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Implementing AIDS Prevention and Care (IMPACT) Project: |
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This document describes the key technical strategies of IMPACT, the world's largest HIV/AIDS prevention, treatment, and mitigation project, funded by the United States Agency for International Development (USAID) and implemented by Family Health International.
These strategies drive an expanded response to the pandemic designed to involve all sectors of society in giving people the knowledge, skills and support they need to prevent HIV transmission and to help those who are already infected or affected by the virus. Through these strategies, IMPACT addresses sexual and non-sexual transmission of HIV, including unsafe handling of blood, injecting drug use and mother-to-child transmission. It also puts greater emphasis on intervening at multiple levels to make social norms, health services, and political and economic environments more supportive of individual behavior change. I. Mission III. Key Values Participation Strategy 1: Reduce Risk and Vulnerability to HIV - Sexual Transmission Strategy 2: Strengthen HIV/AIDS Care and Support Strategy 3: Support Public and Private Sectors and Communities for a Sustainable Response Strategy 4: Improve the Availability and Use of Data for Decision Making - Program Monitoring I. Mission In September 1997, the U.S. Agency for International Development (USAID) awarded Family Health International (FHI) and its partners a five-year cooperative agreement for the Implementing AIDS Prevention and Care (IMPACT) Project. The project was renewed in 2002 for another five years. IMPACT is designed to help countries expand and improve HIV/AIDS prevention and care programs. HIV has reached every corner of the globe and has touched millions of lives. More than 40 million people in over 190 countries have acquired the virus. HIV/AIDS has reduced life expectancy in some countries by 20 years or more and has imperiled hard-won advances in child survival. Clearly an expanded response to the pandemic is required -- one that involves all sectors of society to give more people the knowledge, skills, and support they need to prevent HIV transmission and to help those who are already infected. The IMPACT Project supports USAID in its efforts to achieve the strategic objective of "increased use of improved, effective and sustainable responses to reduce HIV transmission and to mitigate the impact of the HIV/AIDS pandemic." It helps USAID maximize its HIV/AIDS resources by designing state-of-the-art prevention and care programs that promote best practices, implement cost-effective approaches, leverage resources from both the public and private sectors, and strengthen monitoring and evaluation. IMPACT builds on Family Health International's 15 years of global leadership in HIV/AIDS prevention. A nongovernmental organization with a worldwide reputation for research, education, and service delivery in reproductive health, FHI in 1986 became one of the first U.S. NGOs to initiate HIV/AIDS programs in Africa. From 1987 to 1997, FHI managed the USAID-supported AIDSTECH and AIDSCAP projects. This document presents the IMPACT team's strategic approach to mounting an expanded response to reduce HIV transmission and mitigate the impact of the pandemic. The IMPACT team shapes its strategic approach with the insights gained from experience in HIV/ STI prevention and care, and applies global lessons learned that reflect the changing nature of the pandemic. The project's key intervention strategies are to:
HIV/AIDS interventions targeting individuals have shown some success. But individual behavior is profoundly influenced by broader contextual factors, including social norms, service accessibility, and public policy. IMPACT intervenes at multiple levels to influence individual and societal norms, improve the health infrastructure, and alleviate structural and environmental constraints to HIV/AIDS prevention and care. The IMPACT team recognizes that the HIV/AIDS pandemic consists of many separate epidemics with distinct characteristics that depend on the cultural context and geography, the timing of the introduction of the virus, and the state of response. Therefore, interventions are tailored to the local context and stage of the epidemic. IMPACT assists in designing and implementing programs that are locally appropriate, responsive to Mission needs, and targeted to meet strategic objectives. III. Key Values The IMPACT team's strategy for an expanded response to HIV/AIDS risk and vulnerability reflects the core values of FHI and its partners: Participation Community Empowerment Gender Sensitivity Collaboration Capacity Building Applying Effective Practices IMPACT's four key intervention strategies drive a comprehensive response to HIV/AIDS designed to expand the reach and the impact of prevention programs. They also support USAID's strategic objectives and intermediate results, as illustrated in Figure 1. Figure 1: IMPACT Strategies and Their Relation to USAID Intermediate Results Strategy 1: Reduce Risk and Vulnerability to HIV IMPACT aims to reduce the risk of HIV transmission by addressing the factors that facilitate sexual and non-sexual transmission. Sexual Transmission The IMPACT Project's strategy to reduce sexual transmission of HIV includes behavior change interventions (BCIs) that address personal, social, and contextual determinants of behavior and interventions to improve the prevention and management of the sexually transmitted infections (STIs) that enhance HIV transmission. Behavior Change Interventions Sustained change in individual behavior is unlikely unless there is also a change in relevant contextual factors. Therefore, IMPACT develops interventions at multiple levels of influence to encourage risk reduction for behavior change. At the individual level, IMPACT improves peer counseling, couples counseling and testing, and small group interventions. These interventions motivate individuals to change HIV risk behavior by influencing knowledge, attitudes, perceived norms, and safer-sex skills. They are reinforced by initiatives at the societal level, such as mass media campaigns and school and workplace interventions, that mobilize communities to provide a supportive environment for reducing risk. FHI and its partners also identify environmental and structural constraints to behavior change and advocate methods for eliminating or alleviating these barriers. For example, educating policymakers to address access to reproductive health information and services for youth is an essential method of reducing risk for that population. The table below describes illustrative behavior change interventions at multiple levels of influence aimed at reducing HIV transmission among adult populations. Example: Behavior Change Interventions for Adult Populations
STI Management and Prevention Biologic studies that demonstrated increased HIV shedding in the presence of urethral or cervical inflammation and reduced viral shedding after appropriate treatment have strengthened the evidence that STIs facilitate transmission and acquisition of HIV. These data reinforce the importance of STI prevention and management in any effective HIV prevention program. Moreover, many of the behaviors that put people at risk for STIs also put them at risk of HIV infection. While improving STI case management at health facilities shortens the duration of STI infectiousness and helps reduce HIV transmission, it may be insufficient on its own to lower STI prevalence. Therefore, IMPACT uses a targeted combination of clinic- and community-based strategies. The project works directly with local policymakers, clinicians, and program managers to design, implement, evaluate, and refine effective approaches to STI service delivery and community outreach. Like all IMPACT initiatives, the project's STI activities intervene at many levels. IMPACT targets individuals with education and counseling to improve treatment-seeking and preventive behaviors. At the societal level, it addresses stigma and other social barriers to effective treatment and prevention through marketing campaigns and community mobilization. It strengthens the infrastructure for STI management and prevention by developing case management guidelines, improving provider skills, and assessing innovative approaches to reaching STI patients. And at the structural level, IMPACT collaborates with local stakeholders to advocate for policies that support STI prevention and care. The following examples provide an illustration of program initiatives at multiple levels of influence to improve the quality and availability of, and demand for, STI management and prevention services. Example: Interventions to Improve Clinic-Based STI Services
Non-Sexual Transmission Blood Safety HIV transmission related to blood transfusion and medical practices accounts for up to 10 percent of HIV infections in resource-limited countries and approximately 3 to 5 percent of HIV transmissions worldwide. The vast majority of these infections can be prevented through the use of basic precautions. IMPACT supports blood safety by working with public and private sector partners and communities on a wide range of initiatives. At the individual and societal levels, the project develops interventions to educate, screen, and counsel potential blood donors. At the infrastructural level, IMPACT designs systems for safe blood collection and processing, including HIV-antibody screening, and encourages the use of universal precautions. In some cases, the project provides sterilization equipment. At the structural and environmental level, IMPACT promotes appropriate use of blood. For example, developing guidelines to reduce the number of unnecessary blood transfusions can also reduce the HIV vulnerability of mothers and children, who receive most of the transfusions in resource-limited countries. IMPACT also advocates for policy changes to eliminate paid blood donations. Injecting Drug Use Whereas sexual transmission of HIV remains the most significant transmission route at a global level, injecting drug use plays a critical role in fueling the epidemic in many countries. Experience shows that HIV epidemics associated with injecting drug use can be prevented, and even reversed. Strategies preventing HIV infection among injecting drug users (IDUs) may also reduce additional health risks, including overdoses and transmission of other blood-borne infections, such as hepatitis B and C. FHI and its partners support three major prevention components proven to be associated with containment of IDU HIV epidemics. These are early implementation of prevention initiatives while HIV prevalence is low; community outreach and peer education to IDUs to provide HIV/AIDS information and risk-reduction skills and to help develop trust between IDUs and health care providers; and widespread provision of sterile injection equipment (if appropriate funding is available). Mother-to-Child Transmission The first step in reducing mother-to-child HIV transmission is preventing HIV infection in women of childbearing age. FHI and its partners emphasize preventing sexually transmitted HIV among women through BCI and STI interventions for women and men at the individual, societal, and structural levels. IMPACT also advocates the provision and promotion of condoms and other barrier contraceptives to infected mothers to reduce unwanted pregnancies. For HIV-positive women who are pregnant, interventions focus on preventing mother-to-child transmission during pregnancy, delivery, and breast-feeding. Options to be considered include antiretroviral therapy and alternatives to breast-feeding. However, these options are not readily available in resource-limited countries. Other strategies, such as vitamin A supplements, active and passive immunization, and modification of the mode of delivery, are still under study. Current and future interventions to reduce mother-to-child transmission must ensure that pregnant women receive appropriate prenatal care. FHI and its partners support efforts to:
Strategy 2: Strengthen HIV/AIDS Care and Support HIV/AIDS care and support services are an integral part of IMPACT's expanded response to the epidemic. By strengthening such services (treatment of opportunistic infections and tuberculosis, palliative care, and social support for infected and affected persons) the project helps HIV-positive individuals live longer, more productive lives and helps families and communities cope with the impact of HIV/AIDS. FHI and its partners recognize that care and support also significantly contribute to prevention efforts, offering opportunities to involve people living with HIV/AIDS in prevention education. Identification of individuals, especially early in HIV infection, encourages early access to care and is strategic in limiting transmission to others. The major barrier to strengthening care and support services is that demand has overwhelmed fragile health care systems and available resources. These pressures are compounded by additional challenges emerging as the epidemic and treatments evolve. For example, promising new antiretroviral therapy is beyond the reach of many countries. At the same time, the disproportionate rate of increase in HIV infections among women and adolescents places new demands on services. And the stigma of HIV infection influences care-seeking behavior as well as service delivery. FHI and its partners work with communities, health care providers, and policymakers to make services more available and to assess alternate models of care. IMPACT expands and strengthens existing services in order to facilitate early treatment seeking and increased use of voluntary HIV counseling, testing, and support services. Identifying intervention strategies and delivering care to orphaned children are other essential components of IMPACT's expanded response. Ensuring adequate resources for care and support remains a challenge. FHI and its partners help countries and indigenous organizations access additional in-country financial resources through private sector leveraging and coordination of donor funding. IMPACT also provides clear, accurate information for decision making from service delivery evaluations, situation assessments, and socioeconomic impact analyses. The following example illustrates potential program initiatives at different levels of influence to improve the delivery of HIV/AIDS care and support services. Example: Interventions to Develop Improved Strategies and Policies for the Delivery of Basic HIV/AIDS Care and Support Services
Strategy 3: Support Public and Private Sectors and Communities for a Sustainable Response The response of the international donor community to HIV/AIDS has evolved along with the epidemic from an early "crisis" mode to an emphasis on capacity building and sustainability. The initial response focused on delivery of services in critical technical areas, such as controlling blood supplies, surveillance, diagnosis and treatment of opportunistic infections, and distributing condoms and prevention messages. More recent recognition of the epidemic as a long-term problem calls for a sustained, multisectoral response. The key to such a response is building the capacity of local organizations in both the public and private sectors. Community-based organizations and other NGOs have shown that they can reach and mobilize communities for prevention and care, but many need better technical skills and management systems. Although the commercial private sector can also play a critical role in HIV/AIDS prevention and care, few companies have the motivation or the capacity to provide workplace prevention and care programs and to adopt policies that support workers living with HIV/AIDS. And most governments need assistance in expanding programs to involve all relevant government ministries, their regional and local counterparts, and the private sector in prevention and care. The challenge is to expand the reach and sustainability of government and community efforts while making them more effective. IMPACT's strategy is to engage individual leaders in the government and private sector, strengthen community responses, and reduce infrastructural and environmental constraints to community action against HIV/AIDS. The IMPACT team works with local partners to:
On a structural level, IMPACT encourages governments and the private sector to look inward and outward to identify policies that support successful prevention and care programming. Private companies can examine and revise policies that encourage the spread of HIV/STI, such as lack of family housing for long-term workers who are away from home. Commercial and non-profit organizations can join forces to advocate for increased resources for HIV/AIDS programs and incentives such as tax breaks for imported prevention supplies or for companies that provide HIV prevention activities in the workplace. The following example demonstrates how the private sector workplace can be integrated into HIV prevention programs at multiple levels. Example: Interventions to Provide HIV/AIDS Services in the Private Sector Workplace
Strategy 4: Improve the Availability and Use of Data for Decision Making Data on program implementation and impact is critical to making HIV prevention and care programs more effective. IMPACT uses three major approaches to improve the availability and use of data for decision making: program monitoring, outcome/impact assessments, and operations research. Program Monitoring IMPACT monitors programs to track program implementation and document achievements. Through the use of a decentralized, user-oriented program monitoring system, IMPACT ensures that relevant indicators of the progress of each proposed country program or regional work plan are collected, analyzed, and used to improve programs. As a complement to these process indicators, qualitative research plays an important role in explaining how and why a prevention program succeeds or fails to meet its objectives. A monitoring and evaluation plan emphasizes sound standards for documenting implementation and sets benchmarks for achievement. IMPACT addresses not only whether activities take place, but also how well they take place. Program monitoring might include:
Given IMPACT's emphasis on capacity building, measuring increases in local capacity to sustain HIV/AIDS prevention efforts is an important part of program monitoring. IMPACT uses different tools to assess the components that collectively contribute to an effective organization. These components include the:
Outcome/Impact Assessment The effectiveness of HIV/AIDS prevention and care programs can be evaluated by collecting data that measure the extent to which the objectives of a program are achieved. Program outcome and impact assessments address the key question "Does the program make a difference?" IMPACT uses multiple techniques to examine the relationships between available biomedical, behavioral, and sociodemographic data. Linkages between program outcome data and patterns of HIV prevalence and incidence, as well as estimates of cost-effectiveness, are emphasized. This approach consists of different kinds of evaluation activities that can be implemented as part of a nation's prevention efforts. These activities include:
The IMPACT team provides technical assistance and guidance to the local institutions that carry out these activities. In doing so, IMPACT builds the capacity of organizations, both public and private, to design, implement, and evaluate HIV/AIDS interventions. Involving a broad range of partner agencies in planning and decision making at every step of an assessment is a central element of this strategy. Because HIV/AIDS programs are at various stages of implementation, IMPACT advises stratifying evaluation of program effectiveness by short-term and intermediate program effects (program outcome) and long-term program effects (program impact), as illustrated in the following example. Example: Potential Program Outcome/Impact Indicators
Operations Research IMPACT conducts operations research in conjunction with ongoing interventions to assist in developing, testing, and replicating HIV prevention and care models. Operations research questions are defined by the local context and program needs to ensure that the results will be useful and relevant. The methodologies used include:
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