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Module 6: Surveillance of Populations at High Risk for HIV Transmission Emic constructs are accounts, descriptions, and analyses

s that are regarded as meaningful and appropriate by the members of the target community. Etic constructs are accounts, descriptions, and analyses that are regarded as meaningful and appropriate by a community of scientific observers.

Conducting observations allows the researcher to build on information gathered from interviews with key informants or from focus group discussions. Other types of observations include counting, and ethnographic mapping.

Ethnographic Mapping
Conduct ethnographic mapping to create a comprehensive description of the places and time periods of business, and types of high risk activities that occurs in your area. Ethnographic mapping offers the following: plays an important role in learning more about the geographic location and temporal movement of high-risk populations, provides information for the environmental context for data analysis, and leads to new insights on both the differences and the similarities between field locations and target populations.

In terms of drug users, it may aid in the exploration of drug use patterns and the social infrastructure of drug users. Staff conduct ethnographic mapping by: reviewing scientific and prevention literature, local newspapers, and interviewing persons knowledgeable about the target population and HIV prevention services.

The outcome of these investigations is a constructed list of target population-identified venues and the days, times, and characteristics of the population who attend these venues, to identify potential sampling barriers, and to help construct prevention-service measures that will compose part of the questionnaire. Venues are the locations where the target population congregates. Depending on your target population you may find them in the following venues: cafes and restaurants retail businesses brothels

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Module 6: Surveillance of Populations at High Risk for HIV Transmission health clubs social and religious organisations STI clinics bathhouses streets and street corners parks, beaches truck stops tourist locations hotels massage parlours under bridges and fly-overs

During the mapping process, try to list the venues and count the number of your target population in a location. Create a census for the number of your target population in each place and count the number of your target population found on a particular street during particular hours.
Discussing the bullets

Looking at the bullets, answer the following questions: a. Which venues would you be most likely to find SWs in your country? b. Which venues would you be most likely to find IDUs in your country? c. Which venues would you be most likely to find MSM in your country?
Identifying venues

Some possible ways to identify venues include interviews with the following: staff from local health facilities local NGOs and community based organisations members of the target population HIV/AIDS providers staff from the local ministry of health HIV prevention program community leaders venue owners and managers, employees and patrons pimps and madams

One can also review literature and local newspapers for identified venues. To help ensure the representativeness of eligible venues, interviews should be conducted with the people from the target population who may be eligible for the study such as MSM between certain ages, closet MSM, SWs who work in brothels or on the street, and IDUs who do not use shooting galleries. 34

Module 6: Surveillance of Populations at High Risk for HIV Transmission

Listing venues and time periods

To form a list of eligible venues, staff should first construct a list of venues known to be attended by the target population. Potential targets are then asked to review the list and add other venues and the time periods that are well attended by their population. The time periods may be as few as one or two hours per month (e.g., a social organisation that meets only once per month) or as many as 12 hours or more daily (e.g., a busy street corner in a red light district). This process is repeated until additional venues and time periods are no longer revealed. Staff must ensure that possible participants who represent important demographic and social subpopulations review updated lists to ensure all eligible venues have been identified.
Socio-demographic characteristics and operational barriers

In addition to venues and time periods, formative interviews should also obtain, by venue: the socio-demographic characteristics of patrons potential barriers to recruiting and interviewing the target population

Assessing socio-demographic characteristics of venue patrons will enable staff to monitor these distributions and help ensure the inclusion of venues that are attended by important subpopulations. Identifying potential recruitment and interview barriers will help staff to further assess and prevent sampling barriers. Potential barriers that should be assessed include: structural management safety parking (if interview vans are used) competing outreach activities
Prevention-service measures

Countries may construct prevention-service measures in order to systematically monitor the extent to which HIV prevention services are available and indicate the level of service utilisation by members of the target population. To meet this surveillance need, countries must identify the local HIV prevention programs

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Module 6: Surveillance of Populations at High Risk for HIV Transmission choose which organisations, programs, and services will be monitored.

Services that could be considered for monitoring include: outreach HIV testing, condom distribution, and risk reduction efforts individual or group behavioural intervention programs HIV prevention case management public awareness and social marketing campaigns. Reviewing prevention literature and interviews with staff from prevention organisations may be needed to clarify the nature of services provided. Final prevention-service measures may be incorporated within the behavioural surveillance questionnaire.
Time Periods

Patterns vary over time, at different times of the day, or in response to seasonal changes in weather. Time periods are blocks of time that are specific to the business hours of each venue or in the case of street corners, the most popular turnout time block. Especially in terms of TLS, in order to provide staff with reasonably consistent work schedules, time periods should be constructed as much as possible with standard 4-hour periods. The following are examples of time periods: nightclubs have time periods that could be allocated from 10:00 p.m. to 2:00 a.m venues may have very few time periods such as a social club that meets only the first and third Tuesday of every month from 7:00 p.m. to 9:00 p.m venues will have many time periods such as a bar that is well attended Monday through Saturday nights from 5:00 p.m. to 9:00 p.m. and from 9:00 p.m. to 1:00 a.m.
Enumeration

Enumeration is the process of counting people who appear to fit the eligible criteria of the target population at each venue. In terms of TLS, during formative assessment, the purpose of enumeration is to determine whether venues and time periods yield sufficient people to be included within sampling frames (generally at least 8 people). During TLS events, the purpose of enumeration is to obtain a base count of people who might be eligible for the survey and to help standardise the recruitment process across sites and venues.

Utilising RAR and PLACE for Formative Assessments


Rapid Assessment and Response

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Module 6: Surveillance of Populations at High Risk for HIV Transmission Rapid Assessment and Response (RAR) is a method that is used to assess the nature and extent of a public health problem and to suggest ways to address the problem. RAR was not designed as a surveillance tool but rather as a way to quickly assess a situation and bring in the resources needed to address it. It can, however, be used as a method for formative assessments. For example, in HIV surveillance among high-risk groups, RAR has been used extensively for assessing spread among injection drug users (IDU). It can also be used for other hard-to-reach groups, such as sex workers. In practice, the techniques of RAR are quite similar to those outlined for general formative assessments above. RAR has two distinct parts: Needs assessment, or a systematic examination of the type, depth and scope of a problem, and Resource assessment, or a systematic examination of the response (funds, people, buildings, knowledge) that are either available or required to solve the problem.

In assessing a situation and designing interventions, RAR has a number of characteristics that make it different from standard surveillance or standard epidemiologic or social science research. These are summarised in the following table: Table 2.7. Unique characteristics of RAR. Characteristic
Speed Cost-effectiveness Exploitation of existing data Use of multiple indicators and data sources Investigative orientation Inductive analysis Relevance to interventions and practical issues Investigation on many levels of

Description
Rapid assessments are completed in far less time than conventional research projects. RAR uses cost-effective techniques with a focus on small, informative studies rather than expensive, large-scale ones. Rapid assessments make extensive use of existing data, and new data are gathered only when existing sources are inadequate. RAR makes uses of multiple data sources and synthesises them to come up with conclusions. Rapid assessments approach problems like a detective would, cross-checking information that is obtained from various sources. Rapid assessments initially establish descriptions of or hypotheses about a problem and then refine them as further information comes available. RAR focuses on developing interventions to address problems, rather than on perfect studies to assess the impact of interventions. Problems are examined in social, cultural, religious, political and historical contexts.

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Module 6: Surveillance of Populations at High Risk for HIV Transmission


society Community involvement Consultation Adequacy rather than scientific perfection

RAR involves the community of those who are affected and brings them into developing solutions RAR involves consulting a wide range of interested persons, including those affected. RAR uses multiple data sources and combines these data to draw conclusions about how to solve public health problems. This use of multiple data sources to address problems is sometimes called triangulation.

Discussing the table

Looking at the table on the previous page and answer the following questions: a. What is meant by inductive analysis? b. When would you use RAR? Why? c. How does RAR encourage community involvement?
Investigation of behaviours during RAR

Behaviours that place persons at high risk of HIV infection are diverse. Patterns of high-risk behaviour, even among the same high-risk groups, vary from country to country, between places within a country, between different subgroups within high-risk groups and over time. These patterns are investigated during the needs assessment phase of RAR. In addition, the response to high-risk behaviours varies between countries. For instance, how tolerant countries are of injection drug use, male homosexual behaviour or sex work is widely different depending on the country. Similarly, the interventions public health workers can use to reduce risk among these groups and what resources are available to them will also vary widely. Interventions must be appropriate culturally, socially, religiously, politically and economically, not only for the high-risk group but also for society at large. The focus of the response assessment phase of RAR is to develop ideas of what interventions may work. For instance, a country may not allow needle and syringe exchange to prevent transmission among IDUs but would allow an outreach programme that teaches IDUs to clean used needles and syringes with bleach. When used for formative assessment, the emphasis should be on rapid assessment. However, RAR goes further than just formative assessment to

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Module 6: Surveillance of Populations at High Risk for HIV Transmission develop and get interventions into the field. Rapid assessments can also be used to develop novel interventions. By talking to those most affected, in this case by HIV, ideas for what members of high-risk groups need to prevent HIV infection may emerge. Thus RAR is a process that takes a quick initial snapshot of a problem through rapid assessment, develops new or selects existing interventions, implements those interventions and evaluates them. This process is shown in Figure 2.1. Figure 2.1. The rapid assessment process.

Initial consultation Rapid assessment

Evaluation of interventions

Intervention development

Implementation of interventions
Discussing the figure

Looking at the figure and the text above, answer the following questions: a. What would happen if interventions came before rapid assessments? b. How does RAR differ from regular formative assessments?
PLACE

Priorities for Local AIDS Control Efforts (PLACE) is a method that can be used to identify areas of probable high HIV transmission and to focus prevention resources at sites where new sexual partners are being acquired within those areas. PLACE is not a sampling method but is valuable as a formative assessment tool for several high-risk groups. The PLACE method collects four types of data: key informant interviews interviews with knowledgeable people at sites interviews with people socialising at the sites 39

Module 6: Surveillance of Populations at High Risk for HIV Transmission maps of site locations

These data are collected in five discrete steps (Table X.X). The first step is to identify areas likely to have a higher incidence of HIV infection using available epidemiological data, such as HIV prevalence or STI rates, and demographic and contextual factors, such as: poverty over-crowding lack of health care urbanisation and rapid growth high male-to-female ratio alcohol consumption high population mobility unemployment political instability presence of refugee camps

Secondly, within these areas key informants are interviewed to determine where people meet new sexual or, in the case of injection drug users, needle-sharing partners. Sites may include, but are not limited to, hotels, bars, brothels, or hostels. Key informants identify not only the sites but also the sorts of people that go to them and the types of activities that occur. These sites are then placed on a map. There could be as many as 100 key informants interviewed. A good rule of thumb is to interview people until their responses begin to get repetitive and you are not learning anything new. Also, make sure there are key informants from various subpopulations in order to determine locations where everyone in the group frequent. Next, the PLACE team visits the sites and describes the type of people who visit the sites (for example, migrant workers) and whether there are HIV prevention messages and condoms available. The team then interviews patrons to determine the rates at which new partners are acquired and whether condoms are being used or not. Finally the team brings the four sources of data together to understand the extent to which HIV prevention messages and condoms are reaching those most likely to transmit HIV.
Summary of PLACE

The following table summarises the steps in the PLACE method. Table 2.8. Steps in the PLACE method. Step Objective 40

Module 6: Surveillance of Populations at High Risk for HIV Transmission


Preparatory 1 2 3 4 5 To adapt protocol if necessary, obtain community support, and ethical approval To identify and describe areas in a city or district likely to have high HIV incidence and select location(s) for implementing full PLACE assessment To identify sites and events, within selected areas, where people meet new sexual (and needle sharing) partners To conduct site visits to verify key informant reports and obtain site and patron characteristics that aid in development of prevention programmes To describe patrons of sites and estimate the rate of new partner formation among individuals socialising at sites To summarise findings, estimate monitoring indicators, and prepare a map useful for the intervention

Source: MEASURE Evaluation. The PLACE method: Priorities for Local AIDS Control Efforts. Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center. www.cpc.unc.edu/measure

Discussing the table

Looking at the table, answer the following questions: a. What are the preparatory steps for conducting a PLACE assessment? b. How would you use PLACE? Where would you go? What would you ask? c. What are four sources of information used to determine where highrisk sex is occurring?
Using PLACE

While designed as an HIV prevention tool, PLACE can also be useful to assess where high-risk sex is occurring and what high-risk groups may be involved. These groups could potentially include: sex workers and their clients mobile populations (for instance, truck drivers, migrant workers) uniformed personnel (for instance, police and military) men who have sex with men

PLACE has been used primarily in urban areas, but it could also be used in settlements for refugees, involuntary migrants and displaced persons, as well as some border areas. While PLACE has focused primarily on sexual transmission, it can also be used to understand IDU and their injection practices, such as sharing needles.

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Module 6: Surveillance of Populations at High Risk for HIV Transmission

Building Alliances
Forming Alliances

Building alliances is the process of bringing effective people together to accomplish a specific goal or purpose which will benefit all the members of the alliance. Alliances emerge when one or more parties want to further their interests beyond what they can do individually. Alliance members may consist of individuals, organisations, businesses, or other groups. Alliances should be formed with the organisations and individuals that are trusted by the high risk community. Surveillance requires gaining access to high risk populations and this can be difficult due to the key issues and challenges associated with these populations such as stigma, marginalisation, or illicit behaviour. Individuals, groups, and organisations are needed to band together in an attempt to conduct the surveillance. These people and organisations can help to do the following: more fully understand the culture and diversity of the population, identify subgroups, gain access to the population, and help to implement surveillance activities.

For example, former SWs can be hired and trained as recruiters or interviewers. Former IDUs can be hired and trained as recruiters or interviewers. Hiring former IDUs gives you the added advantage of using their experience to distinguish true IDUs from non-injecting drug users. It is important to remember that alliances need to be viewed as mutually beneficial. You should exercise caution and not alienate community gatekeepers.
Steps to forming Alliances

Forming alliances is an ongoing process that must be developed over time and will help in each stage of preparing for surveillance. When planning and implementing surveillance activities, it is important to understand the power structures that influence the movement and behaviour of the various high risk populations. This will be extremely helpful in setting up the infrastructure for the surveillance system and disseminating results of the surveillance activity. There are five main steps to building an alliance: 1) Establish a core working group: A team between four and ten members who represent the target population and organisations that have the most to gain through

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