Jeffrey OMalley

1
Community involvement in HIV Prevention
AIDS 2008, Mexico City 5 August 2008
Jeffrey OMalley Director, HIV/AIDS Group, UNDP
2
Theoretical pathways to explain the power of
community

• Social capital community mobilization to
  enhance positive social capital and enabling
  environments and to challenge / transform
  negative social capital
• Political science community involvement to
  claim rights, create healthier public policy,
  enhance accountability
• Health economics planning community
  involvement in planning and oversight to ensure
  more appropriate system design and targeting
• Management and system studies increasing
  efficiency, sensitivity and accountability
  through the use of community members as health
  care workers

3
Community involvement the bottom lines
1. Consent and consultation are essential but
dont confuse such processes with participation
and empowerment. 2. Authentic participation
with attention to power dynamics promotion of
autonomy, sense of community, and self-efficacy
of the community members themselves. 3.
Participation alone is insufficient need to
build community capacity. 4. Well designed and
implemented participation more effective and
less costly interventions. 5. Ideally, combine
community involvement with government leadership
and action, informed by science.

4
Community involvementThree examples from the
evidence base

• Community researchers provide more relevant
  insight
• PATH Indias Convergence Project
• New insights into prevention using participatory
  research on SRH-HIV linkages
• Empowerment in addition to services for better
  results
• The International HIV/AIDS Alliances Frontiers
  Prevention Project
• Empowerment for prevention and social capital
  strengthening leads to stronger behavioural and
  biological results than IEC and services alone
• Coping with complexity
• TDRs multi-country Community Directed
• Interventions study for primary health care
• Lessons from outside HIV/AIDS on both research
• methods and potential strengths of
  community
• led programming

5
1545 SW, Young people and positive people
participate in mapping
Participatory mapping 4 districts
Information from mapping generates list of
service providers and convergence options for
in-depth interview
160 service providers interviewed
2 staff from each service provider (Manager
Front line worker) interviewed
In-depth interviews generate information on
feasibility of Convergence options suggested by
community and on district/state-level policy
makers who can influence convergence
40 policy-makers interviewed
policy-makers, donors, etc. interviewed
Data analysis, state/district level meetings to
prioritise convergence models for implementation
Convergence models implemented and evaluated
6
Convergence Project Key results
AIDS must remain a top priority on all our
agendas and our daily work must reflect this
through results that support national efforts to
combat AIDS We have to make more determined
efforts in Responding effectively to one of the
most serious Challenges facing the world.
Therefore I am Directing you to establish a
joint UN Team on AIDS with one joint programme of
support - SGs letter to RCs dated 12
December 2005
7
Convergence ProjectLessons Learned

• Community members as researchers with findings
  triangulated with health professionals better
  research, enhanced capacity for follow up action.
  
• Ask people first what they want and need you
  will be surprised.
• Community researches can also effectively conduct
  service and policy research and make a
  significant difference in opening up service
  providers and policy makers to new approaches

8

• Implemented by International HIV/AIDS Alliance
  from 2003 to 2007 with Gates Foundation funding
• Five country programme of community focussed STI
  and HIV prevention
• Four sets of interventions
• Saturate sites
• Focused on and implemented with Key Populations

9
Frontiers Prevention Project conceptual framework
INTERMEDIATE OUTCOMES
GOAL
PURPOSE
Enabling Environment
Decrease in KP risky behaviour
Decrease in KP risky behaviour
Empowerment for prevention for KPs
Decrease in HIV Incidence in site
Decrease in HIV Incidence in site
Decrease in HIV Incidence amongst KPs
Decrease in HIV Incidence amongst KPs
Service and Commodity provision for KPs
Decrease in KP STI Prevalence
10
Four sets of interventions to saturate sites
Community interventions
Advocacy, policy change community awareness
Scaling up, targeting improving services
Individually focused health promotion
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
Frontiers Prevention ProjectLessons Learned

• Investing in prevention programming - saturated
  prevention works
• Community involvement is a critical success
  factor for the success of health system
  interventions.
• More programs are required to build the capacity
  of community orgs to take on expanded roles in
  provision of health services

16
Community Directed Interventions
Began as a community directed response to river
blindness Community members collectively Plan
how, when, where and by whom ivermectin will be
distributed Discuss results and adjust approach
as required District health staff Introduce
CDI concept to the community Provide training,
supervision and supplies
17
Study Design

• STUDY SIZE
• 3 Countries (Nigeria, Cameroon, Uganda)
• 7 Study Sites
• 35 Health Districts
• 2.3 million People

Combinations of interventions
18
P 0.6
Target
19
Plt0.001
RBM target
20
Plt0.001
RBM target
21
Costs of delivery of the 5 interventions
22
Main Conclusions

• CDI more effective than current delivery methods
  for all studied interventions except DOTS
• Malaria treatment coverage two times higher
• ITN coverage two times higher
• Vitamin A coverage significantly higher
• Ivermectin coverage significantly higher
• At least 4 to 5 interventions could be
  effectively implemented through the CDI process
• Coverage increased over time reflecting
  maturation of the CDI process
• CDI is more efficient with respect to costs to
  the health system

23
Community involvement in preventionKey messages
for action and research

• PATHs Convergence Project
• Community members themselves are ideal
  researchers, especially when using qualitative
  and participatory methods. Recruitment and
  training takes time, but the trained community
  members end up becoming key resources in
  subsequent community responses.
• Ask people first what they want and need you
  will be surprised.
• Community
• The AIDS Alliances Frontiers Prevention Project
• The International HIV/AIDS Alliances Frontiers
  Prevention Project
• Empowerment for prevention and social capital
  strengthening leads to stronger behavioural and
  biological results than IEC and services alone
• TDRs Community Directed Interventions study
• TDRs multi-country Community Directed
• Interventions study for primary health care
• Lessons from outside HIV/AIDS on both research
• methods and potential strengths of
  community
• led programming

24
Thank you to P.I.s and research teams at the AIDS
Alliance/INSP, PATH and partners, and TDR.
References via www.undp.org