Incidence Areas, Ask CommunityInformants: Where do people meet new partners?∆ Probe based on strata of interest for mixing∆ Young women and older men∆ Commercial sex workers∆ Mobile and resident∆ Military and civilian∆ People who inject drugs∆ Ask until no new venues are found∆ Output: List of venues with number times reported
Township, South Africa Venues∆ In the first PLACE study, 297 community informants identified 234 venues that interviewers visited and characterized within 3 weeks.∆ We expected 50-60 venues
Step 3: Visit, characterize and map places ∆ Places include where people meet new sexual partners and where people who inject drugs can be reached. ∆ Reported places are visited and mapped. An interview is conducted with a knowledgeable person on-venue to obtain characteristics of the place ∆ A place can be an establishment such as a bar, an outdoor site such as a park or street, an event such as a community festival, an internet site, or a phone number— such as for escort services. ∆ Mapping can be done by hand, onto an aerial photo, or using GPS
Characteristics of places / venuesObtained from interviewing a knowledgeable person at the venueTo Gauge Prevention To describe patrons of venues Program Coverage and Potential at Venues ∆ Male:female ratio∆ Type of venue ∆ Regular patrons∆ Condom availability ∆ Where patrons reside∆ Evidence of AIDS ∆ Whether patrons include prevention commercial sex∆ Busy times workers, gay, military, mobile,∆ Maximum occupancy youth, locals, unemployed, ID∆ Number of staff U∆ Venue stability ∆ Whether people meet new partners at venue
Venue-based indicators from Step 3Township, South Africa – Venues where new partners are met 234 – % with condoms always available 5% – % with condoms never available 80% – % willing to have AIDS program 92% – % with alcohol consumption at venue 88% – % with over 100 patrons at once 10% – % with student patrons 27%
Mapping Risk Venues using the PLACE method inLuanda, Angola identified risk venues without prevention outreach Area with clusters of venues but no prevention program.Weir et al, Results of the application of the PLACE approach to Rocha Pinto, Angola
Step 4: Interview and test people atplaces∆ Opinion: ∆ Socio-demographic & – Do other people behavioral characteristics come here to meet – Number of new and new partners? total partners in the past four weeks, year∆ Behavior: – Condom use – Have YOU ever met – Exposure to intervention a new partner at this venue? – Have YOU ever ∆ Test for HIV & other STI injected?
Interviews with patrons: Example ofSampling Strategy∆ Interviews at busy times at 40 venues∆ An interval sampling strategy with probability of selection proportional to size is used to select 40 venues where interviews with patrons will occur∆ At each selected venue, approximately 24 male and female patrons were systematically selected and interviewed∆ All workers at selected venues also interviewed∆ Total of 960 patron interviews + worker interviewsNOTE: Actual sample size, sampling strategy developedin consultation with Steering Committee and samplingstatisticians
Onsite Testing of Patrons and Workers:The following tests have been used with PLACE:∆ HIV (multiple tests used)∆ Syphilis Testing (multiple tests used)∆ Gonorrhea from urine sample (Gen-Probe)∆ Chlamydia from urine sample (Gen-Probe)∆ Trichomoniasis from urine sample (Gen-Probe)∆ New in summer of 2013: Malaria, anemia, dengue fever
Percentage of Patrons Who Have Ever Met a NewSexual Partner at the Venue: Findings from 6PLACE Studies in Africa including 4 in South Africa 70 These findings 60 confirmed that PLACE found 50 persons at risk. 40 30 20 10 0 CT Twp EL Twp PE Twp PE CBD Area in Banfora, Kampala Burkina Men Women Faso
Even though people reported meeting newsex partners at these venues, few venuesreported commercial sex onsite People with many 35 sex partners often do not self identify 30 as sex workers 25 and the venues do not report 20 commercial sex onsite. 15 10 5 0 CT Twp EL Twp PE Twp PE CBD Area in Banfora, Kampala Burkina 4 Areas in South Africa Faso
Step 5: Use results to improve programs ∆ Maps can be shared with condom distributors to ensure that condoms reach risk venue. ∆ Sub-group analysis can be used to provide reportable M&E indicators for key populations including sex workers, MSM, persons who inject drugs, youth ∆ Coverage indicators for the package of interventions for key populations can be assessed and portrayed on maps
Additional options∆ PLACE protocol can be adapted to estimate size of risk populations.∆ PLACE protocol can be adapted to provide information for MOT analysis.∆ PLACE can be used to promote MC∆ PLACE protocol can be adapted to collect biomarkers.
STEP 5Inform interventionsMaps can show wherecondoms are needed
Impact of PLACE in Jamaica after 10years of implementation∆ Improved Surveillance of MARPS – Identified staff and patrons at venues as high risk via PLACE – Showed the continued high prevalence of other STIs – Improved the tracking of HIV & risk factors among MARPs∆ Improved interventions – Significantly increased access & outreach to MARPs – Developed the scope and expertise of our outreach staff – Spearheaded outreach HIV and STI testing/ youth∆ Increased used of data to guide planning & interventions – Helped us to refine our outreach interventions – Convinced policy makers of need to retain field staff – Showed the importance of social vulnerability – Improved monitoring & evaluation∆ Helped to reduce HIV prevalence among sex workers from 9% to 4.5%
The PLACE method Sex Work At Venues identifies the gaps in HIV prevention in Iringa, Tanzania? 44% of villages and neighborhoods did NOT have recognizable presence of HIV prevention Most male patrons were buying sex Some male patrons buying sexPercentage of Villages and Mtaa WithRecognizable Prevention Outreach by District No male patronsStudy included representative sample of Mtaa and villages buying sex
PLACE can help…∆ Provide understanding of the sexual networks and mixing patterns in a community∆ Identify intervention venues∆ Provide indicators for monitoring prevention∆ Provide estimates of HIV/ STI prevalence among workers and patrons of venues∆ Sub-group analysis can provide estimates for sex workers, MSM other groups
How does PLACE differ fromDemographic and Health Surveys (DHS)?∆ DHS is a very large and expensive household survey that obtains information on a range of health topics including HIV. – PLACE focuses on HIV and is implemented within priority prevention areas at a fraction of the cost of the DHS.∆ DHS provides national-level health indicators using population-based data. It does not provide local estimates. – PLACE data are not representative of the general population. Instead, PLACE monitors the local HIV response in key target areas among persons most likely to acquire and transmit HIV.∆ Since it is a household survey, DHS may miss mobile populations, under- represent young men, and be conducted in a setting where people are less likely to report extra-marital partnerships. – PLACE interviews persons who are socializing at venues identified as places where people meet new sexual partners and thus often includes a large number of sexually active youth and mobile populations. PLACE can miss persons who do not visit public venues.
How does PLACE differ from TargetedRisk Group Surveys?∆ Targeted risk-group surveys require operational definitions of target groups to develop the sampling frame. – PLACE avoids having to define ―men who have sex with men‖ or ―sex workers‖ during data collection because it samples from all venues where any persons meet sexual partners. Indicators for particular groups can be obtained during the analysis phase.∆ Results from targeted risk group surveys are usually specific to the defined target group. – PLACE data allows generalization to the population that visits venues where people meet new sexual partners and allows examination of the overlap between groups.∆ Targeted surveys often aim to get national estimates for key populations and indicators for national level reporting. – PLACE results serve local programs immediately by providing maps of program coverage and identify priority venues where AIDS prevention programs are needed.
How does PLACE differ from respondent drivensampling?∆ Respondent driven sampling often is a strategy to sample sex workers or MSM and uses peer recruitment to identify a sample of people meeting the definition of the population. – PLACE does not recruit individuals with particular behaviors. It identifies risk venues and characterizes those persons at the venue regardless of whether they meet the study definition of sex worker or MSM. Consequently, RDS is often more efficient at getting a large sample of a specific type of person. PLACE provides a broader picture of persons at risk. – RDS usually requires participants to go to a study office for interview. PLACE does not require that a participant go anywhere. – RDS can reach people who are not at risk venues. PLACE can reach people at risk venues who will not go to an RDS study office. – See also • Weir SS, Merli MG, et al. Comparison of Venue-based and respondent driven sampling of sex workers, in press, Sexually Transmitted Infection 2012 Dec 88 (Suppl 2), i95-i101
How does PLACE differ from respondent drivensampling and time-location sampling?∆ PLACE is a type of TLS.∆ Usually TLS is implemented among specific types of venues (such as MSM venues or sex worker venues.) PLACE is implemented at a wide variety of places reported as places where people meet new partners or where IDU can be reached.∆ TLS often screens persons for participation and limits to people meeting certain criteria such as those who report sex work. PLACE casts a wide net and has few exclusion criteria.∆ TLS samples from peak and non-peak times at a venue. PLACE samples from venues at peak times.∆ Often TLS is implemented as part of surveillance and to obtain indicators. PLACE obtains indicators but has a focus on local use of data and development of action plans and use of the maps for outreach.
The research presented here has been supported by thePresident’s Emergency Plan for AIDS Relief (PEPFAR)through the United States Agency for InternationalDevelopment (USAID) under the terms of MEASUREEvaluation cooperative agreement GHA-A-00-08-00003-00. Views expressed are not necessarily those ofPEPFAR, USAID or the United States government.MEASURE Evaluation is implemented by the CarolinaPopulation Center at the University of North Carolina atChapel Hill in partnership with Futures Group, ICFInternational, John Snow, Inc., Management Sciences forHealth, and Tulane University.