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Annex 3: Technical Details of UNGASS Indicators Relevant to MSM and HIV/AIDS

Part of MSM, HIV and the Road to Universal Access: How Far Have We Come?

August 2008

Reprinted, Guidelines on Construction of Core Indicators (2008 Reporting), UNAIDS, 2007.


Most-at-Risk Populations: Reduction in HIV Prevalence

Most-at-risk populations typically have the highest HIV prevalence in countries with either concentrated or generalized epidemics. In many cases, prevalence among these populations can be more than double the prevalence among the general population. Reducing prevalence among most-at-risk populations is a critical measure of a national-level response to HIV. This indicator should be calculated separately for each population that is considered most-at-risk in a given country: sex workers, injecting drug users, men who have sex with men.

Note: Countries with generalized epidemics may also have a concentrated sub-epidemic among one or more most-at-risk population. If so, it would be valuable for them to calculate and report on this indicator for those populations.


Percentage of Most-at-Risk Populations Who Are HIV-Infected
PurposeTo assess progress on reducing HIV prevalence among most-at-risk populations
AppliciabilityCountries with Concentrated/Low Prevalence epidemics, where routine surveillance among pregnant women is not recommended; also includes countries with concentrated sub-epidemics within a generalized epidemic
Data Collection FrequencyAnnual
Measurement ToolUNAIDS/WHO Second Generation Surveillance Guidelines; Family Health International guidelines on sampling in population groups
Method of MeasurementThis indicator is calculated using data from HIV tests conducted among members of most-at-risk population groups in the capital city
NumeratorNumber of members of the most-at-risk population who test positive for HIV.
DenominatorNumber of members of the most-at-risk population tested for HIV.

Prevalence estimates should be disaggregated by sex and age (
To avoid biases in trends over time, this indicator should be reported for the capital city only. In recent years, many countries have expanded the number of sentinel sites to include more rural ones, leading to biased trends resulting from aggregation of data from these sites.


In theory, assessing progress in reducing the occurrence of new infections is best done through monitoring changes in incidence over time. However, in practice, prevalence data rather than incidence data are available. In analyzing prevalence data of most-at-risk-populations for the assessment of prevention programme impact, it is desirable not to restrict analysis to young people but to report on those persons who are newly initiated to behaviours that put them at risk for infection (e.g. by restricting the analysis to people who have initiated injecting drug use within the last year or participated in sex work for less than one year, etc.) This type of restricted analysis will also have the advantage of not being affected by the effect of antiretroviral treatment in increasing survival and thereby increasing prevalence. In the Country Progress Report, it is imperative to indicate whether this type of analysis is used to allow for meaningful global analysis.


Interpretation

Due to difficulties in accessing most-at-risk populations, biases in serosurveillance data are likely to be far more significant than in data from a more general population, such as women attending antenatal clinics. If there are concerns about the data, these concerns should be reflected in the interpretation.

An understanding of how the sampled population(s) relate to any larger population(s) sharing similar risk behaviours is critical to the interpretation of this indicator. The period during which people belong to a most-at-risk population is more closely associated with the risk of acquiring HIV than age. Therefore, it is desirable not to restrict analysis to young people but to report on other age groups as well.

Trends in HIV prevalence among most-at-risk populations in the capital city will provide a useful indication of HIV-prevention programme performance in that city. However, it will not be representative of the situation in the country as a whole.


Further Information

For further information, please consult the following website:


HIV Testing in Most-at-Risk Populations

In order to protect themselves and to prevent infecting others, it is important for most-at-risk populations to know their HIV status. Knowledge of one's status is also a critical factor in the decision to seek treatment. This indicator should be calculated separately for each population that is considered most-atrisk in a given country: sex workers, injecting drug users and men who have sex with men.

Note: Countries with generalized epidemics may also have a concentrated sub-epidemic among one or more most-at-risk populations. If so, they should calculate and report this indicator for those populations.


Percentage of Most-at-Risk Populations Who Received an HIV Test in the Last 12 Months and Who Know Their Results
PurposeTo assess progress in implementing HIV testing and counselling among most-at-risk populations
AppliciabilityCountries with Concentrated/Low Prevalence epidemics, including countries with concentrated sub-epidemics within a generalized epidemic
Data Collection FrequencyEvery two years
Measurement ToolBehavioural surveillance or other special surveys
Method of MeasurementRespondents are asked the following questions:

  1. Have you been tested for HIV in the last 12 months?

    If yes:

  2. I don't want to know the results, but did you receive the results of that test?
NumeratorNumber of most-at-risk population respondents who have been tested for HIV during the last 12 months and who know the results
DenominatorNumber of most-at-risk population included in the sample

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Data for this indicator should be disaggregated by sex and age (
Whenever possible, data for most-at-risk populations should be collected through civil society organizations that have worked closely with this population in the field.

Access to survey respondents as well as the data collected from them must remain confidential.


Interpretation

Accessing and/or surveying most-at-risk populations can be challenging. Consequently, data obtained may not be based on a representative sample of the national, most-at-risk population being surveyed. If there are concerns that the data are not based on a representative sample, these concerns should be reflected in the interpretation of the survey data. Where different sources of data exist, the best available estimate should be used. Information on the sample size, the quality and reliability of the data, and any related issues should be included in the report submitted with this indicator.

Tracking most-at-risk populations over time to measure progress may be difficult due to mobility and the hard-to-reach nature of these populations with many groups being hidden populations. Thus, information about the nature of the sample should be reported in the narrative to facilitate interpretation and analysis over time


Further Information

For further information, please consult the following references:

  • UNAIDS (2006). A Framework for Monitoring and Evaluating HIV Prevention Programmes for Most-at-Risk Populations.

  • UNAIDS (2006). Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access.

  • WHO (2006). Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users.


Most-at-Risk Populations: Knowledge About HIV Prevention

Concentrated epidemics are generally driven by sexual transmission or use of contaminated injecting equipment. Sound knowledge about HIV is an essential prerequisite if people are going to adopt behaviours that reduce their risk of infection. This indicator should be calculated separately for each population that is considered most-at-risk in a given country: sex workers, injecting drug users, men who have sex with men.

Note: Countries with generalized epidemics may also have a concentrated sub-epidemic among one or more most-at-risk populations. If so, it would be valuable for them to calculate and report on this indicator for those populations.


Percentage of Most-at-Risk Populations Who Both Correctly Identify Ways of Preventing the Sexual Transmission of HIV and Who Reject Major Misconceptions About HIV Transmission
PurposeTo assess progress in building knowledge of the essential facts about HIV transmission among most-at-risk populations
AppliciabilityCountries with Concentrated/Low Prevalence epidemics, including countries with concentrated sub-epidemics within a generalized epidemic
Data Collection FrequencyEvery two years
Measurement ToolSpecial behavioural surveys such as the Family Health International Behavioural Surveillance Survey for most-at-risk populations
Method of MeasurementRespondents are asked the following five questions:

  1. Can having sex with only one faithful, uninfected partner reduce the risk of HIV transmission?

  2. Can using condoms reduce the risk of HIV transmission?

  3. Can a healthy-looking person have HIV?

  4. Can a person get HIV from mosquito bites?

  5. Can a person get HIV by sharing a meal with someone who is infected?
NumeratorNumber of most-at-risk population respondents who gave the correct answers to all five questions
DenominatorNumber of most-at-risk population respondents who gave answers, including "don't know", to all five questions

Indicator scores are required for all respondents and should be disaggregated by sex and age (
The first three questions should not be altered. Questions 4 and 5 may be replaced by the most common misconceptions in the country.

Respondents who have never heard of HIV and AIDS should be excluded from the numerator but included in the denominator.

Scores for each of the individual questions -- based on the same denominator -- are required in addition to the score for the composite indicator.

Whenever possible, data for most-at-risk populations should be collected through civil society organizations that have worked closely with this population in the field.

Access to survey respondents as well as the data collected from them must remain confidential.


Interpretation

The belief that a healthy-looking person cannot be infected with HIV is a common misconception that can result in unprotected sexual intercourse with infected partners. Correct knowledge about false beliefs of possible modes of HIV transmission is as important as correct knowledge of true modes of transmission. For example, the belief that HIV is transmitted through mosquito bites can weaken motivation to adopt safer sexual behaviour, while the belief that HIV can be transmitted through sharing food reinforces the stigma faced by people living with AIDS.

This indicator is particularly useful in countries where knowledge about HIV and AIDS is poor because it allows for easy measurement of incremental improvements over time. However, it is also important in other countries because it can be used to ensure that pre-existing high levels of knowledge are maintained.

Surveying most-at-risk populations can be challenging. Consequently, data obtained may not be based on a representative sample of the national, most-at-risk population being surveyed. If there are concerns that the data are not based on a representative sample, these concerns should be reflected in the interpretation of the survey data. Where different sources of data exist, the best available estimate should be used. Information on the sample size, the quality and reliability of the data, and any related issues should be included in the report submitted with this indicator.


Further Information

For further information, please consult the following references:

  • UNAIDS (2006). A Framework for Monitoring and Evaluating HIV Prevention Programmes for Most-at-Risk Populations.

  • UNAIDS (2006). Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access.

  • WHO (2006). Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users.


Men Who Have Sex With Men: Condom Use

Condoms can substantially reduce the risk of the sexual transmission of HIV. Consequently, consistent and correct condom use is important for men who have sex with men because of the high risk of HIV transmission during unprotected anal sex. In addition, men who have anal sex with other men may also have female partners, who could become infected as well. Condom use with their most recent male partner is considered a reliable indicator of longer-term behaviour.

Note: Countries with generalized epidemics may also have a concentrated sub-epidemic among men who have sex with men. If so, it would be valuable for them to calculate and report on this indicator for this population.


Percentage of Men Reporting the Use of a Condom the Last Time They Had Anal Sex With a Male Partner
PurposeTo assess progress in preventing exposure to HIV among men who have unprotected anal sex with a male partner
AppliciabilityCountries with Concentrated/Low Prevalence epidemics, including countries with concentrated sub-epidemics within a generalized epidemic
Data Collection FrequencyEvery two years
Measurement ToolSpecial surveys including the Family Health International Behavioural Surveillance Survey for men who have sex with men
Method of MeasurementIn a behavioural survey of a sample of men who have sex with men, respondents are asked about sexual partnerships in the preceding six months, about anal sex within those partnerships and about condom use when they last had anal sex.
NumeratorNumber of respondents who reported that a condom was used the last time they had anal sex
DenominatorNumber of respondents who reported having had anal sex with a male partner in the last six months

Data for this indicator should be disaggregated by age (
Whenever possible, data for men who have sex with men should be collected through civil society organizations that have worked closely with this population in the field.

Access to survey respondents as well as the data collected from them must remain confidential.


Interpretation

For men who have sex with men, condom use at last anal sex with any partner gives a good indication of overall levels and trends of protected and unprotected sex in this population. This indicator does not give any idea of risk behaviour in sex with women among men who have sex with both women and men. In countries where men in the sub-population surveyed are likely to have partners of both sexes, condom use with female as well as male partners should be investigated. In these cases, data on condom use should always be presented separately for female and male partners.

Surveying men who have sex with men can be challenging. Consequently, data obtained may not be based on a representative sample of the national, most-at-risk population being surveyed. If there are concerns that the data are not based on a representative sample, these concerns should be reflected in the interpretation of the survey data. Where different sources of data exist, the best available estimate should be used. Information on the sample size, the quality and reliability of the data, and any related issues should be included in the report submitted with this indicator.


Further Information

For further information, please consult the following references:

  • UNAIDS (2006). A Framework for Monitoring and Evaluating HIV Prevention Programmes for Most-at-Risk Populations.

  • UNAIDS (2006). Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access.


Most-at-Risk Populations: Prevention Programmes

Most-at-risk populations are often difficult to reach with HIV prevention programmes. However, in order to prevent the spread of HIV among these populations as well as into the general population, it is important that they access these services. This indicator should be calculated separately for each population that is considered most-at-risk in a given country: sex workers, injecting drug users, men who have sex with men.

Note: Countries with generalized epidemics may also have a concentrated sub-epidemic among one or more most-at-risk populations. If so, they should calculate and report this indicator for those populations.


Percentage of Most-at-Risk Populations Reached With HIV Prevention Programmes
PurposeTo assess progress in implementing HIV prevention programmes for most-at-risk populations
AppliciabilityCountries with Concentrated/Low Prevalence epidemics, including countries with concentrated sub-epidemics within a generalized epidemic
Data Collection FrequencyEvery two years
Measurement ToolBehavioural surveillance or other special surveys
Method of MeasurementRespondents are asked the following questions:

  1. Do you know where you can go if you wish to receive an HIV test?

  2. In the last twelve months, have you been given condoms? (e.g. through an outreach service, drop-in centre or sexual health clinic)

    Injecting drug users (IDUs) should be asked the following additional question:

  3. In the last twelve months, have you been given sterile needles and syringes? (e.g. by an outreach worker, a peer educator or from a needle exchange programme)
NumeratorNumber of most-at-risk population respondents who replied "yes" to both (all three for IDUs) questions
DenominatorTotal number of respondents surveyed

Scores for each of the individual questions -- based on the same denominator -- are required in addition to the score for the composite indicator.

Data collected for this indicator should be reported separately for each most-at-risk population and disaggregated by sex and age (
Whenever possible, data for most-at-risk populations should be collected through civil society organizations that have worked closely with this population in the field.

Access to survey respondents as well as the data collected from them must remain confidential.


Interpretation

Accessing and/or surveying most-at-risk populations can be challenging. Consequently, data obtained may not be based on a representative sample of the national, most-at-risk population being surveyed. If there are concerns that the data are not based on a representative sample, these concerns should be reflected in the interpretation of the survey data. Where different sources of data exist, the best available estimate should be used. Information on the sample size, the quality and reliability of the data, and any related issues should be included in the report submitted with this indicator.

The inclusion of these indicators for reporting purposes should not be interpreted to mean that these services alone are sufficient for HIV prevention programmes for these populations. The set of key interventions described above should be part of a comprehensive HIV prevention programme, which also includes elements such as provision of HIV prevention messages (e.g. through outreach programmes and peer education), and opioid substitution therapy for injecting drug users.

Since the Global Progress Report in 2006, it has been recommended that the issue of quality and intensity of reported services among most-at-risk populations be addressed more explicitly in terms of criteria for the measurement of the components of provided services. Taking into account the complexity of this element of measurement, particularly within the context of most-at-risk populations, the development of such criteria requires an intensive process of information gathering, synthesis and recommendations formulation. This was difficult to address between the reporting processes of 2005 and 2007. However, the process has been initiated and is expected to have recommendations for the next reporting round. In the meantime, it is recommended that the guidelines mentioned below be referred to as reference documents that can facilitate interpretation of the collected data from a quality and intensity perspective.


Further Information

For further information, please consult the following references:

  • UNAIDS (2006). A Framework for Monitoring and Evaluating HIV Prevention Programmes for Most-at-Risk Populations.

  • UNAIDS (2006). Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access.

  • WHO (2006). Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users.





  
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This article was provided by amfAR, The Foundation for AIDS Research. Visit amfAR's website to find out more about their activities and publications.
 

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