SUPPLEMENT TOOL TO SET AND MONITOR TARGETS FOR HIV PREVENTION, DIAGNOSIS, TREATMENT AND CARE FOR KEY POPULATIONS

Transcription

1 SUPPLEMENT TOOL TO SET AND MONITOR TARGETS FOR HIV PREVENTION, DIAGNOSIS, TREATMENT AND CARE FOR KEY POPULATIONS SUPPLEMENT TO THE 2014 CONSOLIDATED GUIDELINES FOR HIV PREVENTION, DIAGNOSIS, TREATMENT AND CARE FOR KEY POPULATIONS JULY 2015

2

3 TOOL TO SET AND MONITOR TARGETS FOR HIV PREVENTION, DIAGNOSIS, TREATMENT AND CARE FOR KEY POPULATIONS SUPPLEMENT TO THE 2014 CONSOLIDATED GUIDELINES FOR HIV PREVENTION, DIAGNOSIS, TREATMENT AND CARE FOR KEY POPULATIONS JULY 2015

4 WHO Lirry Ctloguing-in-Puliction Dt Tool to set nd monitor trgets for HIV prevention, dignosis, tretment nd cre for key popultions. I.World Helth Orgniztion. ISBN Suject hedings re ville from WHO institutionl repository World Helth Orgniztion 2015 All rights reserved. Pulictions of the World Helth Orgniztion re ville on the WHO wesite ( or cn e purchsed from WHO Press, World Helth Orgniztion, 20 Avenue Appi, 1211 Genev 27, Switzerlnd (tel.: ; fx: ; e-mil: ookorders@who.int). Requests for permission to reproduce or trnslte WHO pulictions whether for sle or for non-commercil distriution should e ddressed to WHO Press through the WHO wesite ( The designtions employed nd the presenttion of the mteril in this puliction do not imply the expression of ny opinion whtsoever on the prt of the World Helth Orgniztion concerning the legl sttus of ny country, territory, city or re or of its uthorities, or concerning the delimittion of its frontiers or oundries. Dotted lines on mps represent pproximte order lines for which there my not yet e full greement. The mention of specific compnies or of certin mnufcturers products does not imply tht they re endorsed or recommended y the World Helth Orgniztion in preference to others of similr nture tht re not mentioned. Errors nd omissions excepted, the nmes of proprietry products re distinguished y initil cpitl letters. All resonle precutions hve een tken y the World Helth Orgniztion to verify the informtion contined in this puliction. However, the pulished mteril is eing distriuted without wrrnty of ny kind, either expressed or implied. The responsiility for the interprettion nd use of the mteril lies with the reder. In no event shll the World Helth Orgniztion e lile for dmges rising from its use. Lyout L IV Com Sàrl, Villrs-sous-Yens, Switzerlnd. Printed y the WHO Document Production Services, Genev, Switzerlnd.

5 1 CONTENTS ACKNOWLEDGEMENTS ABBREVIATIONS PART INTRODUCTION THE MONITORING AND TARGET-SETTING PROCESS Ntionl level progrmme ssessment Meningful community prticiption in the ssessment process Indictors Trget setting Dt sources TYPES OF INDICTORS Assessing key fctors ssocited with the enling environment Mesuring the vilility of helth sector interventions Mesuring intervention coverge Mesuring intervention qulity Mesuring the outcome nd impct of interventions Disggregting dt to etter understnd diversity Trget setting PART INDICATORS Strengthening the enling environment Qulity indictors for ll progrmmes nd interventions Comprehensive condom nd luricnt progrmming Needle nd syringe progrmmes Opioid sustitution therpy Overdose prevention nd mngement Reducing hrms relted to injecting sustnces for gender ffirmtion Behviourl interventions Pre-exposure prophylxis HIV testing nd counselling HIV tretment nd cre, including ntiretrovirl therpy Prevention nd mngement of co-infections nd other co-moridities Sexul nd reproductive helth Comined pckge of interventions Outcome nd impct indictors REFERENCES

6 2 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions ACKNOWLEDGEMENTS This document ws written y Brdley Mthers (The Kiry Institute for Infection nd Immunity in Society, University of New South Wles, Austrli), Keith Sin (Joint United Ntions Progrmme on HIV/AIDS (UNAIDS), Switzerlnd) nd Annette Verster (Deprtment of HIV/AIDS, World Helth Orgniztion (WHO), Switzerlnd) with support from Michelle Rodolph, Txem Grci Cllej nd Rchel Bggley (Deprtment of HIV/AIDS, WHO, Switzerlnd). The tool is sed on the frmework of the WHO, UNODC, UNODC Technicl Guide for Countries to Set Trgets for Universl Access to HIV Prevention, Tretment nd Cre for Injecting Drug Users which ws uthored y Mrtin Donoghoe, Annette Verster nd Brdley Mthers (WHO, 2009; nd revised in 2012). The uthors grtefully cknowledge the experts who reviewed nd provided comments nd input to this document (in lpheticl order y ffilition): Klint Kinder, Owen Ryn (mfar, The Foundtion for AIDS Reserch, United Sttes of Americ); Stef Brl (Center for Pulic Helth nd Humn Rights, Johns Hopkins Bloomerg School of Pulic Helth, USA); Jordi Cson (Centre d Estudis Epidemiològics sore les ITS/SIDA de Ctluny, Spin); Dvid Lewis (Centre for HIV nd STIs, Ntionl Institute for Communicle Diseses, South Afric); Ptrick Sullivn (Emory University, USA); Justus Eisfeld (Glol Action for Trns* Equlity (GATE)); Mtthew Greenll, Ruth Morgn Thoms, Neil McCulloch, Khrtini Slmh (Glol Network of Sex Work Projects, UK); Be Vuylsteke (Institute of Tropicl Medicine, Belgium); Ann Dovkh, Deinek Elen, Deelyuk Myroslv, Gen Vrn (Interntionl HIV/AIDS Allince, Ukrine); Christoforis Mllouris, Slil Pnkdn, Alison Crocket, Peter Ghys, Krl Dehne (United Ntions Progrmme on HIV/AIDS (UNAIDS), Switzerlnd); UNAIDS MERG (Monitoring nd Evlution Reference Group); Agnet Mithi (Ntionl AIDS & STI Control Progrmme, Keny); Elliot Alers (Interntionl Network of People who Use Drugs); Toni Potet (Office of the U.S. Glol AIDS Coordintor (OGAC), USA); George Ayl (The Glol Forum on MSM & HIV (MSMGF), USA); Muro Gurinieri, Sumn Jin, Sndr Kuzmnovsk nd Jinkou Zho (The Glol Fund to Fight AIDS, Tuerculosis nd Mlri, Switzerlnd); Clifton Cortez, Ludo Bok, Vivek Divn, Susn Fried (United Ntions Development Progrmme (UNDP), USA); Fienne Hrig, Monic Ciupge (United Ntions Office on Drugs nd Crime (UNODC), Austri); Tim Sldden, Jennifer Butler (United Ntions Popultion Fund (UNFPA), USA); Geoffrey Okumu (UNFPA, Keny); Tish Wheeler (United Sttes Agency for Interntionl Development (USAID), USA); Gillin Anderson, Romel Lcson (United Sttes Centers for Disese Control nd Prevention (CDC), USA); Crlos F. Cáceres, Alfonso Silv-Sntiesten (Universidd Perun Cyetno Heredi, Peru); Susn Ksedde, United Ntions Children Fund, Prinit Bhttchrjee (University of Mnito, Keny); John de Wit (University of New South Wles, Austrli); Shron Weir (University of North Crolin, USA); Annel Bddeley, Avinsh Knchr, Lori Newmn, Teodor Wi nd Andrew Bll (WHO, Switzerlnd); Mrtin Donoghoe, Smiljk de Lussigny (WHO Regionl Office for Europe (EURO), Denmrk); Rzi Pendse (WHO Regionl Office for South-Est Asi (SEARO), Indi), Monic Alonso Gonzlez, Rfel Mzin (WHO Regionl Office for the Americs (AMRO/PAHO), USA); Joumn Hermez (WHO Regionl Office for the Estern Mediterrnen (EMRO), Egypt); Pengfei Zho (WHO Regionl Office for the Western Pcific (WPRO), Philippines). A consulttion on the development of this document ws held in 2013 in Genev, Switzerlnd. The following people prticipted (in lpheticl order): Gillin Anderson (CDC, USA); George Ayl (MSMGF, USA); Stefn Brl (Center for Pulic Helth nd Humn Rights, Johns Hopkins Bloomerg School of Pulic Helth, USA); Gerrd Belimc (Deprtment of Helth, Philippines); Irene Benech (CDC, USA); Prinit Bhttchrjee (University of Mnito, Keny); Gin Dllett (Bill nd Melind Gtes Foundtion, USA); John de Wit (The University of New South Wles, Austrli); Ann Dovkh (Interntionl HIV/AIDS Allince, Ukrine); Andre Gonzlez (HIV/AIDS Progrmme, Mexico); Muro Gurinieri (The Glol Fund to Fight AIDS, Tuerculosis nd Mlri, Switzerlnd); Sumn Jin (The Glol Fund to Fight AIDS, Tuerculosis nd Mlri, Switzerlnd); Bonit Kilm (Ntionl AIDS Control Progrmme, Tnzni); Romel Lcson (CDC, USA); N.R. Mnill (Ministry of Helth & Fmily Welfre, Indi); Brdley Mthers (Kiry Institute, University of New South Wles, Austrli); Agnet Mithi (Ntionl AIDS nd STI Control Progrm, Keny); Ko Ko Ning (Ntionl AIDS Progrmme, Mynmr); Toni Potet (OGAC, USA); Owen Ryn (mfar, USA); Pul Semugom (Africn Men for Sexul Helth nd Rights, South Afric); Alfonso Silv-Sntiesten (Universidd Perun Cyetno Heredi, Peru); Khrtini Slmh (Glol Network of Sex Work Projects, Mlysi); Ptrick Sullivn (Emory University, USA); Siti Ndi Trmizi (Ministry of Helth, Repulic of Indonesi); Be Vuylsteke (Institute of Tropicl Medicine, Belgium); Shron Weir (University of North Crolin, USA); Tish Wheeler (USAID, USA); Cmeron Wolf (USAID, USA). United Ntions gencies: Ludo Bok (UNDP); Geoffrey Okumu, Tim Sldden (UNFPA); Keith Sin (UNAIDS); Frnk Lule (WHO Regionl Office for Afric, Repulic of Congo), Rfel Mzin (AMRO), Rzi Pendse (SEARO), Pengfei Zho (WPRO); Rchel Bggley, Gottfried Hirnschll, Antonio Lee, Michelle Rodolph nd Annette Verster (WHO, Switzerlnd).

7 3 ABBREVIATIONS AIDS ART CDC GARPR Glol Fund HBV HCV HIV HTC MSM MSMGF NCPI NGO NSP OST PEPFAR PMTCT PrEP RITA STI TB UN UNAIDS UNDP UNFPA UNGASS UNODC USAID WHO cquired immunodeficiency syndrome ntiretrovirl therpy Centers for Disese Control nd Prevention Glol AIDS Response Progress Reporting Glol Fund to Fight AIDS, Tuerculosis nd Mlri heptitis B virus heptitis C virus humn immunodeficiency virus HIV testing nd counselling men who hve sex with men The Glol Forum on MSM & HIV Ntionl Commitments nd Policies Instrument (formerly the Ntionl Composite Policy Index) nongovernmentl orgniztion needle nd syringe progrmme opioid sustitution therpy The United Sttes President's Emergency Pln for AIDS Relief prevention of mother-to-child trnsmission pre-exposure prophylxis recent infection testing lgorithm sexully trnsmitted infection tuerculosis United Ntions Joint United Ntions Progrmme on HIV/AIDS United Ntions Development Progrmme United Ntions Popultion Fund United Ntions Generl Assemly Specil Session on HIV/AIDS United Ntions Office on Drugs nd Crime United Sttes Agency for Interntionl Development World Helth Orgniztion Note on terminology: Lnguge used in this document relting to key popultions follows United Ntions guidelines on preferred terminology. The use of lnguge tht reltes to certin ehviours, chrcteristics nd popultion groups hs importnt implictions. Memers of these popultions hve the right to define nd determine how they wish to e identified nd referred to. It is lso importnt to e wre tht different terminology my e pproprite in different contexts nd for different uses nd tht preferred lnguge evolves over time. In this document, wherever possile, the use of revitions to refer to people or popultion groups is voided.

8 4 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions PART 1 INTRODUCTION This document is supplement to the World Helth Orgniztion (WHO) Consolidted guidelines on HIV prevention, dignosis, tretment nd cre for key popultions (1). It provides technicl guidnce to ssist countries in plnning nd monitoring efforts to ddress HIV mong key popultions: men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers nd trnsgender people. 1 Specificlly this document provides guidnce on monitoring nd evluting the implementtion of the comprehensive pckge of interventions to ddress HIV mong key popultions. The frmework presented here is designed to help pln nd ssess progress t the mcro level, in prticulr for ntionl nd suntionl progrmming. This plnning nd ssessment process should involve government gencies, nongovernmentl orgniztions (NGOs), communities nd service providers involved in developing, implementing, monitoring nd evluting HIV prevention, tretment nd cre progrmmes for these key popultions. This frmework uilds on similr existing frmework specific to progrmmes for people who inject drugs: WHO, UNODC, UNAIDS technicl guide for countries to set trgets for universl ccess to HIV prevention, tretment nd cre for injecting drug users (2). This document provides countries with: 1. A set of hrmonized indictors to exmine the implementtion of the pckge of interventions to ddress HIV mong key popultions The WHO Consolidted guidelines on HIV prevention, dignosis, tretment nd cre for key popultions recommends comprehensive pckge of interventions to respond effectively to HIV mong key popultions; this pckge is summrized in Box 1. This document presents set of meningful nd prcticl indictors, selected through review of current prctice nd ville evidence, to ssess the implementtion of the comprehensive pckge. These recommended indictors re ligned with indictors used y other United Ntions (UN) nd donor gencies nd meet estlished indictor stndrds. The informtion tht these indictors provide is importnt for policy development nd effective progrmming to guide ntionl responses to HIV mong these key popultions. The indictors lso cn e used to prepre proposls nd report on progress to donor orgniztions. Only indictors tht cn e prcticlly reported t the ntionl level, nd for which dt re commonly ville, hve een included. In some countries with more sophisticted ntionl level dt collection systems it my e possile to report on dditionl indictors, prticulrly those tht exmine progrmme coverge using progrmmtic dt. 2. Guidnce on setting trgets for these indictors Countries epidemics mong key popultions vry. Ech country will e t different stge of progress in ringing progrmmes to scle. Setting cler, mitious ut chievle trgets helps to pln for the scle-up of progrmmes with the gretest possile impct. The trget-setting process is strongest when undertken s multisectorl process with the meningful prticiption of ll key popultions. Indictive trgets re proposed for selected numer of indictors to ssist countries with clirting their own trgets nd response. The content of this document derives from existing WHO guidnce. It rings together vrious spects of progrmming the response to HIV s well s tuerculosis (TB), heptitis B virus (HBV) nd heptitis C virus (HCV), nd sexully trnsmitted infections (STIs) for these key popultions. Relted key UN documents nd reporting processes re detiled in Boxes 2 nd 3. 1 Definitions for ech of these key popultions re provided in the WHO Consolidted guidelines on HIV prevention, dignosis, tretment nd cre for key popultions.

9 5 Box 1. The comprehensive pckge of interventions for key popultions The pckge hs two prts: ) Essentil helth sector interventions 1. comprehensive condom nd luricnt progrmming 2. hrm reduction interventions for sustnce use, in prticulr needle nd syringe progrmmes (NSP), opioid sustitution therpy (OST) nd nloxone 3. ehviourl interventions 4. HIV testing nd counselling 5. HIV tretment nd cre 6. prevention nd mngement of co-infections nd other comoridities, including virl heptitis, TB nd mentl helth conditions 7. sexul nd reproductive helth interventions, including contrception, dignosis nd tretment of STIs, cervicl screening. ) Essentil strtegies for n enling environment 1. supportive legisltion, policy nd finncil commitment, including decriminliztion of ehviours of key popultions 2. ddressing stigm nd discrimintion, including in the helth sector 3. community empowerment 4. ddressing violence ginst people from key popultions. The WHO Consolidted guidelines on HIV prevention, dignosis, tretment nd cre for key popultions provides further detil on ech of the elements in this pckge nd their implementtion (1). Box 2. How does this document relte to other UN pulictions? This document is compnion to other pulictions developed y WHO, together with the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS), the United Ntions Popultion Fund (UNFPA), the United Ntions Office on Drugs nd Crime (UNODC) nd the United Ntions Development Progrmme (UNDP), tht provide evidence-sed recommendtions on ddressing HIV mong key popultions. These pulictions include: Consolidted guidelines on HIV prevention, dignosis, tretment nd cre for key popultions, WHO, Technicl guide for countries to set trgets for universl ccess to HIV prevention, tretment nd cre for injecting drug users, WHO, Consolidted guidelines on the use of ntiretrovirl drugs for treting nd preventing HIV infection, WHO, Prevention nd tretment of HIV nd other sexully trnsmitted infections for sex workers in low nd middle income countries: recommendtions for pulic helth pproch, WHO, Prevention nd tretment of HIV nd other sexully trnsmitted infections mong men who hve sex with men nd trnsgender people: recommendtions for pulic helth pproch, WHO, Guidnce on pre-exposure orl prophylxis (PrEP) for serodiscordnt couples, men nd trnsgender women who hve sex with men t high risk of HIV, WHO, Implementing comprehensive HIV/STI progrmmes with sex workers: prcticl pproches nd collortive interventions, WHO, HIV prevention, tretment nd cre in prisons: comprehensive pckge of interventions, UNODC, HIV, sexully trnsmitted infections nd other helth needs mong trnsgender people in Asi nd the Pcific: joint regionl technicl rief, WHO, Opertionl guidelines for monitoring nd evlution of HIV progrmmes for sex workers, men who hve sex with men nd trnsgender people, UNAIDS, Opertionl guidelines for monitoring nd evlution of HIV progrmmes for people who inject drugs: monitoring nd evlution t the service delivery level. UNAIDS, Guidnce note on HIV nd sex work, UNAIDS, 2012.

10 6 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Universl ccess for men who hve sex with men nd trnsgender people: UNAIDS ction frmework, UNAIDS, Glol HIV epidemics mong people who inject drugs, World Bnk, Glol HIV epidemics mong sex workers, World Bnk, Glol HIV epidemics mong men who hve sex with men, World Bnk, Consolidted strtegic informtion guide for HIV in the helth sector, WHO, Box 3. How does this document relte to other interntionl reporting mechnisms? This document outlines frmework nd indictors for evluting the response to HIV mong men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers nd trnsgender people. The indictors descried in this document re intended to enle deeper ssessment of the response for these key popultions in order to ssist with progrmming nd the preprtion of funding proposls nd monitoring the progress of ntionl nd/or donor funded progrmmes. There re, however, numer of interntionl reporting mechnisms tht include indictors relted to key popultions. These include: Monitoring progress in the helth sector towrds chieving universl ccess to HIV prevention, tretment nd cre, nd support, , WHO, frmework_ pdf Glol AIDS response progress reporting (GARPR), UNAIDS, 2014 (formerly Reporting on monitoring the UNGASS Declrtion of Commitment on HIV/AIDS) document/2014/garpr_2014_guidelines_en.pdf Memer Sttes hve mde commitments to sumit reports to these glol dt collection processes.

11 7 THE MONITORING AND TARGET-SETTING PROCESS Ntionl level progrmme ssessment This document presents frmework for monitoring progress in implementing the evidence-sed pckge of interventions t the ntionl level. Assessing progrmmes t the service provider level is n importnt component of comprehensive monitoring nd evlution system, ut this is not the focus of this document; guidnce on service-level progrmme monitoring nd evlution is ville elsewhere. 1 Monitoring certin spects of progrmmes t the ntionl level does, however, require the collection of dt y service providers nd tht these dt to e collted nd nlysed centrlly. To llow for such dt to e ggregted, dt collection systems must e consistent cross different service providers. Indictors included in this document were selected ecuse in most settings the dt re redily ville, cn e redily collected, cn e reported t the ntionl level nd cn e disggregted y key popultion group. Meningful community prticiption in the ssessment process Community enggement is n essentil prt of this ssessment process. Multiple stkeholders, in prticulr, memers of these key popultions, hve n invlule contriution to mke to progrmme design nd to the evlution of progress, highlighting strtegies for improvement nd developing pproprite trgets. Mny donor orgniztions nd interntionl reporting mechnisms stipulte ctive prticiption y civil society groups in this process. It is importnt to ensure tht findings from the ssessment process re fed ck to communities for their use. Indictors The set of indictors descried ssesses key fctors relted to the enling environment, mesures the vilility, coverge nd qulity of specific interventions, nd exmines the outcome nd impct of these efforts. To understnd where nd how policy nd progrmmes need to e developed further, it is importnt to consider ech of the following spects: progrmmes need to e ccessile to people from key popultions (mesured y vilility indictors); progrmmes need to rech those who need them (mesured y coverge indictors); interventions need to e properly implemented to e effective (mesured y qulity indictors); it is importnt to determine whether or not the intended gols nd ojectives hve een relized (mesured y outcome nd impct indictors); the successful implementtion nd impct of ech intervention depends on supportive policy, legisltion nd other structurl fctors (mesured y enling environment indictors). In ddition to guiding progrmme development nd mngement, the indictors cn lso e used for the preprtion of proposls or reporting on progress to donor orgniztions. Trget setting Trget setting is fundmentl to effective monitoring nd evlution. Trgets concretely define wht successful ntionl progrmme nd/or projects should chieve within specific time frme. They should e set for oth cross-cutting nd intervention-specific indictors. Trgets should e set t the ntionl level nd for suntionl res. Modelling cn help to identify how different trget levels will ffect the epidemic. Trgets should reflect progrmme strtegies tht re tilored to the locl epidemic nd e sed on wht cn relisticlly e chieved given ville resources nd ny 1 See, for exmple: Opertionl guidelines for monitoring nd evlution of HIV progrmmes for people who inject drugs: monitoring nd evlution t the service delivery level, UNAIDS, 2011 t nd Opertionl guidelines for monitoring nd evlution of HIV progrmmes for sex workers, men who hve sex with men, nd trnsgender people, UNAIDS, 2012 t

12 8 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions dditionl cpcity nd funding tht my need to e moilised. Prt 2 of this document offers guidnce on how trgets might e set for the listed indictors, nd proposes indictive trgets for numer of indictors to ssist countries in clirting their own trgets. Trget setting should e collortive, with input from the community nd other stkeholders. Idelly, trgets should e set with the involvement of ntionl stkeholder meeting tht cn comment on whether the trgets re relistic nd determine whether they re prcticl for dt collection in the field. Dt sources The indictors descried require dt gthered from rnge of different sources. Dt from ech of these sources provides importnt informtion, nd ech source hs different strengths nd limittions tht need to e considered when reporting on nd interpreting indictors. Desk review nd expert consulttion Importnt informtion cn e glened from the review of vrious policy documents or legisltion to identify the presence or sence of different lws or policies which my ffect people from key popultions. Indictors using dt gthered through desk review nd expert consulttion ENV 1 Audit of current legisltion nd policy checklist 28 ENV 2 Involvement of key popultion in ntionl policy nd strtegy formultion 29 NSP 6 NSP-relted policy nd prctice checklist 42 OST 4 OST-relted policy nd prctice checklist 45 PRP-1 Orl PrEP for HIV prevention is ville for men who hve sex with men 52 Pge Progrmmtic or dministrtive dt Most progrmmes routinely record t lest some sic informtion when providing service; this might include count of the numer of people who receive service, detils out the person served, or record of the mount of mterils distriuted, such s condoms nd luricnt. To exmine services provided to people from key popultions, progrmme dt must e disggregted y key popultion group. Progrmmes focused on key popultions my e le to provide dt specific to the popultions they serve. This informtion is not commonly ville, however, from progrmmes tht provide services to mny different groups or to the generl popultion. Service providers (for exmple ART progrmmes) my not know, or my not record, whether or not client is mn who hs sex with men, sex worker, if they inject drugs or if they re trnsgender, s this informtion my not e relevnt to the provision of services. However if progrmmtic dt, disggregted y key popultion group, re ville t the ntionl level, nd re collected nd recorded consistently cross service providers, then these dt cn e used to exmine progrmme coverge. Furthermore, clients of these services my not wish to disclose this informtion. Requiring them to do so might deter people from key popultions from ccessing the service. In some settings disclosing one s sttus s mn who hs sex with men, person who uses drugs, sex worker or trnsgender person my mke person vulnerle to discrimintion nd even violence or prosecution. Hence, collection of such informtion my not e dvisle. It should e noted, however, tht ddressing drug dependence is n importnt prt of HIV tretment nd cre for people living with HIV who re drug dependent. Therefore, disclosure of drug use my e relevnt in these circumstnces. In ntionl-level ssessment it is necessry to collte dt from multiple service providers. To enle ggregtion of dt from multiple sources, dt collection methods need to e consistent cross ll sites. In most countries dt re not collected y single gency nd my not e routinely gthered t the ntionl level. Hving single, ntionl-level gency responsile for regulrly collting nd reporting ntionl dt is highly dvntgeous. We-sed dtses cn fcilitte dt ggregtion from different services. If Internet ccess is not ville, offline computers or pper-sed recording systems cn e used.

13 9 A numer of indictors in this document use progrmmtic dt tht descrie certin spects of service provision, such s the type of service provided t prticulr loction, the trining tht the stff hve received or some other spect of intervention qulity. This type of progrmmtic dt cn e collected through fcility-sed ssessments or udits. Indictors using progrmmtic dt Pge ENV 3 Legl support services for key popultion 29 ENV 4 Support services for people from key popultions who experience violence 30 ENV 5 Sensitiztion trining on key popultions for lw enforcement officers 30 Q 1 Progrmme qulity checklist 31 Q 2 Sensitiztion trining on key popultions for service providers 32 CCP 1 Sites providing comprehensive condom progrmming 33 CCP 3 Key popultion provided with condoms nd comptile luricnt 34 CCP 4 Quntity of condoms nd condom-comptile luricnt distriuted 35 CCP 6 Consistent condom-comptile luricnt distriution 36 NSP 1 Sites providing injecting equipment needle nd syringe progrmmes (NSPs) 38 NSP 3 Quntity of needles syringes distriuted 39 NSP 4 People who inject drugs reched y NSPs 40 OST 1 Sites providing mintennce opioid sustitution therpy (OST) 43 OST 2 OST progrmme cpcity 43 OST 3 Individuls receiving mintennce OST 44 OST 5 Individuls receiving mintennce OST continuously for t lest 6 months 46 OST 6 Individuls receiving mintennce dose of OST the recommended minimum dose 46 OST 7 Individuls on mintennce OST receiving psychosocil support 47 ODM 1 Sites providing community-sed distriution of nloxone 48 ODM 2 Quntity of nloxone distriuted 48 GDR 1 Sites providing equipment for sfe injecting of sustnces for gender ffirmtion 49 BHV 1 Sites providing ehviourl interventions for sexul risk reduction 50 BHV 2 Sites providing rief intervention counselling for prolemtic sustnce use 51 PRP 2 Men who hve sex with men receiving orl pre-exposure prophylxis (PrEP) 52 HTC 1 Sites providing HIV testing nd counselling 53 ART 1 Sites providing ntiretrovirl therpy (ART) 56 CMB 1 Sites providing TB prevention, screening nd mngement 58 CMB 2 Sites providing HBV vccintion 59 CMB 3 Key popultion receiving HBV vccintion 59 SRH 1 Sites providing sexul nd reproductive helth services 60 SRH 3 Key popultion ttending sexul helth services 61 PKG 1 Sites providing defined pckge of helth sector interventions 62

14 10 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Survey dt Behviourl nd sero-surveillnce surveys of key popultions re n importnt source of prevlence dt nd informtion on experiences, risk nd service utiliztion of people from these groups. Mny countries lredy undertke such surveys periodiclly s prt of the ongoing monitoring of the HIV epidemic. It is importnt tht ll reserch nd dt collection ctivities dhere strictly to ethicl reserch prctices. It is lso importnt tht the community of interest hs role in the design, implementtion nd interprettion of these reserch ctivities. Mny countries use the 2000 Fmily Helth Interntionl Guidelines for repeted ehviourl surveys in popultions t risk of HIV (3) s sis for the ehviourl component of these surveys mong key popultions. A revised version of these guidelines is due for relese in The generlizility of survey findings depends on how representtive the smple is of the roder popultion of men who hve sex with men, people in prisons nd other closed settings, people who use drugs, sex workers nd trnsgender people. It is importnt to consider selection is ssocited with how nd where prticipnts re recruited. Significnt is my result if smples re drwn from limited numer nd rnge of loctions. Methods such s respondent-driven smpling my reduce such is, ut they require specific technicl cpcity nd resources nd tke time to complete. In mny cses survey results my relte only to the loction from which the smple ws drwn. Behviourl surveys re susceptile to numer of sources of is. Socil desirility is my occur when respondents who hve een in contct with progrmme give nswers out their ehviour tht they know re more cceptle. Recll is occurs when respondents re required to recollect experiences. Questions should e ppropritely worded nd use locl lnguge to ensure they cn e understood y respondents. Assuring nonymity, mintining privcy, nd using self-interviewing techniques my reduce such ises. Indictors using survey dt Pge CCP 2 Key popultion reporting condoms re redily ccessile 33 CCP 5 Key popultion reporting they hve received condoms nd luricnt 36 CCP 7 Key popultion reporting hving received luricnt when receiving condoms 37 NSP 2 People who inject drugs reporting sterile needles syringes re redily ccessile 39 NSP 5 People who inject drugs reporting they hve received sterile injecting equipment 41 HTC 2 Key popultion reporting HIV testing nd counselling is redily ccessile 54 HTC 3 Key popultion reporting they hve received HIV test nd results 54 HTC 4 Key popultion reporting they received results following HIV testing 55 ART 2 Key popultion living with HIV reporting they currently receive ART 57 SRH 2 Key popultion reporting sexul helth services re redily ccessile 61 SRH 4 Key popultion reporting they hve een tested for STIs 61 PKG 2 Key popultion reporting they hve received comined pckge of helth sector interventions 63 O 3 Infection prevlence mong key popultions 65 O 4 Prevlence of risk ehviours nd knowledge round HIV mong key popultion 65 O 5 Stigm nd discrimintion experience y key popultion 66 O 6 Attitudes towrds key popultion held y service providers 66

15 11 TYPES OF INDICTORS 1. Assessing key fctors ssocited with the enling environment Existing ssessment tools, such s the UNAIDS Ntionl Commitments nd Policy Instrument (NCPI), cn e used to identify whether or not key fctors necessry for n enling environment re present in prticulr setting. In this document dditionl indictors re descried tht look t importnt structurl fctors ffecting men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers nd trnsgender people. Prt of this ssessment involves undertking legl udit to exmine the impct of existing legisltion nd lw enforcement upon memers of these key popultions nd how ccessile the legl system is to them (4). In ddition, included indictors look t levels of community empowerment, ledership nd prticiption in policy nd strtegy formultion; the existence of support services for victims of violence; nd stigm nd sensitiztion trining for service providers nd lw enforcement officers. Indictors ssessing key fctors ssocited with the enling environment Pge ENV 1 Audit of current legisltion nd policy checklist 28 ENV 2 Involvement of key popultion in ntionl policy nd strtegy formultion 29 ENV 3 Legl support services for key popultion 29 ENV 4 Support services for people from key popultions who experience violence 30 ENV 5 Sensitiztion trining on key popultions for lw enforcement officers 30 Further reding on ssessment of legisltion Legl environment ssessment for HIV: n opertionl guide to conducting ntionl legl, regultory nd policy ssessments for HIV, UNDP, Prcticl%20Mnul%20LEA%20FINAL%20we.pdf 2. Mesuring the vilility of helth sector interventions Numer of sites where n intervention is ville Counting the numer of sites or loctions where n intervention is ville gives gross indiction of the scle of roll-out of the intervention. Site definitions For purpose of such n ssessment, it is importnt to define wht constitutes n intervention site s definitions my differ for different interventions. In the cse of outrech or moile services, single service provider my deliver n intervention t multiple loctions. It is suggested tht ech of these sites re counted ut tht the timing nd frequency of service provision is lso reported. Minstrem progrmmes versus key popultion-focused progrmmes When ssessing where interventions re provided, it is useful to distinguish etween progrmmes tht re specificlly designed to serve memers of key popultions which re referred to in this document s key popultion-focused

16 12 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions progrmmes nd progrmmes tht re not specificlly focused on key popultions ut which provide n intervention for the generl popultion so clled minstrem progrmmes. Key popultion-focused progrmmes might include services such s stnd-lone needle nd syringe progrmmes or drug dependence tretment services for people who use nd inject drugs, or drop-in centres, outrech or helth-cre services tht re estlished to cter specificlly to key popultions. Some minstrem progrmmes my hve only limited experience with providing services to people from key popultions nd my hve difficulty responding to their needs. In some cses stff my hold negtive ttitudes towrds people from these key popultions, which my result in discrimintory prctices. People from key popultions re less likely to ccess progrmmes tht re not equipped to meet their needs nd where they might fce discrimintion. Service providers cn tke numer of steps to ddress stigm nd discrimintion. These include implementing codes of conduct tht im to gurd ginst stigm nd discrimintion nd providing stff with pproprite sensitiztion trining nd support to ensure tht they hve the skills nd understnding to ensure ptients rights to helth, confidentility nd non-discrimintion. Accordingly, when mesuring intervention vilility for key popultions, it is useful to differentite etween sites tht hve tken such steps nd those tht hve not. It my lso e pproprite for services to employ stff who re memers of key popultions. As descried in the section Mesuring intervention qulity (pge 18), checklist exmining progrmme policy nd prctice cn help ssess whether or not site meets sensitiztion stndrds for service provision (see Indictor Q 1 Progrmme qulity checklist, pge 31). In ddition, n indictor monitoring the numer of helth-cre workers who hve received pproprite sensitiztion trining on key popultions cn lso e used (see Indictor Q 2 Sensitiztion trining on key popultions for service providers, pge 32). The following site counts re suggested to mesure the vilility of ech intervention: c d The numer of sites where key popultion-focused progrmmes currently provide the intervention The numer of sites where minstrem progrmmes meeting key popultion sensitiztion stndrds currently provide the intervention The totl numer of ll sites where ny key popultion-focused progrmmes re currently offered The totl numer of sites where minstrem progrmmes currently provide the intervention It is then possile to use these counts to clculte the following indictors: e f g The percentge of key popultion-focused progrmmes currently providing the intervention [] = x 100 [c] Depending on the intervention in question, this indictor cn help to identify which key popultion-focused progrmme sites my e pproprite plces to provide the intervention. The percentge of minstrem progrmme sites where the intervention is provided tht meet key popultion sensitiztion stndrds [] = x 100 [d] This indictor is helpful in identifying minstrem sites offering the intervention ut which do not currently meet key popultion sensitiztion stndrds. The percentge of ll sites where the intervention is currently provided tht meet key popultion sensitiztion stndrds tht is, minstrem progrmmes meeting key popultion sensitiztion stndrds nd sites of key popultion-focused progrmmes []+[] = x 100 []+[d] This indictor identifies which sites currently provide the intervention ut which might not e sensitized or focused on the needs of people from key popultions.

17 13 The following indictors use this formultion to mesure intervention vilility for key popultions: Indictors ssessing the numer of sites where interventions re provided Pge ENV 4 Support services for people from key popultions who experience violence 30 CCP 1 Sites providing comprehensive condom progrmming 33 NSP 1 Sites providing injecting equipment needle nd syringe progrmmes (NSPs) 38 OST 1 Sites providing mintennce opioid sustitution therpy (OST) 43 ODM 1 Sites providing community-sed distriution of nloxone 48 GDR 1 Sites providing equipment for sfe injecting of sustnces for gender ffirmtion 49 BHV 1 Sites providing ehviourl interventions for sexul risk reduction 50 BHV 2 Sites providing rief intervention counselling for prolemtic sustnce use 51 HTC 1 Sites providing HIV testing nd counselling 53 ART 1 Sites providing ntiretrovirl therpy (ART) 56 CMB 1 Sites providing TB prevention, screening nd mngement 58 CMB 2 Sites providing HBV vccintion 59 SRH 1 Sites providing sexul nd reproductive helth services 60 There cn e considerle enefit gined from providing multiple interventions t single loction. Such integrted service delivery cn increse ccess to importnt interventions for people from key popultions nd cn fcilitte coordinted, multidisciplinry cse mngement. Therefore, site providing multiple interventions will e counted in more thn one of these indictors tht look t specific intervention. In ddition, n indictor cn e used to identify sites where multiple interventions re provided. The indictor could e defined to identify sites providing ll, or suset of, the essentil helth sector interventions of the recommended pckge. Indictors ssessing the numer of sites where multiple interventions re provided PKG 1 Sites providing defined pckge of helth sector interventions 62 Knowing the numer of sites lone does not indicte how ccessile n intervention is to the popultion it is intended to rech. The following two methods cn provide some dditionl informtion to etter understnd the ccessiility of n intervention. Pge Accessiility of n intervention s reported y people from key popultions Access to interventions is not determined y loction lone, ut lso y mny different fctors such s hours of opertion, the cost of using the intervention nd n individul s ility nd willingness to py, the presence of deterrents such s police ctivity, nd the cceptility of the progrmme to those it is intended to rech. An importnt method of evluting whether or not n intervention is ccessile is to sk people from key popultions out their experiences. Relevnt questions cn e included in key popultion surveys. Indictors using surveys to ssess intervention ccessiility CCP 2 Key popultion reporting condoms re redily ccessile 33 NSP 2 People who inject drugs reporting sterile needles syringes re redily ccessile 39 HTC 2 Key popultion reporting HIV testing nd counselling is redily ccessile 54 SRH 2 Key popultion reporting sexul helth services re redily ccessile 61 Pge

18 14 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Mpping of key popultions nd services Geogrphic mpping exercises identify where people from specific popultions live nd congregte in reltion to where interventions re provided. This informtion cn e used to inform where services should e locted so tht they re ccessile to the gretest numer of people or to those most t risk. Mpping lso cn provide informtion on ptterns of socil interction nd sptil fctors tht my e relevnt to disese trnsmission ptterns. Mpping is most relevnt when key popultions re concentrted in n re. For exmple, in mny countries sex work my most often tke plce in specific res such s long trde routes, in lrge urn settings or in designted res; this my vry sesonlly (e.g. trding sesons) or e linked to migrtory trends. It is lso importnt to consider virtul spces nd online communities in which memers of key popultions my prticipte. These online spces my e importnt points of ccess for these communities nd my e used to deliver informtion nd some ehviourl interventions; virtul spces cn lso e used for conducting surveys in mnner tht is sfe nd confidentil. In some circumstnces mpping of key popultions cn hve the unintended negtive consequence of putting community memers in dnger of violence nd stigm y identifying these popultions nd where they re locted. When undertking such exercises, it is importnt to ensure the sfety nd security of community memers y strictly mintining privcy, confidentility nd the security of informtion collected (5, 6). Detiled mpping t the ntionl level cn e techniclly chllenging nd expensive undertking. Mpping is more commonly done for smller ctchment res such s t district, neighourhood, street nd venue levels. Further reding on mpping methods An overview to sptil dt protocols for HIV/AIDS ctivities: why nd how to include the where in your dt, The MEASURE Evlution Project, Mesuring intervention coverge In this document the term coverge is used to descrie the extent to which n intervention is delivered to key popultion. Indictors tht mesure the extent of coverge reltive to need or to the size of the popultion of interest re prticulrly useful for ssessing progrmme implementtion. The coverge indictors listed in this document utilize informtion gthered from: A. Progrmmtic or dministrtive dt B. Key popultion surveys As discussed on pge 8, ech method of estimting intervention coverge hs limittions tht re importnt to consider when interpreting results. If dt re ville from more thn one source, these cn e used in process of tringultion to etter understnd levels of coverge. 1 Note: While these interventions cn e provided on single occsion, it does not men tht they need to e provided to n individul only once. For exmple, condoms should e distriuted on multiple occsions, nd mde continuously ville to those who require them.

19 15 Using progrmme or dministrtive dt to ssess coverge Dt collected y service providers re n importnt source of informtion for ssessing intervention coverge. The progrmmtic or dministrtive dt of most interest include: The numer of people who received the intervention If interventions tht cn e provided on single occsion (e.g. the dispensing of condoms nd luricnt) 1 or within short period of time (e.g. HBV vccintion ccelerted schedule), then it is pproprite to count the numer of people who received the intervention during specified time period (e.g. the lst 12 months). If n intervention involves long-term or even indefinite tretment (e.g. ART for HIV), then it is pproprite to count the numer of people who re receiving the intervention t specified census dte (i.e. t single point in time). The totl numer of times n intervention ws provided This my lso e termed the numer of occsions of service. It is count of ll occsions, within specified time period, when the intervention ws provided to person from key popultion. Multiple contcts with the sme client re included in this count. The dt collection system does not require unique identifier code to void doule counting (see elow). For exmple: the totl numer of HIV tests performed within the specified reporting period. The numer of items distriuted For exmple: the numer of condoms nd comptile luricnt or needles nd syringes distriuted within specified time period. In mny countries dt re collected routinely (dily or weekly) t the service delivery level nd reported to the suntionl level t regulr intervls (for exmple, every qurter). When counting events tht occur within certin period of time, it is common to report dt for the lst 12 months, this eing nturl reporting period for mny registry nd progrmme dt collection systems. It my e useful, however, nd more pproprite in some contexts, to define specific reporting periods. In prticulr, donors such s The Glol Fund to Fight AIDS, Tuerculosis nd Mlri nd The United Sttes President s Emergency Pln for AIDS Relief (PEPFAR) my require reporting t 3- or 6-month intervls. Furthermore, some interventions need to e provided repetedly, nd it is desirle for people from key popultions to ccess services more frequently thn only every 12 months, such s the provision of condoms nd luricnt nd sterile injecting equipment. Accordingly it is useful to look t shorter reporting periods when ssessing these interventions. To mesure coverge mong key popultions, progrmmtic dt needs to e disggregted y ech key popultion group. As discussed on pge 12, while key popultion-focused progrmmes my e le to provide dt specific to the popultions they serve, progrmmes tht provide services to mny different groups or the generl popultion more rodly (for exmple, ART progrmmes) typiclly do not hve disggregted dt for different key popultions. In light of this the coverge indictors included in this document tht use progrmmtic dt cll specificlly for dt from key popultion-focused progrmmes. If dt for key popultion groups re lso ville from minstrem progrmmes nd re collected nd recorded consistently cross service providers, then these dt cn lso e included in these indictors. To determine the numer of people who received n intervention during specified period of time, it is necessry to void doule counting those who my hve received the intervention on more thn one occsion during this time period. Dt collection systems cn use unique identifier code for ech individul client so tht multiple visits y the sme individul cn e noted. It is essentil tht such dt collection system mintins clients nonymity nd confidentility. Alterntively, the recll lst contct method cn e used, in which ech individul is sked, when using service if this is the first time they hve done so within the reporting period. Ntionl-level coverge cn e more ccurtely estimted if the sme unique identifier coding system is used cross different service providers. Becuse of these vrious technicl chllenges, in most settings it is unlikely tht count of the totl numer people from key popultion who received n intervention (the numertor) will e ville. This mkes it difficult to estimte the level of coverge reltive to need or key popultion size (the denomintor). The only indictors included in this document tht ttempt to mesure coverge in this wy re those for comprehensive condom progrmming; these indictors hve een included ecuse the numer of condoms distriuted y key popultion-focused services reltive to the size of tht key popultion is often ville nd cn e useful indictor of the overll rech of these services t the ntionl level.

20 16 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions CCP 3 Percentge of the totl key popultion provided with condoms nd comptile luricnt y key popultionfocused progrmmes during the specified reporting period (pge 34) = [Numer of people provided with condoms from key popultion-focused progrmmes during specified reporting period] [Estimted key popultion size] x 100 CCP 4 Totl numer of condoms distriuted to people from key popultion during the specified reporting period (pge 35) = [Numer of condoms provided y key popultion-focused progrmmes during specified reporting period] [Estimted key popultion size] Indictors using progrmme dt to ssess intervention coverge Pge CCP 3 Key popultion provided with condoms nd comptile luricnt 34 CCP 4 Quntity of condoms nd condom-comptile luricnt distriuted 35 NSP 3 Quntity of needles syringes distriuted 39 NSP 4 People who inject drugs reched y NSPs 40 OST 3 Individuls receiving mintennce OST 44 ODM 2 Quntity of nloxone distriuted 48 PRP 2 Men who hve sex with men receiving orl pre-exposure prophylxis (PrEP) 52 CMB 3 Key popultion receiving HBV vccintion 59 SRH 3 Key popultion ttending sexul helth services 61 These indictors require n estimte of the size of the key popultion in question; guidnce on estimting key popultion size is presented elow. Popultion size estimtes It is importnt to hve cler definition of the popultion for which size estimte is to e derived. If the size estimte is to e used for the purpose of estimting intervention coverge, the popultion definition should e relevnt to the progrmme or intervention of interest. For exmple, if the coverge of needle nd syringe progrmme is to e estimted, popultion definition for people who currently inject drugs would e more relevnt thn n estimte of people who hve injected nytime in their life (so clled lifetime injecting drug use ). Determining the size of key popultions cn e chllenging. Surveys of the generl popultion, such s household surveys, my mrkedly underestimte the prevlence of some key popultions. Respondents my e reluctnt to disclose informtion out stigmtized ehviours or identity. Indirect estimtion methods, such s multiplier nd enchmrk clcultions tht mke use of existing dt sources or cpture recpture methods, re extremely useful; guidnce on these methods is ville (see ox). When using informtion from multiple sources for the purpose of estimting popultion size, it is essentil tht confidentility is lwys mintined. When interpreting n indictor tht hs een clculted using n estimte of popultion size, it is importnt to consider the limittions of the method y which tht estimte ws derived s well s ny tendency for tht method to systemticlly over- or underestimte popultion size. When reporting the results for such indictors, these limittions should lso e reported. For the mesurement of coverge indictors for prison nd other closed settings, the numer of people detined needs to e estimted. When deriving estimtes for this purpose, it is importnt to keep in mind the high turnover of detinees nd tht further disggregtion y key popultion my e required. For exmple, coverge indictors for NSP nd OST require estimtes of the numer of people in detention who inject drugs or who re opioid dependent.

21 17 It is recommended tht ntionl expert group meetings e held regulrly to evlute ville dt nd to rech consensus on the estimte or rnge of estimtes tht should e used. These meetings should involve reserchers nd key government personnel, NGOs nd orgniztions representing key popultions. Where recent, high-qulity estimtes re not ville, it is recommended tht countries mke efforts to cquire such estimtes. Technicl nd finncil resources re required for such estimtion reserch ctivities. If resource constrints exist, countries cn seek externl donor ssistnce for these types of reserch ctivities s prt of funding for the roder response to HIV. The Glol Fund encourges countries to include popultion size estimtion ctivities in funding pplictions nd in ongoing grnts s one of the monitoring nd evlution system strengthening ctivities for improving the vilility of dt on key popultions t risk (7). Similrly, PEPFAR supports opertionl reserch nd strengthening of monitoring nd evlution systems (8). If, for ny indictor, n pproprite popultion size estimte is not ville for use s the denomintor, it is still useful nd importnt to record nd report the indictor numertor. The numertors lone cn provide some useful, lthough more limited, indiction of the extent of progrmme delivery nd my e prticulrly useful in monitoring progress over time. Indictors using popultion size estimtes CCP 3 Key popultion provided with condoms nd comptile luricnt 34 CCP 4 Quntity of condoms nd condom-comptile luricnt distriuted 35 NSP 3 Quntity of needles syringes distriuted 39 NSP 4 People who inject drugs reched y NSPs 40 OST 3 Individuls receiving mintennce OST 44 Pge Further reding on popultion size estimtion UNAIDS/WHO Working Group on Glol HIV/AIDS nd STI Surveillnce. Guidelines on estimting the size of popultions most t risk to HIV, WHO, Centers for Disese Control nd Prevention (CDC), GAP Surveillnce Tem. Most t risk popultions smpling strtegies nd design tool, CDC, Glol ssessment progrmme on drug use. Estimting prevlence: indirect methods for estimting the size of the drug prolem, UNODC, 2003 (9). Hickmn M et l. Estimting the prevlence of prolemtic drug use: review of methods nd their ppliction. UN Bulletin on Nrcotics, 2002, 54:15 32 (10). Using surveys to ssess intervention coverge Intervention coverge cn e estimted through surveys of people from key popultions. These surveys re importnt sources of such informtion, especilly when progrmmtic dt disggregted y key popultion group re not ville. Mny of the indictors relting to key popultions in the Glol AIDS Response Progress Report (GARPR, previously referred to s UNGASS core indictors) involve this survey methodology. As noted, mny countries use Fmily Helth Interntionl s Guidelines for repeted ehviourl surveys in popultions t risk of HIV (3) s sis for surveys mong key popultions; revised edition of these guidelines is due for relese in In ddition to cpturing informtion on risk ehviours, surveys lso cn collect detiled informtion on individuls service utiliztion history. As discussed on pge 10, the reliility of survey findings depends on how representtive the survey smple is of the roder key popultion of interest. For exmple, if smple is recruited only t site where services re provided or if

22 18 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions community memers re selected y peer eductors working for the intervention, the smple is likely to e ised towrds people who re in contct with services nd so my overestimte levels of coverge. The indictors in this document tht use survey dt to mesure coverge follow the following sic formultion: Percentge of key popultion who nswer yes to the question: In the lst [X months] hve you received [NAME OF INTERVENTION]? An pproprite time period should e selected for these indictors. This time period should e relevnt to the intervention of interest nd the context in which it is eing mesured. Some indictors (for exmple those exmining HIV testing nd counselling nd condom distriution) re lso included in the GARPR. The GARPR indictors sk out receiving services t lest once in the pst 12 months. Becuse it is desirle for mny interventions to e provided more frequently thn once yer, it is pproprite to sk out receiving n intervention within shorter time period, for exmple the lst one, three or six months. Indictors using surveys to ssess intervention coverge CCP 5 Key popultion reporting they hve received condoms nd luricnt 36 NSP 5 People who inject drugs reporting they hve received sterile injecting equipment 41 HTC 3 Key popultion reporting they hve received HIV test nd results 54 ART 2 Key popultion living with HIV reporting they currently receive ART 57 SRH 4 Key popultion reporting they hve een tested for STIs 61 PKG 2 Key popultion reporting they hve received comined pckge of helth sector interventions 63 Pge 4. Mesuring intervention qulity The qulity of n intervention mkes criticl difference to its ccessiility, coverge nd impct. Qulity encompsses the scope, completeness, effectiveness, efficiency nd sfety of n intervention, how it is delivered nd, importntly, its cceptility to the intended clientele. Intervention qulity cn e understood in terms of the wy in which n intervention is delivered. Qulity stndrds re those fctors tht cn either: ) enhnce the effectiveness nd desired impct of n intervention; or ) improve ccess to it nd thus increse coverge. The indictors ssessing intervention qulity listed in this document use informtion gthered from: review of progrmme policy nd prctice key popultion surveys progrmmtic or dministrtive dt. Review of progrmme policy nd prctice Progrmme qulity ssessment checklist For n intervention to e effective, it needs to e delivered in wy tht responds to the needs of those it is intended to serve. This is especilly importnt when providing n intervention for key popultions, whose needs differ from those of the generl community. A numer of fctors importnt for effective progrmming nd service provision for key popultions hve relevnce to ll the interventions in the evidence-sed pckge. These common indictors re presented in checklist tht cn e used to ssess progrmmes or services providing ny of the essentil helth sector interventions. The items on this checklist cn lso e used to evlute whether or not progrmme or service is dequtely sensitized to meeting the needs of key popultions; progrmmes tht meet these criteri cn e counted s provider tht meets key popultion sensitiztion stndrds for the purpose of reporting indictors on vilility (see pge 11).

23 19 The checklist cn e used for evlution t the progrmme level or site level, nd results cn e ggregted t the ntionl level to determine wht proportion of sites meet some or ll of these criteri. The checklists cn e completed y service providers themselves s form or self-ssessment or could e used in n externl independent review, including evlution y key popultion community representtives. An importnt component of ssessing intervention qulity is gthering clients opinions through stisfction surveys. Whether or not service conducts such client stisfction surveys is n item on the progrmme qulity checklist itself. These surveys should elicit clients perceptions of the ccessiility nd ppropriteness of n intervention nd how it is delivered. Indictors using progrmmtic qulity ssessment checklists ENV 1 Audit of current legisltion nd policy checklist 28 NSP 6 NSP-relted policy nd prctice checklist 42 OST 4 OST-relted policy nd prctice checklist 45 Pge Helth worker trining How n intervention is delivered depends on the workers responsile for providing the service. Service providers must e le to effectively nd sensitively meet the needs of their clients. Workers should receive trining on the specific helth nd welfre needs of men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers nd trnsgender people nd ensure tht they hve the skills nd understnding necessry to protect ptient s rights to helth, confidentility nd non-discrimintion. Monitoring the percentge of new nd current stff memers who hve received sensitiztion trining lso is useful. Indictors exmining helth worker trining Q 1 Sensitiztion trining on key popultions for service providers 31 Pge Indictors mesuring specific spects of intervention qulity using survey nd progrmme dt A numer of dditionl indictors re descried tht mesure the extent to which importnt supplementry ctivities or services hve een delivered, for exmple, the provision of comptile luricnt when condoms re distriuted or the receipt of test results following n HIV test. Dt on these indictors come from surveys or progrmme dt or oth. These indictors re similr in formultion to those for vilility nd coverge descried ove. Indictors using progrmme nd survey dt to ssess qulity of interventions CCP 6 Consistent condom-comptile luricnt distriution 36 CCP 7 Key popultion reporting hving received luricnt when receiving condoms 37 OST 5 Individuls receiving mintennce OST continuously for t lest 6 months 46 OST 6 Individuls receiving mintennce dose of OST the recommended minimum dose 46 OST 7 Individuls on mintennce OST receiving psychosocil support 47 HTC 4 Key popultion reporting they received results following HIV testing 55 Pge

24 20 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions 5. Mesuring the outcome nd impct of interventions The strtegies nd interventions of the evidence-sed pckge descried in this document shre common gols: to prevent new infections to reduce relted moridity nd mortlity to reduce risk ehviour to protect the rights nd dignity of men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers nd trnsgender people. Oserved chnges or progress towrds these gols will lwys result from multiple fctors nd comintion of interventions. Chnges re unlikely to e ttriutle to single, isolted intervention or to single project or progrmme. In fct, the success of one intervention my depend on the success of nother. For exmple, n enling environment is essentil to mximize the impct nd effectiveness of the recommended helth sector interventions. This document descries set of outcome nd impct indictors to mesure progress towrd the chievement of these gols. These indictors re relevnt to helth sector interventions nd to strtegies for n enling environment, even if the influence of the ltter on the mesured outcomes nd impcts is lrgely indirect. Incidence (HIV, STIs, HBV nd HCV) Chnges in incidence reflect the impct of interventions intended to prevent infection. Mesuring incidence, however, is chllenging. Vrious methods my e used to estimte incidence indirectly, ut the limittions of ech method must e considered when interpreting results. Inferring incidence from cse reporting systems for newly noted infections hs limittions, generlly resulting in n underestimte of the totl numer of new infections. Cse reporting systems re le to count infections only mong those who re tested, nd they depend on roust nd consistent notifiction procedures. Becuse individuls my undergo test sometime fter the dte of seroconversion, cse notifictions reflect infections tht my hve occurred severl yers in the pst in the cse of HIV, HBV nd HCV. Limittions of currently ville serologicl HIV incidence ssys for recent infection testing lgorithms (RITA) to detect new infections restrict their usefulness for estimting incidence t the popultion level. These methods lso require lortory nd finncil resources tht re eyond the cpcity of most HIV surveillnce systems (11). Cse reporting for highly symptomtic STIs such s gonorrhoe in men my e useful. In contrst, cse reporting of STIs with few or sutle symptoms (such s chlmydi or syphilis) is unrelile s direct mesure of incidence; such cse reporting is more likely mesure of screening prctices. If screening prctices nd ptterns of utiliztion re firly stle over time, however, cse reporting my e le to provide some insight into trends in prevlence. An individul s drug use, sexul ehviour, trnsgender identity or prticiption in sex work my not e recorded in these cse notifiction systems. The mode of trnsmission ctegory recorded lso my not identify n individul s mn who hs sex with men or sex worker. Testing nd notifiction dt from sentinel sites ccessed y people from key popultions my provide more specific estimte of incidence, ut considertion should e given to how representtive these dt re of the entire key popultion. Mthemticl modelling cn estimte incidence. Tools such s the UNAIDS Spectrum Pckge cn e used to estimte HIV incidence for vrious popultion groups. To produce estimtes, these models require relile surveillnce nd progrmme dt such s informtion on modes of trnsmission, key popultion prevlence estimtes, nd dt from ART progrmmes. The prevlence of HIV mong young people in key popultions or those new to sex work or recently strting to inject drugs cn e used s proxy mesure of incidence for the respective key popultion of interest. This requires surveillnce dt to e disggregted y ge nd to include informtion on the durtion of time since strting injecting drug use, sex work, or, for men who hve sex with men, since ecoming sexully ctive. Longitudinl cohort studies of key popultions lso cn estimte incidence if prticipnts re tested regulrly. The likely representtiveness of the cohort nd the generlizility of the findings to the wider key popultion should e considered. Undertking prospective cohort studies is, however, typiclly complex, time-consuming nd expensive.

25 21 Indictors exmining incidence O 1 Infection incidence mong key popultion 64 Pge Prevlence (HIV, STIs, HBV nd HCV) Typiclly, HIV prevlence cn e mesured more esily thn incidence, ut is limited in its ility to determine the impct of interventions upon infection rtes. Chnges in oserved prevlence my not even necessrily e due to chnges in rtes of infection. Chnges in HIV prevlence could e the result of different surveillnce nd testing techniques used. Apprent decreses in prevlence could e the result of incresed stigmtiztion nd reluctnce of memers of key popultions to e tested, while rel decreses could e the result of mortlity mong people living with HIV. In ddition, when ccess to effective HIV tretment nd cre is improved, HIV prevlence is likely to increse s the life expectncy of HIV-positive people increses, even if the incidence of HIV infection remins stle or decreses. Prevlence cn e mesured y sentinel surveillnce of key popultions. Monitoring the STI prevlence of syphilis, gonorrhoe, or chlmydi in key popultions through sentinel system my lso provide useful informtion on recent unprotected sexul ctivity. Indictors exmining HIV nd STI prevlence O 3 Infection prevlence mong key popultion 65 Pge AIDS-relted deths HIV tretment nd cre im to prevent the progression of HIV to AIDS nd to reduce AIDS-relted deths. Direct mesurement of AIDS-relted mortlity relies upon notifiction systems nd deth registries. To monitor this outcome mong men who hve sex with men, people who inject drugs, sex workers nd trnsgender people, risk group sttus needs to e recorded in these systems nd deth registries lso must record AIDS-relted cuses of deth nd e linked with HIV registrtion dtses. Deths while in detention mong people in prisons nd other closed settings re likely to e recorded in registry systems; deths tht occur fter relese my e more difficult to identify. Longitudinl cohort studies of key popultions cn provide estimtes of the incidence of AIDS nd relted mortlity. The likely representtiveness of these cohorts should e considered when interpreting dt. Mthemticl models, such s the UNAIDS Spectrum Pckge, cn produce estimtes of AIDS-relted mortlity. Indictors exmining AIDS-relted deths O 2 Incidence of AIDS-relted mortlity 64 Pge Risk ehviours Outcome indictors tht exmine chnges in risk ehviour, such s condom use, cn e useful in ssessing the impct of relted interventions. Behviour surveys cn provide informtion on chnges in the prevlence of risk ehviours. Mny countries lredy undertke such surveys s prt of the ongoing monitoring of the HIV epidemic nd my periodiclly survey men who hve sex with men, people in prisons or other closed settings, people who inject drugs, sex workers nd trnsgender people s specific key popultions. As noted, the 2000 Fmily Helth Interntionl Guidelines for repeted ehviourl surveys in popultions t risk of HIV (3) is used in mny countries s sis for these surveys mong key popultions; revised version of these guidelines is due for relese in 2015.

26 22 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Collecting demogrphic, socioeconomic nd other dt in surveillnce studies llows for useful disggregtion nd nlyses. For exmple, differences etween younger nd older individuls cn e discerned. As discussed on pge 17, when undertking ehviourl surveys of key popultions nd when interpreting results, it is importnt to consider the representtiveness of the smples recruited nd the extent of potentil is ssocited with how nd where prticipnts re recruited. Indictors exmining risk ehviours O 4 Prevlence of risk ehviours nd knowledge round HIV mong key popultion 65 Pge Stigm nd discrimintion The People Living with HIV Stigm Index is vlidted survey mesuring stigm nd discrimintion experienced y people living with HIV, nd remedies ville to them. It includes numer of items on stigm nd discrimintion relted specificlly to men who hve sex with men, sex workers nd trnsgender people. Attitudes towrds key popultions held y service providers, lw enforcement officers nd the generl community cn lso e exmined through surveys; relevnt questions to e included in such surveys re proposed in this document. These indictors ssess the following: the fer of csul trnsmission of HIV nd refusl of contct with people living with HIV or memers of key popultions; vlue- nd morlity-relted ttitudes towrds memers of key popultions, including lme, judgement nd shme; nd ctions tht reflect stigm or discrimintion. Indictors exmining stigm nd discrimintion O 5 Stigm nd discrimintion experience y key popultion 66 O 6 Attitudes towrds key popultion held y service providers 66 Pge 6. Disggregting dt to etter understnd diversity There is significnt diversity within key popultions. Chrcteristics of vrious sugroups my e ssocited with differing HIV risks, rtes of service utiliztion nd helth outcomes. When exmining the coverge nd impct of interventions, it is useful to seprte the dt collected into relevnt sugroups to etter understnd ny differences within the popultion tht my need to e ddressed. In some cses, however, disggregtion my result in smll numers of individuls in prticulr group. Relying upon only very smll smple to estimte prevlence or coverge results in sustntil uncertinty round the estimte, nd estimtes my vry widely when mesured t different points in time. Disggregtion y ge In mny settings young people hve poorer rtes of ccess to HIV prevention nd cre services thn older people. There cn e vriety of resons, including ge discrimintion y progrmmes, lws denying services to people under certin ge without prentl consent, nd young people feeling tht services do not meet their needs. At minimum, it is dvisle to disggregte indictor dt for those younger thn 18 yers of ge, those etween 18 nd 25 yers of ge nd those 25 yers nd older. If the dt re ville, further disggregtion into nrrower ge rnges is useful, such s 10 14, 15 19, 20 24, 25+ for some indictors. Seprting dt on individuls younger thn 18 is prticulrly importnt with respect to key popultions in prticulr for legl issues such s ge of consent nd ccess to services nd for sex work, the definition of which includes only consensul sex etween dults; sex with people younger thn 18 yers should not e considered sex work (1, 12). However, this my e chllenging due to prcticl nd legl considertions.

27 23 Disggregtion y gender Dt on those who prticipte in sex work, injecting drug use or those detined in closed settings should e disggregted y gender including mle, femle, trnsgender men nd women. Trnsgender men nd women hve different helth issues. Therefore, it is recommended to disggregte dt on trnsgender people y gender, including msculine-identifying, feminine-identifying or whtever locl terms my e most pproprite. Disggregtion y other chrcteristics It is lso useful to exmine differing levels of risk within key popultions. It is prticulrly importnt to recognize the overlp etween ech of these key popultions. For exmple, men who hve sex with men, people in prisons nd other closed settings, sex workers nd trnsgender people my use nd inject drugs nd mny people from these key popultions my engge in sex work. Therefore, they re my e t greter risk of infection thn those with only one type of risk fctor. Hence, disggregting dt on specific key popultion y these other key popultion groups helps develop etter understnding of the dditionl needs of the popultion concerned. People from ech key popultion re typiclly over-represented in prisons nd other closed settings, often s consequence of the criminliztion of their identities or ehviours. The provision of services in prisons nd other closed settings presents numer of chllenges nd importnt differences compred to the provision of the sme services in community setting (13). Accordingly, dt on people in closed settings should e collected nd reported on seprtely Sugroups of key-popultions my hve especilly high risk for HIV infection, nd it is informtive to disggregte dt for these different sugroups. For exmple, when reporting indictors on sex workers, disggregtion distinguishing different types of sex work or sex work setting my e relevnt, prticulrly if services pproprite for these groups differ. Disggregtion might include indoor versus street-sed sex workers or might differentite y frequency of sex work for exmple, sex work s regulr pid employment versus occsionl pid sex. It is importnt to use definitions tht re pproprite to the locl context. Some men who hve sex with men my lso hve femle sexul prtners nd, therefore, hve dditionl HIV nd STI prevention needs. Disggregtion of dt into groups of those who hve femle sex prtner(s) nd those who do not provides useful informtion for ddressing these specific needs. Disggregting intervention dt y service provider chrcteristics Dt on the provision of interventions lso cn e disggregted y the type of service provider. In prticulr, s countries increse provision of interventions y community-led services, disggregting dt etween community-led nd other service providers cn help with monitoring progress in this direction. As descried ove, it is importnt to collect dt descriing the provision of services in prisons nd other closed settings. Disggregting dt y prisons nd other closed settings nd community settings is importnt nd cn help identify disprities in ccess to helth services etween these settings nd to evlute whether the principle of equivlence of cre is eing upheld. Disggregting y geogrphic re Reporting seprtely for different geogrphic res will e relevnt for mny countries nd is importnt to inform plnning decisions on where services should e locted. For exmple, disggregtion y rurl nd urn res my e prticulrly relevnt due to the different chrcteristics of key popultions in these settings nd different issues relted to service provision.

28 24 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions 7. Trget setting Setting trgets for the indictors descried in the preceding section ssists with strtegic, results-sed plnning to uild n effective response to the epidemic. Trgets cn e set for: ) Intervention nd enling environment indictors These include trget levels for vilility, coverge nd qulity indictors nd for enling environment fctors such s chnges in legisltion within specific time frme. Trget levels re set with the im of chieving reductions in HIV risk sufficient to control the epidemic nd ensuring the provision of pproprite mngement to those living with HIV. ) Outcome nd impct indictors These re trgets for the impct on the HIV epidemics themselves (for exmple, reductions in incident HIV or STIs) or trgets for chnges in risk ehviours (for exmple, the percentge of people who use condoms consistently). These trgets identify specific res tht need to e ddressed nd the scle of progrmmtic responses required. Trgets cn ssist with designing ctions tht contriute to meeting the high-level commitments tht hve een mde y Memer Sttes including the United Ntions Generl Assemly 2011 Politicl Declrtion on HIV/AIDS (14), see Box 4. While only one of these gols mentions key popultion specificlly, these trgets re still relevnt to the response to HIV mong key popultions more rodly. Box 4. United Ntions 2011 Politicl Declrtion on HIV/AIDS gols nd trgets to e chieved y Reduce sexul trnsmission of HIV y 50% 2. Hlve the trnsmission of HIV mong people who inject drugs 3. Eliminte HIV infections mong children nd reduce mternl deths 4. Rech 15 million people living with HIV with lifesving ntiretrovirl tretment 5. Hlve tuerculosis deths mong people living with HIV 6. Close the glol AIDS resource gp 7. Eliminte gender inequlities nd gender-sed use nd violence nd increse the cpcity of women nd girls to protect themselves from HIV 8. Eliminte HIV-relted stigm, discrimintion, punitive lws nd prctices 9. Eliminte HIV-relted restrictions on entry, sty nd residence 10. Strengthen HIV integrtion Becuse of the complexity of the interction of numerous fctors tht determine HIV risk nd intervention impct in prticulr setting, there is no universl formul for setting trget for prticulr indictor. Trgets need to reflect locl fctors such s the nture of the HIV epidemic, the current stge of the response, ville resources nd cpcity nd structurl fctors tht shpe risk nd influence intervention impct. Therefore, countries must undertke process for setting trgets relevnt nd specific to their own epidemic nd context. Trgets should e spirtionl ut lso chievle; prgmtic pproch is necessry. The following generl principles re importnt when setting trgets (see lso Fig. 1): Multiple interventions re more effective thn single interventions lone, nd they re essentil to preventing HIV trnsmission in key popultions. Without providing ll needed interventions of the pckge of recommended interventions, single intervention implemented lone will need to hve much higher level of coverge thn if other interventions were ville nd even my not e le to produce n impct on its own. Higher-qulity interventions deliver greter impct thn those tht re implemented t lower qulity. Greter levels of coverge re superior to lower levels. While greter intervention coverge rings out greter reductions in HIV risk nd, hence, incidence, this reltionship is not necessrily liner.

29 25 The higher the level of HIV prevlence (oth in the generl popultion nd mong key popultions), the greter the level of intervention coverge tht will e required. The erlier in n epidemic tht n intervention is introduced the more effective it cn e in controlling the spred of HIV. How should countries go out setting trgets? The trget setting process should e collortive, involving input from community-led orgniztions nd networks nd other stkeholders including representtives of government nd civil society, service providers nd clinicins. It is useful to mesure first the scle of the current response, ssessing the vilility, coverge, nd qulity of interventions nd to ssess enling environmentl fctors. Currently ville resources nd cpcity must lso e determined. This informtion serves s seline ginst which future progress cn e mesured. It is then necessry to estimte how much scle-up is possile within set time period, given ville resources nd technicl cpcity, nd how much dditionl cpcity nd resources cn e moilized. From this, relistic, chievle trget levels cn e set, nd the time period in which they re to e chieved cn e defined. It my e necessry to strengthen systems for progrmme monitoring to improve the trcking of progress towrd these trgets. Fig. 1. Reltionships etween intervention implementtion nd impct Higher coverge levels impct Multiple interventions ville (e.g. condom progrmmes + ddressing STIs + ART + community moiliztion) impct High qulity interventions impct Erly introduction of interventions effectiveness If HIV prevlence is lredy high coverge levels needed Indictive trgets In this document indictive trgets hve een proposed for numer of selected indictors. These trgets re intended to provide those responsile for implementing progrmmes with guide to help understnd the trget tht might e required to mke n impct nd to wht level services should e mintined or expnded to effectively control the epidemic. These proposed trgets should e considered s rodly indictive only, nd countries will need to consider the locl context to ssess wht levels they should im to chieve. In the future, s new nd more roust evidence emerges, these indictive trget levels my e revised. In numer of cses these trgets re sed on commitments mde y countries s set out in vrious glol declrtions (see Box 4, ove). Other trgets re lso considered including the mitious, ut chievle, Fst-Trck Trgets to moilize glol efforts nd resources in order to end the AIDS epidemic y 2030 (15), lunched y UNAIDS t the end of These Fst-Trck Trgets include: By 2020, 90% of people living with HIV knowing their HIV sttus, 90% of people who know their sttus receiving

30 26 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions tretment nd 90% of people on HIV tretment hving supressed virl lod, nd y 2030 incresing ech of these trgets to 95% respectively; Reducing the numer of new HIV infections mong dults in low nd middle income countries to 500,000 per yer y 2020 nd to 200,000 per yer y 2030; Achieving zero discrimintion with no new HIV discrimintory lws, regultions nd polices pssed nd for those countries tht hve such lws nd policies to repel them. These glol trgets hve n importnt role in mintining ttention nd ction t the glol level nd require countries to mke decisions s to how they should e trnslted nd progrmmed for t the ntionl level in response to the locl epidemic nd context. At the ntionl level pproprite intermedite trgets cn e set to guide incrementl progress towrds chieving these Fst-Trck Trgets. Further reding on trget setting Trget setting of HIV services, USAID, 2012 (16). Opertionl guidelines for monitoring nd evlution of HIV progrmmes for people who inject drugs. Genev, UNAIDS, 2011 (17) Opertionl guidelines for monitoring nd evlution of HIV progrmmes for sex workers, men who hve sex with men nd trnsgender people. UNAIDS, 2012 (18). Fst-Trck Ending the AIDS epidemic y UNAIDS, 2014 (15).

31 27 PART 2 INDICATORS This section descries indictors for ssessing key fctors relted to the enling environment, for mesuring the vilility, coverge nd qulity of specific helth sector interventions, nd for exmining the outcome nd impct of efforts to ddress HIV mong men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers nd trnsgender people. Except where specified, these indictors re relevnt to ech of these key popultions. For this reson, the term key popultion is used insted of referring to ech popultion seprtely. However, countries should develop progrmmes nd plns nd mesure progress for ech key popultion seprtely. Ech indictor nd its component prts re descried, nd dt sources re listed. Mny of these indictors re common to other dt collection processes (s noted). How ech indictor cn e used for trget setting is lso descried. Ech indictor hs reference numer descriing the type of indictor or intervention it exmines. The following convention is used: Intervention: ENV Indictor numer: 1 Arevitions: ENV Enling environment Q Qulity indictor (not specific to ny single intervention) CCP Comprehensive condom progrmming NSP Needle nd syringe progrmme OST Opioid sustitution therpy ODM Overdose prevention nd mngement GDR Reducing hrms relted to injecting sustnces for gender ffirmtion BHV Behviourl interventions PRP Pre-exposure prophylxis HTC HIV testing nd counselling ART HIV tretment nd cre, including ntiretrovirl therpy CMB Prevention nd mngement of co-infections nd other co-moridities SRH Sexul nd reproductive helth PKG Comined pckge of helth sector interventions O Outcome/impct indictor (not specific do ny single intervention)

32 28 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Strengthening the enling environment ENV 1 Audit of current legisltion nd policy checklist Does current legisltion nd policy include ny of the following which my negtively impct key popultions nd efforts to ddress HIV? c d e f g Lws criminlizing ehviours of key popultions including: sex cts etween consenting dults of the sme gender; nl sex etween consenting dults; involvement in sex work y consenting dults; cross dressing or gender impersontion ; drug use or possession of drugs for personl use Legisltion defining homosexul nd heterosexul ges of consent s not equl Lws or policing prctices criminlising or preventing the distriution of condoms or informtion on condom use nd sfe sex Lws criminlizing the crrying of condoms; or policing prctices where crrying condoms cn e used s evidence of sex work (if sex work is illegl) Lws or policing prctices criminlizing or preventing the distriution of injecting equipment nd informtion on sfer injecting prctices Lws or policies mking provision for mndtory HIV testing of key popultions Lws or policies mking provision of mndtory testing in prisons or for the segregtion of prisoners living with HIV Does current legisltion nd policy include ny of the following, which re supportive of the rights of key popultions nd efforts to ddress HIV? h i j k l m n o p The Ntionl HIV Strtegy specificlly ddresses key popultions Lws tht protect ginst humn rights violtions nd discrimintion (generlly not specific to HIV or key popultions) Lws tht protect ginst humn rights violtions nd discrimintion on the sis of sexul orienttion, gender identity, enggement in sex work or drug use Legisltion tht requires people in prisons nd other closed settings hve ccess to helth cre of equl stndrd s tht ville in the community Lws tht recognize sex work s work Lws tht criminlize ll forms of exploittion nd victimiztion, consistent with interntionl lw Lws tht regulte occuptionl helth nd sfety conditions to protect sex workers nd their clients Regultions llowing trnsgender people to esily chnge their nmes officilly nd to cquire legl recognition nd identifiction cknowledging their chosen gender identity Lws tht unmiguously support the provision of mintennce opioid sustitution therpy nd needle nd syringe progrmmes Desk review nd stkeholder consulttion The items listed in the checklist ove cn e used s guide when conducting n udit of current legisltion nd policy to identify lws nd policies tht might either support or negtively ffect the rights, helth or welfre of men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers or trnsgender people. An udit of this kind should e undertken with the prticiption of government, civil society nd community-led networks, nd orgniztions of key popultions. Where legisltion or policy is found to e in need of reform, processes for chnge should e identified nd evluted. Guidnce on undertking n ssessment of legisltion is ville. See Legl environment ssessment for HIV: n opertionl guide to conducting ntionl legl, regultory nd policy ssessments for HIV, UNDP, Prcticl%20Mnul%20LEA%20FINAL%20we.pdf.

33 29 ENV 1 continued Audit of current legisltion nd policy checklist Setting trgets: Introducing legisltion nd policy tht is supportive of the rights, helth nd welfre of key popultions nd removing ny tht dversely ffect these groups should e the intended im. While developing policy nd legisltion cn e slow process, countries where lw nd policy reform is required should set out relistic ut mitious time frme for chnge nd monitor progress towrd these gols. It should e noted tht the 2011 Politicl Declrtion on HIV/AIDS included the commitment y Memer Sttes to eliminte HIV-relted stigm, discrimintion, punitive lws nd prctices y 2015 (14); in ddition recent UNAIDS trgets cll for no new HIV-relted discrimintory lws, regultions or policies nd tht 50% of countries tht hve such lws, regultions nd policies repel them y 2020 (15). ENV 2 Involvement of key popultion in ntionl policy nd strtegy formultion Are representtives from key popultion-led orgniztions memers of the ntionl multisectorl HIV coordinting ody? Desk review nd stkeholder consulttion Tht representtives from key popultion-led orgniztions re memers of ntionl coordinting odies does not necessrily indicte tht key popultions re meningfully involved in the development of policy nd strtegy, ut it is n essentil element in chieving it. Setting trgets: If the ntionl multisectorl HIV coordinting ody does not hve representtion from key popultion-led orgniztions, representtives should e recruited. If key popultion-led orgniztions re not estlished, n initil trget would e to support their formtion, nd set time frme for their estlishment. ENV 3 Legl support services for key popultions Numer of services providing legl support to people from key popultions Fcility-sed ssessment/progrmme dt Providing legl support to people from key popultions is importnt to ensure ccess to justice. For this indictor the type of legl support should e documented. Legl support includes pro ono legl id nd support from community prlegls, including memers of key popultions trined s legl dvoctes. Where pproprite, legl support services my lso fcilitte ccess to trditionl dispute resolution mechnisms with the support of trditionl leders. Similrly, the type of service or progrmme providing this legl support should e reported. These might include services tht provide legl support to key popultions in ddition to other helth or welfre services, or legl services tht might either specilize in legl issues relted to key popultions or tht my e sensitive to the needs of people from these popultions. Setting trgets: Trgets cn e set for n incresed numer of services (or sites) where legl support is provided to people from key popultions, nd time frme set for this scle-up. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 24 for further discussion).

34 30 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions ENV 4 c Support services for people from key popultions who experience violence Numer of sites where key popultion-focused progrmmes provide pproprite medicl, psychologicl nd legl support for those who hve experienced violence Totl numer of sites where key popultion-focused progrmmes re offered [] x 100 = [] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where pproprite medicl, psychologicl nd legl support for those who hve experienced violence is provided This indictor is sed on the following UNAIDS Unified Budget, Results nd Accountility Frmework (UBRAF) indictor nd hs een dpted to look t key popultions specificlly nd, mong them, those who re victims of physicl, sexul nd other forms of violence: Numer or percentge of service-delivery points providing pproprite medicl, psychologicl nd legl support for women nd men who hve een rped or who hve experienced incest. When reporting on this indictor, the site definitions used should e documented. See pge 11 for further informtion on this type of indictor. Setting trgets: Countries cn set trgets for n incresed totl numer of sites providing medicl, psychologicl nd legl support for people from key popultions who hve experienced violence nd set time frme for scle-up. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 13 for further discussion). Not every site where key popultion-focused progrmmes operte will e n pproprite plce to offer medicl, psychologicl nd legl support to people who hve experienced violence, ut mny will e. When setting trgets for indictor ENV 4c, it is necessry to determine which sites not currently offering this type of support hve the potentil to do so. It should lso e noted tht the 2011 Politicl Declrtion on HIV/AIDS included the commitment y Memer Sttes to eliminte gender inequlities nd gender-sed use nd violence nd increse the cpcity of women nd girls to protect themselves from HIV y 2015 (14). ENV 5 Sensitiztion trining on key popultions for lw enforcement officers Numer (nd percentge) of lw enforcement officers who received key popultion sensitiztion trining over the specified reporting period. Records held y relevnt police or justice uthority Trining should e in line with ntionl endorsed stndrds. The trining curriculum should cover: the rights of key popultions; lw enforcement officers responsiilities for protecting these rights; nd lw enforcement prctice guidelines on supporting the provision of HIV prevention nd other services for key popultions. This trining should e prt of the pre-service officer trining progrmme nd should lso e provided on n ongoing nd regulr sis to officers in service. Community-led orgniztions nd key popultion networks cn mke n importnt contriution to this trining, if done in sfe nd non-stigmtizing mnner. Setting trgets: If the current ntionl lw enforcement officer trining curriculum does not include key popultion sensitiztion trining, the first trget will e to develop this. Trgets should then e set for the rpid roll-out of this curriculum to ll trining sites. As ll new officers should receive this trining, the trget should e tht ll grduting officers complete key popultion sensitiztion trining. A relistic ut mitious time frme for chieving this trget should e set. Trgets cn lso e set for trining current officers, with the gol tht ll officers should receive trining on regulr nd ongoing sis. The frequency of this trining should e decided with input from stkeholders.

35 31 Qulity indictors for ll progrmmes nd interventions Q 1 Progrmme qulity checklist c d e f g h i All stff memers hve received trining nd sensitiztion relevnt to working with key popultions. Service providers should receive nti-stigm nd nti-discrimintion sensitiztion nd trining on the specific helth nd welfre needs of key popultions. Trining should ensure they hve the skills nd understnding necessry to ensure tht ptient s rights to helth, confidentility nd non-discrimintion re protected. See lso indictor Q-2 (elow). The progrmme hs cler ntidiscrimintion policy nd code of conduct. This policy should lso include mechnism for oversight to ensure tht stndrds re mintined. The progrmme hs ctively involved key popultion representtives in plnning the provision of the service for the key popultions. This involves consulttion with nd meningful involvement of people from the key popultion in the development of services to ensure these re pproprite nd cceptle to the popultion of focus. The progrmme seeks regulr nonymous feedck from clients. Mechnisms re in plce wherey clients cn confidentilly/nonymously provide feedck on the service, nd the progrm reviews nd is responsive to this informtion. People from key popultions re not required to meet specific criteri in order to ccess the intervention. Access is not restricted on the sis of minimum ge, gender identity or expression, sexul orienttion, occuption, drug use, citizenship or residency sttus, incrcertion or criminl history. This includes restriction of ccess to ART on the sis of pst or current drug use. The intervention is provided to people from key popultions t no cost or t cost tht is ffordle. Cost cn e significnt rrier to ccess if clients re required to cover these costs themselves ut do not hve the resources to do so. To increse ccessiility, the intervention should e offered to memers of the key popultion free of chrge (where possile), the costs covered y helth insurnce provisions, the costs to ptients prtly susidized, or the services provided free or t reduced costs specificlly for finncilly disdvntged ptients. The progrmme mintins client confidentility. Services hve systems in plce to ensure tht client records re kept securely nd remin confidentil. Client informtion is not shred with other services or lw enforcement without client consent, unless required y lw. Progrmme dt collection systems do not contin clients personl or identifying informtion. The progrmme hs cler chin of ccountility to ensure tht minimum stndrds for the provision of the intervention re met. Long-term funding hs een secured to ensure the sustinility of providing the intervention to the key popultion. Long-term funding should e committed to the ongoing opertion of progrmmes providing the intervention to the key popultion. If services re funded y externl sources, the sustinility of this funding should e ssessed, nd contingencies for filling funding gps should e determined. Fcility-sed ssessment The items in this checklist cn e used s guide when conducting service provider ssessment. This checklist hs relevnce to ll progrmmes tht provide services to people from key popultions nd, long with indictor Q 1, cn e used to determine whether service meets defined key popultion sensitiztion stndrds. (See vilility indictors CCP 1, NSP 1, OST 1, HTC 1, ART 1 nd SRH 1 which mke use of this informtion.) Countries my wish to dd or dpt items in this checklist, ut there should e clerly defined stkeholder-endorsed definition of minimum set of stndrds.

36 32 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Q 1 Progrmme qulity checklist continued Setting trgets: Trgets using this checklist cn e set in vrious wys: 1. At the service level time frme cn e set for the chievement of items on the checklist tht hve not yet een chieved. 2. At the ntionl level trget cn e set for the percentge of ll sites tht meet defined minimum set of stndrds, nd time frme for chieving these cn e set. 3. At the ntionl level trget cn e set for the percentge of ll sites tht meet n individul item from this checklist, nd time frme for chieving this cn e set. Q 2 Sensitiztion trining on key popultions for service providers c d e f Numer of stff recruited in the lst 12 months who hve received key popultion sensitiztion trining Numer of stff recruited in the lst 12 months [] x 100 = [] Percentge of stff recruited in lst 12 months who hve received key popultion sensitiztion trining Numer of current stff who hve received sensitiztion trining Numer of current stff [d] x 100 = [e] Fcility-sed ssessment Percentge of current stff memers who hve received sensitiztion trining These indictors re relevnt to ll progrmmes tht provide services to key popultions. Stff from these progrmmes should e trined in key popultions rights nd needs. The trining provided should e consistent nd include nti-stigm nd ntidiscrimintion sensitiztion s well clinicl competency trining on the specific helth nd welfre needs of people from these key popultions. Development of ntionl trining stndrds nd guidelines cn help to ensure tht trining is comprehensive nd of good qulity. For indictor Q 2d the numer of current stff memers who hve received trining could e recorded for those who hve ever received trining or those who hve received trining within defined time period, such s 12 or 24 months. Setting trgets: All new nd current stff of progrmmes tht provide services to key popultions should receive trining in providing pproprite, cceptle, high-qulity services to people from these key popultions. Thus, it is pproprite for service providers to im for trgets of 100% for indictors Q 2c nd Q 2f. Countries should then set out n mitious ut relistic time frme to scle up sensitiztion trining to rech these 100% trgets.

37 33 Comprehensive condom nd luricnt progrmming CCP 1 c d e f AVAILABILITY: Sites providing comprehensive condom progrmming Numer of sites where key popultion-focused progrmmes provide condoms nd comptile luricnt Numer of sites where minstrem progrmmes meeting key popultion sensitiztion stndrds provide condoms nd comptile luricnt Totl numer of ll sites where ny key popultion-focused progrmmes re offered Totl numer of sites where minstrem progrmmes provide condoms nd comptile luricnt [] x 100 = [c] []+[] x 100 = []+[d] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where condoms nd comptile luricnt re provided Percentge of ll sites where condoms nd comptile luricnt re provided tht re either key popultion-focused progrmmes or minstrem progrmmes meeting key popultion sensitiztion stndrds This indictor counts only sites where condom-comptile luricnt is provided long with condoms. For this indictor the definition of site should e documented. Sites might include fixed-site services nd loctions where outrech nd moile services operte. See pge 11 for further informtion on vilility indictors of this type. Setting trgets: In most contexts the mjority of sites where services re provided to key popultions re likely to e pproprite condom nd luricnt distriution points. Accordingly, in mny countries trget of 100% of sites my e pproprite for indictor CCP 1e. Similrly, people from key popultions should e le to ccess minstrem services tht provide condoms nd luricnt, nd, idelly, ll minstrem services should meet key popultion sensitiztion stndrds. Accordingly, in mny countries trget of 100% of sites my e pproprite for indictor CCP 1f. Countries should then set out n mitious ut relistic time frme for scling up comprehensive condom progrmming to rech these trgets. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out condom progrmming to key popultion-focused progrmmes nd key popultion sensitiztion trining nd procedures to minstrem services. CCP 2 Behviourl survey AVAILABILITY: Key popultion reporting condoms re redily ccessile Percentge of key popultion in smple who gree with the sttement: Condoms re ville when I need them. Percentge of key popultion in smple who nswer yes to the question: In the lst 12 months, hve you ever hd sex without condom ecuse you weren t le to either uy condom or get one for free? The time frme for this indictor cn vry; for exmple, the question could e sked out condom use nd vilility in the lst 1, 3 or 6 months. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for these indictors. Countries cn then set trgets nd time frme for chieving them, linked with trgets for progrmme ctivities nd scle-up.

38 34 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions CCP 3 COVERAGE: Key popultion provided with condoms nd comptile luricnt Numer of people from key popultion provided with condoms nd comptile luricnt y key popultionfocused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months). [] Percentge of totl key popultion provided with condoms nd Estimted key popultion size x 100 = comptile luricnt y key popultion-focused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) Progrmme dt Popultion size estimtes This indictor counts only clients who received oth condoms nd comptile luricnt; those who received condoms only, without lso receiving luricnt, re excluded from this count. If key popultion-specific dt re lso ville from minstrem progrmmes, these cn lso e included in this indictor. To void doule counting, methods such s unique identifier codes or the recll lst contct method cn e used (see pge 15). Different time periods my e selected when mesuring this indictor. Time periods of different durtion provide different insights into progrmme rech nd frequency of service utiliztion. For exmple, reporting on ccess in the lst one month provides snpshot of current utiliztion nd pproximtes the numer who might regulrly use the service. If popultion size estimtes re not ville, monitoring chnges in the numer of people provided with condoms nd luricnt over time cn still provide vlule insights into progrmme implementtion nd progress in scling up. See pge 15 for further informtion on this type of coverge indictor. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frme for scling up comprehensive condom progrmming to rech greter totl numer nd greter proportion of people from the key popultion. These time frmes nd trgets should e sed on n ssessment of the logisticl issues nd the resources required to roll-out condom progrmming to key popultion-focused progrmmes. In setting trgets it is importnt to recognize in nerly ll countries tht condoms nd luricnt will e ville for sle from different outlets. Hence, distriution y key popultion-focused services, while mking vitl contriution to the ccessiility of condoms nd luricnt, does not constitute the only source of condoms contriuting to overll condom coverge, this should e reflected in the trgets set.

39 35 CCP 4 c d COVERAGE: Quntity of condoms nd condom-comptile luricnt distriuted Numer of condoms provided to key popultion from key popultion-focused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) [] Numer of condoms distriuted per memer of key popultion over the = Key popultion size estimte specified reporting period (e.g. the lst 1, 3, 6 or 12 months) Numer of schets of condom-comptile luricnt provided to key popultion from key popultionfocused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) [c] Key popultion size estimte Progrmme dt Popultion size estimtes Numer of schets of condom-comptile luricnt distriuted per memer = of key popultion over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) If key popultion-specific dt re lso ville from minstrem progrmmes, these cn lso e included in this indictor. If luricnt is provided in tues or other continers insted of in schets, these should e counted. Different time periods my e selected when mesuring this indictor. If popultion size estimtes re not ville, monitoring chnges in the numer of condoms distriuted over time cn still provide vlule insights into progrmme implementtion nd progress in scling up. See pge 15 for further informtion on this type of coverge indictor. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frmes for scling up comprehensive condom progrmming to distriute greter numer of condoms oth in solute terms (CCP 4; CCP 4c) nd reltive to estimted key popultion size (CCP 4; CCP 4d). These time frmes nd trgets should e sed on n ssessment of the logisticl issues nd the resources required to roll-out condom progrmming to key popultion-focused progrmmes. In setting trgets, it is importnt to recognize in nerly ll countries tht condoms nd luricnt will e ville for sle from different outlets. Hence, distriution y key popultion-focused services, while mking vitl contriution to the ccessiility of condoms nd luricnt, does not constitute the only source contriuting to overll coverge. These fctors need to e ccounted for when setting trgets for condom distriution from key popultion-focused services.

40 36 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions CCP 5 COVERAGE: Key popultion reporting they hve received condoms nd luricnt Percentge in smple of key popultion who nswer yes to the questions: c d Behviourl survey In the lst [X months], hve you een given condoms? (e.g. through n outrech service, drop-in centre or sexul helth clinic.) In the lst [X months], hve you een given schets of luricnt? (e.g. through n outrech service, drop-in centre or sexul helth clinic.) In the lst [X months], hve you ever een unle to get condom when you needed one? In the lst [X months], hve you ever not used condom when hving sex ecuse you were unle to get one? The time period for these indictors cn vry; for exmple, the question could e sked out condom use nd vilility in the lst 1, 3, 6 or 12 months. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for these indictors. Countries cn then set trgets nd time frme for chieving them, linked with trgets for progrmme ctivities nd scle-up. CCP 6 c Progrmme dt QUALITY: Consistent condom-comptile luricnt distriution Numer of schets of luricnt provided to key popultion y key popultion-focused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) Numer of condoms provided to key popultion from key popultion-focused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) [] x 100 = [] Rtio of totl numer of schets of luricnt distriuted to totl numer of condoms distriuted over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: Condom-comptile luricnt should e provided with every condom given out. Accordingly, if single-use schets of luricnt re distriuted, the trget for indictor CCP 6c should e 1:1. Bseline levels should first e mesured. Countries should then set n mitious ut relistic time frme for incresing the prctice of providing luricnt with ll condoms distriuted.

41 37 CCP 7 Behviourl survey QUALITY: Key popultion reporting hving received luricnt when receiving condoms Percentge in smple of key popultion who nswer yes to the question: The lst time you were given condoms, were you lso provided with luricnt? (e.g. through n outrech service, drop-in centre or sexul helth clinic.) See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: Condom-comptile luricnt should e provided with every condom given out. Accordingly, the trget for this indictor should e 100%. The results of n initil survey cn e used to set seline for these indictors. Countries should then set n mitious ut relistic time frme for incresing the prctice of providing luricnt with ll condoms distriuted.

42 38 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Needle nd syringe progrmmes NSP 1 c d e f g f AVAILABILITY: Sites providing injecting equipment needle nd syringe progrmmes (NSPs) Totl numer of sites where sterile needles nd syringes re provided free of chrge (i.e. NSP sites) Totl numer of phrmcies or other outlets where needles nd syringes re ville for purchse Numer of sites where key popultion-focused progrmmes provide sterile needles nd syringes Numer of NSP sites meeting key popultion sensitiztion stndrds Totl numer of sites where key popultion-focused progrmmes re offered [c] x 100 = [e] [c] x 100 = [] []+[] x 100 = []+[d] Fcility-sed ssessment/progrmme dt Percentge of NSP sites meeting key popultion sensitiztion stndrds Percentge of key popultion-focused progrmme sites where sterile needles nd syringes re provided Percentge of ll sites where sterile needles nd syringes re provided tht re either key popultion-focused progrmmes or NSPs meeting key popultion sensitiztion stndrds The numer of NSPs sites (NSP 1) is n importnt indictor for monitoring NSP scle up. NSP sites re, y definition, key popultion-focused services in so fr s their primry intention is to provide sterile injecting equipment to people who inject drugs. As noted, people who inject drugs include men who hve sex with men, people in prisons nd other closed settings, sex workers nd trnsgender people. As such it is importnt tht NSPs re ccessile to people from these key other popultions nd sensitized to meet their needs. Mny sites tht focus on providing vrious services to these key popultions my lso e pproprite sites for the distriution of sterile injecting equipment (see elow). The definition of site should e documented. NSPs my operte in vriety of loctions nd service models, including fixed sites, moile services nd outrech. For the purpose of reporting this indictor, it is recommended tht, for loction to e considered site, the following conditions must e met: It is the loction of fixed site or site tht is serviced y moile or outrech service. If fixed site, it must hve frequent nd regulr hours of opertion. If moile service, the service must operte t the site on frequent nd regulr sis. If n outrech service, the specific site or defined re must e ccessed on frequent nd regulr sis y outrech workers. In some countries injecting equipment my e ville for purchse from phrmcies, while in others the sle of injecting equipment my e more restricted. For exmple, only certin phrmcy outlets my provide needles nd syringes. See pge 11 for further informtion on vilility indictors of this type. Setting trgets: Mny sites where services re provided to key popultions my e pproprite distriution points for needles, syringes nd other injecting prphernli. When setting trgets for indictor NSP 1e, it is necessry to determine which sites not currently distriuting needles nd syringes might hve the potentil to provide this intervention. People from key popultions should e le to ccess minstrem NSPs without fer of fcing stigm or discrimintion. Idelly, ll minstrem services should meet key popultion sensitiztion stndrds. Accordingly, in mny countries trget of 100% my e pproprite for indictors NSP 1f nd NSP 1g. Countries should then set n mitious ut relistic time frme for scling up NSPs ccessile to key popultions to rech these trgets. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out NSP cpcity to key popultion-focused progrmmes nd key popultion sensitiztion trining nd procedures to minstrem NSPs.

43 39 NSP 2 Behviourl survey AVAILABILITY: People who inject drugs reporting sterile needles syringes re redily ccessile Percentge of people who use drugs in smple who gree with the sttement: Sterile needles nd syringes re ville when I need them. Percentge of key popultion in smple who nswer yes to the question: In the lst [X months], hve you ever injected with used needle or syringe ecuse you weren t le to either uy or get for free sterile injecting equipment? The time period for this indictor cn vry. For exmple, the question could e sked out sterile injecting equipment use nd vilility in the lst 1, 3, 6 or 12 months. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for these indictors. Countries cn then set trgets nd time frme for chieving them, linked with trgets for progrmme ctivities nd scle-up. NSP 3 c COVERAGE: Quntity of needles syringes distriuted Totl numer of needles syringes distriuted y NSPs in the lst 12 months Totl numer of needles syringes sold to people who inject drugs y phrmcies or other outlets in the lst 12 months [] + [] Estimted numer of people who = inject drugs Progrmme dt Phrmcy retil dt Popultion size estimtes Numer of needles syringes distriuted per person who injects drugs per yer This indictor looks t the totl quntity of new/sterile needles syringes tht re distriuted nd, hence, estimtes the totl numer of clen units of injecting equipment in circultion tht might e used y the popultion of injecting drug users. NSPs my provide vrious types of needles nd syringes, including seprte needles nd syringe or syringes with needles ttched. For the purpose of counting the numer of needles syringes for this indictor, it is recommended to count the totl numer of equivlent single sterile injecting units distriuted. For exmple, if 10 seprte syringes nd 20 seprte needles re dispensed, totl of 10 sterile injecting units (ech comprising 1 needle nd 1 syringe) would e counted; similrly, if 12 seprte syringes nd 6 seprte needles re dispensed, totl of 6 sterile injecting units would e counted. This indictor should still e clculted even if dt on the numer of needles syringes sold y phrmcies is not ville. If such dt re collected nd collted, however, more complete picture of the totl numer of needles nd syringes in circultion nd, hence, of coverge cn e otined. If popultion size estimtes re not ville, monitoring chnges in the quntity of injecting equipment distriuted over time cn still provide vlule insights into progrmme implementtion nd progress in scling up nd should e reported. This indictor is included in the Glol AIDS Response Progress Reporting guidelines (19, 20). See pge 15 for further informtion on this type of coverge indictor.

44 40 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions NSP 3 continued COVERAGE: Quntity of needles syringes distriuted Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frmes for scling up needle-syringe distriution oth in solute terms (NSP 3; NSP 3) nd reltive to estimted key popultion size (NSP 3c). The following indictive trget cn e used s enchmrk ginst which country s own trgets cn e compred: Possile trgets: Low 100 Mid 200 High These trget levels re sed upon studies in developed-country settings nd mthemticl modelling investigting the levels of syringe distriution nd its impct on HIV trnsmission (21, 22). Note tht the levels required for the prevention of HCV re likely to e much higher thn those proposed here. Time frmes nd trgets set should e sed on n ssessment of the logisticl issues nd the resources required to roll-out NSP cpcity to key popultion-focused progrmmes. NSP 4 c d e f COVERAGE: People who inject drugs reched y NSPs Numer of people who inject drugs who ccessed n NSP over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) [] Estimted numer of people who x 100 = inject drugs Percentge of people who inject drugs ccessing n NSP over the specified reporting period Numer of people who inject drugs who ccessed n NSP t lest once per month over the specified reporting period (e.g. the lst 3, 6 or 12 months) [c] Estimted numer of people who x 100 = inject drugs Percentge of people who inject drugs ccessing n NSP t lest once per month over the specified reporting period Numer of NSP occsions of service (totl contcts) in the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) [e] Estimted numer of people who x 100 = inject drugs Progrmme dt Popultion size estimtes Rtio of the numer of NSP occsions of service for the specified reporting period per 100 people who inject drugs These indictors exmine utiliztion of NSPs reltive to the estimted popultion size of people who inject drugs. NSP 4 nd NSP 4c require services to hve dt collection system using methods such s unique identifier code or the recll lst contct method to void doule counting (see pge 15). People who inject drugs regulrly require n ongoing supply of injecting equipment nd, therefore, continul ccess to NSPs. If the quntity of injecting equipment tht client is le to otin per visit is limited, it my e necessry to ccess n NSP more regulrly to hve sufficient supply of clen injecting equipment nd void used needles nd syringes. NSP 4d provides n indiction of regulr rech, for this purpose defined s ccessing n NSP once per month. A 1-month reporting period for NSP 4 cn e used s proxy for recent or current coverge. NSP 4e counts the totl numer of NSP client service events or occsions of service nd does not require the use of unique identifier code. This includes every visit to n NSP service in which needles syringes were dispensed. Multiple visits y the sme client re included in this count. See pge 15 for further informtion on this type of coverge indictor.

45 41 NSP 4 continued COVERAGE: People who inject drugs reched y NSPs Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frmes for scling up NSPs to increse rech oth in solute terms (NSP 4, NSP 4c, NSP 4e) nd reltive to estimted key popultion size (NSP 4, NSP 4d, NSP 4f). The following indictive trget cn e used s enchmrk ginst which country s own trgets for NSP 3d (Percentge of people who inject drugs ccessing n NSP t lest once per month over 12 months) cn e compred: Possile trgets: Low 20 Mid 60 High The high trget level is sed on retrospective nlysis of the coverge mong people who inject drugs in n urn setting in high income country (23). Trget levels for NSP 4 should e set higher s this does not mesure regulr rech, ut rther ccess t ny point over the reporting period. Trget levels for NSP 4f should lso e set higher s this indictor includes doule counting of individuls who ccess on multiple occsions. Time frmes nd trgets set should e sed on n ssessment of the logisticl issues nd the resources required to roll-out NSP cpcity to key popultion-focused progrmmes. NSP 5 Behviourl survey COVERAGE: People who inject drugs reporting they hve received sterile injecting equipment Percentge in smple from key popultion who inject drugs nd who nswer yes to the question: In the lst [X months], hve you een given clen needles or syringes? (e.g. y n outrech worker or through needle nd syringe progrm.) The time period for this indictor cn vry; for exmple, the question could e sked out receiving sterile injecting equipment in the lst 1, 3, 6 or 12 months. Depending on the nture of the smple investigted, the numer of people from key popultions who report injecting drugs my e quite smll reltive the rest of the smple. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for this indictor. Countries cn then set trget nd time frme for its chievement.

46 42 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions NSP 6 QUALITY: NSP-relted policy nd prctice checklist Do current ntionl guidelines nd policy include the following stipultions which mximize the impct of needle nd syringe distriution through NSPs? c Ntionl guidelines stipulte tht there e no limit on the quntity of injecting equipment provided y NSPs. This distriution policy seeks to mximize the quntity of injecting equipment dispensed (i.e. there is no rtioning of equipment provided). Ntionl guidelines stipulte tht the return of used injecting equipment is not prerequisite for clients to receive new injecting equipment. While returning used injecting equipment should not e prerequisite for receiving new injecting equipment, people who inject drugs should e encourged nd helped to dispose of injecting equipment sfely. Ntionl guidnce stipultes tht NSPs provide rnge of injecting equipment tht is pproprite for locl injecting prctices nd sustnces injected nd tht is cceptle to the trget popultion. Needles nd syringes provided should e suited to the locl drug mrket nd context nd cceptle to clients. People who inject drugs should e consulted to determine the most pproprite nd cceptle equipment for distriution. Idelly, the smllest guge needles should e provided in order to cuse miniml tissue dmge t the site of injection. Lrger guge needles my e required for the injection of some drugs, including those tht re more viscous in solution nd in some instnces where drugs my e of poor qulity. Syringes should e of pproprite volume (lrger for sustnces tht re injected in greter volumes, such s methdone, which my require dilution). Needles nd syringes should hve miniml ded-spce, s lrger syringe ded-spce my retin greter quntity of infective prticles, thus incresing risk of infection on reuse (24, 25). Other relted mterils should lso e provided where pproprite, including sterile wter, sfe shrps disposl continers, filters, mixing vessels (e.g. spoons), disposle tourniquets, cidifiers (e.g. scoric or citric cid powders) nd mterils to encourge non-injecting routes of dministrtion s sfer lterntive to injecting, such s sterile pipes, ppers or foil. Desk review nd stkeholder consulttion The items listed in the checklist ove cn e used s guide when conducting n udit of current legisltion nd policy to identify lws nd policies tht might either support or negtively ffect the rights, helth or welfre of men who hve sex with men, people in prisons nd other closed settings, people who inject drugs, sex workers or trnsgender people. Where policies nd guidelines re found to e in need of reform, processes for chnge should e identified nd evluted. Setting trgets: Aligning polices nd guidelines with recommended prctice should e the intended im. Countries should set out relistic ut mitious time frme for chnge nd monitor progress towrd these gols.

47 43 Opioid sustitution therpy OST 1 c AVAILABILITY: Sites providing mintennce opioid sustitution therpy (OST) Numer of sites where mintennce OST is prescried nd/or dispensed Numer of sites where mintennce OST is prescried or dispensed tht meet key popultion sensitiztion stndrds [] x 100 = [] Fcility-sed ssessment/progrmme dt The definition of site should e documented. Percentge of mintennce OST sites meeting key popultion sensitiztion stndrds The numer of sites where OST is provided (OST 1) is n importnt indictor for monitoring OST scle-up. Sites where OST is prescried my include: specilist services, generl prctitioner prescriers/office-sed nd other primry cre settings. Sites where OST is dispensed my include: phrmcies, specilist services, moile dispensing services. This indictor cn e disggregted y the opioid gonist prescried, including: methdone; uprenorphine; dimorphine (phrmceuticl heroin); slow-relese morphine preprtions; tincture of opium. To certin extent OST sites re, y definition, key popultion-focused services in so fr s their primry intention is to provide drug tretment to people who use drugs nd who re opioid dependent. As noted, people who use drugs include men who hve sex with men, people in prisons nd other closed settings, sex workers, nd trnsgender people. As such, it is importnt tht OST services re ccessile to people from these other key popultions nd sensitized to meet their needs. See pge 11 for further informtion on vilility indictors of this type. Setting trgets: People from key popultions should e le to ccess OST without fer of fcing stigm or discrimintion. Idelly, ll minstrem services should meet key popultion sensitiztion stndrds. Accordingly, in mny countries trget of 100% my e pproprite for indictors OST 1c. Countries should set n mitious ut relistic time frme for scling up OST nd ensuring tht services re ccessile to key popultions. Trgets nd time frmes set should e sed on n ssessment of the logisticl issues nd the resources required to roll-out OST nd key popultion sensitiztion trining. OST 2 Progrmme dt AVAILABILITY: OST progrmme cpcity Numer of people on witing list for OST on specified dte In some countries OST progrmmes my hve fixed numer of OST tretment plces or slots. This indictor provides mesure of the extent to which demnd for OST is mtched y the cpcity of the progrmme. Setting trgets: Countries should im for OST cpcity to meet demnd, nd s such, the numer of people witing for OST, s well s the durtion of the witing time, should e minimized.

48 44 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions OST 3 c d COVERAGE: Individuls receiving mintennce OST Numer of ll individuls on OST t specified dte [] Estimted numer of opioiddependent x 100 = Percentge of opioid-dependent people on OST people Numer of ll individuls on OST t specified dte [c] Estimted numer of opioiddependent x 100 = people Progrmme dt Popultion size estimtes These indictors exmine the coverge of OST ssessed t specific census dte. Percentge of opioid-dependent people who use drugs receiving OST It is importnt to recognize tht not ll people who inject drugs re dependent upon opioids nd wnt or need OST, nd not ll people receiving OST will e injecting drug users. Accordingly, it is importnt to ensure tht the numertors nd denomintors of indictors mesuring OST coverge mtch. Tht is, if the numertor is the numer of ll individuls on OST (OST 3) the denomintor should e ll opioid-dependent people (including people who inject nd those who do not) (OST 3). Similrly, to estimte the coverge of OST mong people who use drugs (OST 3d), the numertor needs to count only those on OST who inject drugs nd the denomintor the numer of people who inject drugs who re opioid dependent. See pge 15 for further informtion on this type of coverge indictor. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frmes for scling up OST to increse rech oth in solute terms (OST 3, OST 3c) nd reltive to estimted popultion size (OST 3, OST 3d). The following indictive trget cn e used s enchmrk ginst which country s own trgets for OST 3 nd OST 3d cn e compred: Possile trgets: Low 20 Mid 40 High The high trget level is sed on levels of coverge chieved in countries with well-estlished OST progrmmes. Time frmes nd trgets set should e sed on n ssessment of the logisticl issues nd the resources required to roll-out OST cpcity to key popultion-focused progrmmes.

49 45 OST 4 QUALITY: OST-relted policy nd prctice checklist Do current ntionl guidelines nd policy fulfil the following? c Ntionl OST guidelines re developed t the country level or lower. These guidelines re detiled, comprehensive nd evidence-sed, reflect locl lws, policies nd conditions, nd re consistent with interntionl guidnce. See Guidelines for psychosocilly-ssisted phrmcotherpy for the mngement of opioid dependence, WHO, These should include cler guidnce on: ptient ssessment gining informed consent for tretment dosing nd durtion of tretment provision of psychosocil support dispensing protocols ptient review nd follow-up provision of OST for pregnnt women Ntionl policy requires OST prescriers to receive ccredited trining nd to e registered. OST prescriers re required to tke ccredited post-grdute trining in OST, prticipte in continuing eduction, monitoring nd evlution, nd e registered to prescrie OST. Prescriers re respectful towrds people who inject drugs, hve crediility with the trget popultion nd re non-judgementl in their ttitudes towrds drug users. Ntionl policy includes provision to ensure tht OST is ffordle, so s to mximize ccess. The cost of OST cn e significnt rrier to tretment ccess for mny opioid-dependent people. To increse ccessiility, OST my e offered free of chrge (this would e the est prctice ut likely not possile in the mjority of resource-limited settings); the costs covered y helth insurnce provisions; or the costs to ptients prtly susidized or t reduced cost especilly for finncilly disdvntged ptients. Desk review nd stkeholder consulttion The items listed in the checklist ove cn e used when conducting n udit of current policy nd guidnce. If these re found to e in need of reform, processes for chnge should e identified nd evluted. Setting trgets: Aligning polices nd guidelines with recommended prctice should e the intended im. Countries should set out relistic ut mitious time frme for chnge nd monitor progress towrd these gols.

50 46 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions OST 5 c Progrmme dt QUALITY: Individuls receiving mintennce OST continuously for t lest 6 months Numer of people strting OST during time period defined s the cohort recruitment period Numer of people in the cohort still in tretment 6 months fter strting OST [] x 100 = [] Percentge of individuls receiving OST who received tretment for t lest 6 months This indictor exmines the retention of ptients in OST for minimum period of 6 months; evidence demonstrtes tht mximum enefit from OST is gined when tretment lsts t lest 6 months (1). Hence, this indictor cn e understood s mesure oth of how OST is prescried nd of ptient retention. This indictor mkes use of OST register dt, using cohort study-type pproch. This pproch is similr to tht used to monitor ART retention nd survivl nd hs een piloted in the monitoring of progrmmes funded y the Glol Fund. OST register dt cn e used to determine the numer of people strting OST in the defined period, s cohort, nd the numer of those who re still in tretment 6 months fter strting OST. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets iming to mximize the percentge of people mintined on OST for the minimum period demonstrted to provide enefit. The following indictive trget cn e used s enchmrk ginst which country s own trgets for OST 5c cn e compred: Possile trgets: Low 60 Mid 80 High OST 6 c Progrmme dt QUALITY: Individuls receiving mintennce dose of OST greter thn or equl to the recommended minimum dose Numer of people, t specified dte, mintined on methdone receiving dose 60 mg or currently mintined on uprenorphine receiving dose of 12 mg Numer of people receiving mintennce dose of methdone or uprenorphine t specified dte [] x 100 = [] Percentge of ptients receiving mintennce dose of OST greter thn or equl to the recommended minimum dose OST register dt cn e used if these registers record ptients OST dose received. Alterntively, service-level dt cn e used. If service-level dt collection systems do not include ptient dose, then n udit of ptient chrts (medicl records) cn e undertken; this could e limited to rndom smple of ptient records or could e review of ll ptients, if resources llow. This indictor does not include those ptients currently eing inducted on OST nd who re yet to rech the mintennce dose, nor does it include those ptients on reducing doses of OST. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets iming to mximize the percentge of people receiving the recommended minimum mintennce dose. The following indictive trget cn e used s enchmrk ginst which country s own trgets for OST 6c cn e compred: Possile trgets: Low 60 Mid 90 High

51 47 OST 7 c Progrmme dt QUALITY: Individuls on mintennce OST receiving psychosocil support Numer of OST ptients who hve received psychosocil support in the lst 12 months Numer of ptients receiving OST in the lst 12 months [] x 100 = [] Percentge of OST ptients receiving psychosocil support Psychosocil support my include, s minimum: ssessment of psychosocil needs supportive counselling links to existing fmily nd community services. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets iming to mximize the percentge of people on mintennce OST receiving minimum pckge of psychosocil support. The following indictive trget cn e used s enchmrk ginst which country s own trgets for OST 7c cn e compred: Possile trgets: Low 50 Mid 80 High

52 48 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Overdose prevention nd mngement ODM 1 AVAILABILITY: Sites providing community-sed distriution of nloxone Numer of sites where nloxone is dispensed to ly providers (including people who use opioids, their peers nd fmily memers) for mngement of opioid overdose Fcility-sed ssessment/progrmme dt The definition of site should e documented. The numer of sites where nloxone is dispensed is n importnt indictor for monitoring the scle-up of communitysed distriution. See pge 11 for further informtion on vilility indictors of this type. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frmes for scling up community-sed distriution of nloxone for overdose mngement. In principle NSP nd OST sites will e well plced to provide community-sed nloxone distriution. ODM 2 Progrmme dt COVERAGE: Quntity of nloxone distriuted Numer of nloxone doses/kits dispensed through community-sed distriution progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) This indictor looks t the totl quntity of nloxone doses or kits for the mngement of opioid overdose distriuted to people who use opioids, their peers nd fmily memers. See pge 11 for further informtion on vilility indictors of this type. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frmes for scling up community-sed distriution of nloxone for overdose mngement.

53 49 Reducing hrms relted to injecting sustnces for gender ffirmtion GDR 1 AVAILABILITY: Numer of sites providing equipment for sfe injecting of sustnces for gender ffirmtion Numer of sites where progrmmes serving trnsgender people provide equipment for sfe injecting of sustnces for gender ffirmtion Fcility-sed ssessment/progrmme dt This indictor is specific to trnsgender people. It my not e relevnt to ll trnsgender people, however, s not ll inject sustnces for gender ffirmtion. The definition of site should e documented. Sites might include fixed-site services nd loctions where outrech nd moile services operte nd provide equipment for sfe injecting of sustnces for gender ffirmtion. See pge 11 for further informtion on vilility indictors of this type. Setting trgets: Mny sites where services re provided to trnsgender people my e pproprite distriution points for the provision of equipment for sfe injecting of sustnces for gender ffirmtion. NSPs tht provide equipment for drug injecting should lso hve equipment pproprite for sfe injecting of sustnces for gender ffirmtion nd these sites should e sensitized to the needs of trnsgender clients. When setting trgets for this indictor, it is necessry to determine which sites not currently providing such equipment might hve the potentil to ecome provision site. Countries should then set n mitious ut relistic time frme for scling up the provision of sfe injecting equipment ccessile to trnsgender people to rech these trgets. This time frme should e sed on n ssessment of the logisticl issues nd the resources required.

54 50 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Behviourl interventions BHV 1 c AVAILABILITY: Sites providing ehviourl interventions for sexul risk reduction Numer of sites where key popultion-focused progrmmes provide ehviourl interventions for sexul risk reduction Totl numer of sites where key popultion-focused progrmmes re offered [] x 100 = [] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where ehviourl interventions for sexul risk reduction re provided The site definitions used should e documented. See pge 11 for further informtion on this type of indictor. Setting trgets: When scling up services for key popultions, it is useful to trck the totl numer of sites providing ehviourl interventions for sexul risk reduction (BHV 1). Countries cn set trgets for increses in the totl numer of sites over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 11 for further discussion). Not every site where key popultion-focused progrmmes operte will necessrily e pproprite for offering ehviourl interventions for sexul risk reduction. For exmple, certin structured ehviourl interventions tht involve multiple, regulr sessions my e difficult to provide through outrech. When setting trgets for BHV 1c, it is necessry to determine which sites where sexul helth services re not currently offered hve the potentil to provide this intervention. Countries should set out n mitious ut relistic time frme for scling up ehviourl interventions to rech the trget. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out trining to service providers.

55 51 BHV 2 c AVAILABILITY: Sites providing rief intervention counselling for prolemtic sustnce use Numer of sites where key popultion-focused progrmmes provide rief intervention counselling for prolemtic drug nd lcohol use Totl numer of sites where key popultion-focused progrmmes re offered [] x 100 = [] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where rief intervention counselling for prolemtic drug nd lcohol use is provided Brief intervention counselling is type of evidence-sed motivtionl counselling technique nd is used extensively in ddressing prolemtic sustnce use. It cn e delivered in non-specilized settings (i.e. those tht re not specilized drug tretment services). The site definitions used should e documented. See pge 11 for further informtion on this type of indictor. Setting trgets: When scling up services for key popultions, it is useful to trck the numer of sites providing rief intervention counselling for prolemtic drug nd lcohol use to people from key popultions (BHV 2). Countries cn set trgets for increses in the totl numer of sites over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 11 for further discussion). In mny settings, if workers re ppropritely trined, sites where services re provided to key popultions re likely to e pproprite loctions for rief intervention counselling for prolemtic drug nd lcohol use. When setting trgets for BHV 2c it is necessry to determine which sites where counselling for prolemtic drug nd lcohol use is not currently offered hve the potentil to provide this intervention. Countries should then set out n mitious ut relistic time frme for scling up rief intervention counselling for prolemtic drug nd lcohol use to rech the set trget. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out trining in rief intervention counselling.

56 52 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Pre-exposure prophylxis (PrEP) PRP 1 AVAILABILITY: Orl pre-exposure prophylxis (PrEP) for HIV prevention is ville for men who hve sex with men Is orl PrEP for HIV prevention ville for men who hve sex with men? Desk review, stkeholder consulttion or fcility-sed ssessment This indictor exmines whether ART is currently pproved for use s orl PrEP for HIV prevention nd is offered to men who hve sex with men, in line with WHO recommendtions (1). PRP 2 Progrmme dt COVERAGE: Men who hve sex with men receiving orl pre-exposure prophylxis (PrEP) for HIV prevention Numer of men who hve sex with men prescried orl PrEP during the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) This indictor looks t the totl numer of men who hve sex with men who re prescried orl pre-exposure prophylxis nd is n importnt indictor to trck the uptke of PrEP. Sites where PrEP is provided will need to e identified in order to collect relevnt progrmmtic dt. See pge 11 for further informtion on vilility indictors of this type. Setting trgets: Bseline levels should first e mesured. Countries should then set mitious ut relistic trgets nd time frmes for scling up PrEP for men who hve sex with men.

57 53 HIV testing nd counselling See lso Guide for monitoring nd evluting ntionl HIV testing nd counselling (HTC) progrmmes: field-test version, 2011, WHO (26). HTC 1 c d e f g AVAILABILITY: Sites providing HIV testing nd counselling Numer of sites where key popultion-focused progrmmes provide HTC Numer of sites where minstrem progrmmes meeting key popultion sensitiztion stndrds provide HTC Totl numer of sites where key popultion-focused progrmmes re offered Totl numer of sites where minstrem progrmmes provide HTC [] x 100 = [c] [] x 100 = [d] []+[] x 100 = []+[d] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where HTC is provided Percentge of minstrem progrmme sites where HTC is provided tht meet key popultion sensitiztion stndrds Percentge of ll sites where HTC is provided tht re either key popultion-focused progrmmes or minstrem progrmmes meeting key popultion sensitiztion stndrds The site definitions used should e documented. These sites might include fixed-site services where HTC is ville or loctions where outrech nd moile services operte nd provide HTC. All sites included here should meet ntionl service qulity stndrds for HTC. See pge 11 for further informtion on this type of indictor. Setting trgets: When scling up HTC for key popultions, it is useful to trck the totl numer of sites providing HTC to people from key popultions (i.e. key popultion-focused services (HTC 1) nd minstrem services meeting key popultion sensitiztion stndrds (HTC 1)). Countries cn set trgets for increses in the totl numer of sites over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 11 for further discussion). In ll contexts the provision of HTC must meet minimum stndrds (26, 27). Not every site where key popultionfocused progrmmes operte will e pproprite for offering HTC, ut mny will e. When setting trgets for indictor HTC 1e, it is necessry to determine which sites where HIV testing nd counselling is not currently offered hve the potentil to provide this intervention. People from key popultions should e le to ccess minstrem services tht provide HTC without fer of fcing stigm or discrimintion. Idelly, ll minstrem services should meet key popultion sensitiztion stndrds. Accordingly, in mny countries trgets of 100% my e pproprite for indictors HTC 1f nd HTC 1g. While voluntry HTC should e ville in prisons nd other closed settings, HIV testing should never e mndtory in these or ny other setting (28). Countries should then set out n mitious ut relistic time frme for scling up testing nd counselling to rech these trgets. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to rollout HIV testing nd counselling to key popultion-focused progrmmes nd key popultion sensitiztion trining nd procedures to minstrem services.

58 54 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions HTC 2 AVAILABILITY: Key popultion reporting HIV testing nd counselling is redily ccessile Percentge in smple of key popultion who nswer yes to oth these questions: Behviourl survey Do you know where you cn go if you wish to receive n HIV test? Would you e comfortle with using this service if you wnted to e tested for HIV? HTC 2 is included in the GAPR 2014 (Indictor 1.11). It provides some indiction of the potentil ccessiility of HTC to people from key popultions. HTC 2 provides dditionl nd vlule informtion on the cceptility of the service to people from key popultions, which directly ffects ccessiility. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: Results of n initil survey cn e used to set seline for these indictors. Countries cn set trgets for increses over seline levels nd time frme for their chievement. HTC 3 Behviourl survey COVERAGE: Key popultion reporting they hve received HIV test nd results Percentge in smple of key popultion who nswer yes to oth the following questions: Hve you een tested for HIV in the lst [X months]? I don t wnt to know the results, ut did you receive the results of tht test? The time period for this indictor cn vry; for exmple, the question could e sked out eing tested for HIV in the lst 1, 3, 6 or 12 months. This indictor is included in the GARPR 2014 guidelines on core indictors with survey prticipnts sked to report on HIV testing in the lst 12 months. Individuls dignosed HIV-positive prior to the specified reporting period will (lmost certinly) not hve een tested gin within tht time period. Accordingly, it is desirle, when reporting on this indictor, to exclude people who were wre tht they were HIV-positive prior to the specified reporting period. There re numer of wys tht this cn e done. For exmple: If respondent nswers no to the question, Hve you een tested for HIV in the lst [X months]?, the survey cn sk, Ws this ecuse you lredy knew you were living with HIV? All those nswering yes to this follow-up question cn e excluded from the denomintor for this indictor. The question cn e sked If you elieve your HIV sttus to e negtive or you don t know, hve you tested in the pst [X months]? Or skip pttern in the questionnire cn e formulted for those who report they re HIV positive, in which cse only respondents who report they re HIV negtive or tht they don t know their HIV sttus will e sked whether or not they were tested in the pst [X months]. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for this indictor. Countries cn then set trgets nd time frme for their chievement. In 2014, UNAIDS lunched mitious new trgets for the scle-up of ntiretrovirl tretment, the so-clled 90:90:90 trgets. This includes the trget: By 2020, 90% of ll people living with HIV will know their HIV sttus (29). If the indictor HTC 3 is included in n integrted io-ehviourl survey, it cn provide insight into the chievement of this gol mong key popultions.

59 55 HTC 4 c QUALITY: Percentge of key popultion reporting they received results following HIV testing Numer of people in smple of key popultion who nswer yes to oth questions: Hve you een tested for HIV in the lst [X months]? I don t wnt to know the results, ut did you receive the results of tht test? Numer of people from key popultion in smple who nswer yes to the question: Hve you een tested for HIV in the lst [X months]? [] x 100 = [] Behviourl survey Percentge of key popultion tested for HIV in the lst [X months] who report hving received the results of tht test The time period for this indictor cn vry; for exmple, the question could e sked out eing tested for HIV in the lst 1, 3, 6 or 12 months. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: Efforts should e mde to ensure tht people who re tested for HIV receive their results. Accordingly, the trget for indictor HTC 4c cn e set t 100%. The results of n initil survey cn e used to set seline for these indictors. Countries should then set out n mitious ut relistic time frme for incresing the proportion of tests for which the results re provided.

60 56 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions HIV tretment nd cre, including ntiretrovirl therpy ART 1 c d e f g AVAILABILITY: Sites providing ntiretrovirl therpy (ART) Numer of sites where key popultion-focused progrmmes provide ART Numer of sites where minstrem progrmmes meeting key popultion sensitiztion stndrds provide ART (including services for the prevention of mother to child trnsmission(pmtct)) Totl numer of sites where key popultion-focused progrmmes re offered Totl numer of sites where minstrem progrmmes provide ART [] x 100 = [c] [] x 100 = [d] []+[] x 100 = []+[d] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where ART is provided Percentge of minstrem progrmme sites where ART is provided tht meet key popultion sensitiztion stndrds The site definitions used should e documented. Percentge of ll sites where ART is provided tht re either key popultion-focused progrmmes or minstrem progrmmes meeting key popultion sensitiztion stndrds See pge 11 for further informtion on this type of indictor. Setting trgets: When scling up services for key popultions, it is useful to trck the totl numer of sites providing ART to people from key popultions (i.e. key popultion-focused services (ART 1) nd minstrem services meeting key popultion sensitiztion stndrds (ART 1)). Countries cn set trgets for increses in the totl numer of sites over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 13 for further discussion). In ll contexts the provision of ART must meet minimum stndrds (30). Not every site where key popultion-focused progrmmes operte will e pproprite for providing ART, ut some my e. When setting trgets for indictor ART 1e, it is necessry to determine which sites where ART is not currently offered hve the potentil to provide this intervention. People from key popultions should e le to ccess minstrem services tht provide ART without fer of fcing stigm or discrimintion nd to e le to receive cre from helth-cre workers who hve the clinicl knowledge to meet their specific needs. Idelly, ll of these minstrem services should meet key popultion sensitiztion stndrds. Accordingly, in mny countries trget of 100% my e pproprite for indictors ART 1f nd ART 1g. Countries should then set out n mitious ut relistic time frme for scling up ART to rech these trgets. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out ART provision to pproprite key popultion-focused progrmmes nd key popultion sensitiztion trining nd procedures to minstrem services tht offer ART.

61 57 ART 2 c COVERAGE: Key popultion living with HIV reporting they currently receive ART Numer of people from key popultion in smple who nswer yes to the question: Are you currently receiving tretment for HIV? Numer in smple of key popultion who test positive for HIV [] x 100 = [] Integrted io-ehviourl survey Percentge of key popultion testing positive for HIV who report currently receiving tretment Not ll those living with HIV will meet eligiility criteri for ART. See pge 9 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for this indictor. Countries cn then set trget nd time frme for its chievement. In 2014 UNAIDS lunched Fst-Trck Trgets to moilize glol efforts nd resources in order to end the AIDS epidemic y These trgets include: y 2020, 90% of people living with HIV knowing their HIV sttus, 90% of people who know their sttus receiving tretment nd 90% of people on HIV tretment hving supressed virl lod, nd y 2030 incresing ech of these trgets to 95%, respectively (15). ART 3 cn provide insight into the chievement of this gol mong key popultions.

62 58 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Prevention nd mngement of co-infections nd other co-moridities CMB 1 c d e f g h i AVAILABILITY: Sites providing TB prevention, screening nd mngement Numer of sites where key popultion-focused progrmmes provide TB infection control Numer of sites where key popultion-focused progrmmes provide TB preventive therpy Numer of sites where key popultion-focused progrmmes provide TB screening for people from key popultions living with HIV Numer of sites where key popultion-focused progrmmes provide TB mngement Totl numer of sites where key popultion-focused progrmmes re offered [] x 100 = [] [] x 100 = [] [] x 100 = [] [] x 100 = [] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where TB infection control is provided Percentge of key popultion-focused progrmme sites where TB preventive therpy is provided Percentge of key popultion-focused progrmme sites where TB screening for people from key popultions living with HIV is provided Percentge of key popultion-focused progrmme sites where TB mngement is provided The site definitions used should e documented. Sites might include fixed-site services nd loctions where outrech nd moile services operte nd provide these TB-relted interventions. See pge 11 for further informtion on this type of indictor. Setting trgets: When scling up TB progrmmes for key popultions, it is useful to trck the totl numer of sites providing ech of these TB-relted interventions to people from key popultions (CMB 2,, c nd d). Countries cn set trgets for increses in the totl numer of sites over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 11 for further discussion). Not every site where key popultion-focused progrmmes operte will e pproprite for offering these TB-relted interventions, ut mny will e. When setting trgets for indictors CMB 2f, g, h nd i, it is necessry to determine which sites tht currently do not offer TB interventions hve the potentil to do so. Countries should then set n mitious ut relistic time frme for scling up TB interventions to rech these trgets. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out TB interventions to key popultion-focused progrmmes.

63 59 CMB 2 c AVAILABILITY: Sites providing HBV vccintion Numer of sites where key popultion-focused progrmmes provide HBV vccintion Totl numer of sites where key popultion-focused progrmmes re offered [] x 100 = [] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where HBV vccintion is provided The site definitions used should e documented. Sites might include fixed-site services nd loctions where outrech nd moile services operte nd provide HBV vccintion. See pge 11 for further informtion on this type of indictor. Setting trgets: When scling up HBV vccintion for key popultions, it is useful to trck the totl numer of sites providing HBV vccintion to people from key popultions (CMB 1). Countries cn set trgets for increses in the totl numer of sites over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 13 for further discussion). Not every site where key popultion-focused progrmmes operte will e pproprite for offering HBV vccintion, ut mny will e. When setting trget for indictor CMB 1c, it is necessry to determine which sites where HBV vccintion is not currently offered hve the potentil to provide this intervention. Countries should then set n mitious ut relistic time frme for scling up HBV vccintion to rech the trget. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out HBV vccintion to key popultion-focused progrmmes. CMB 3 Progrmme dt COVERAGE: Key popultion receiving HBV vccintion Numer of people from key popultion provided with HBV vccintion t key popultion-focused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) If key popultion-specific dt re lso ville from minstrem progrmmes, these cn lso e included in this indictor. Different time periods my e selected when mesuring this indictor. See pge 15 for further informtion on this type of coverge indictor. Setting trgets: Bseline levels should first e mesured. Countries should then set n mitious ut relistic trget nd time frme for scling up HBV vccintion for people from key popultions. The time frme nd trget should e sed on n ssessment of the logisticl issues nd the resources required to roll-out HBV vccintion services to key popultion-focused progrmmes.

64 60 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Sexul nd reproductive helth SRH 1 c d e f g AVAILABILITY: Sites providing sexul nd reproductive helth services Numer of sites where key popultion-focused progrmmes provide sexul nd reproductive helth services Numer of sites where minstrem progrmmes meeting key popultion sensitiztion stndrds provide sexul nd reproductive helth services Totl numer of sites where key popultion-focused progrmmes re offered Totl numer of sites where minstrem progrmmes provide sexul nd reproductive helth services [] x 100 = [c] [] x 100 = [d] []+[] x 100 = []+[d] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites where sexul nd reproductive helth services re provided Percentge of minstrem progrmme sites where sexul nd reproductive helth services re provided tht meet key popultion sensitiztion stndrds Percentge of ll sites where sexul nd reproductive helth services re provided tht re either key popultion-focused progrmmes or minstrem progrmmes meeting key popultion sensitiztion stndrds For this indictor, the definition of wht constitutes site providing sexul nd reproductive helth services should e documented. This documenttion should include not only the type of loction or method of service delivery (such s fixed sites nd sites where moile services operte) ut lso the nture of the sexul nd reproductive helth services provided. These might include screening/dignostic services, sexul helth counselling nd tretment, contrceptive counselling, screening nd referrl for reproductive trct cncer (cervicl, no-rectl, prosttic) nd rest cncer, nd sfe ortion nd post-ortion cre. Services should meet ntionl stndrds for the provision of sexul helth services. See pge 15 for further informtion on this type of indictor. Setting trgets: When scling up services for key popultions, it is useful to trck the totl numer of sites providing sexul nd reproductive helth services to people from key popultions (i.e. key popultion-focused services (SRH 1) nd minstrem services meeting key popultion sensitiztion stndrds (SRH 1)). Countries cn set trgets for increses in the totl numer of sites over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 13 for further discussion). In ll contexts the provision of sexul nd reproductive helth services must meet minimum stndrds (see pge 31). Not every site where key popultion-focused progrmmes operte will necessrily e pproprite for offering integrted sexul nd reproductive helth services, ut some will e. When setting trgets for indictor SRH 1e, it is necessry to determine which sites where sexul nd reproductive helth services re not currently offered hve the potentil to provide this intervention. People from key popultions should e le to ccess minstrem services tht provide sexul nd reproductive helth services without fer of fcing stigm or discrimintion nd to e le to receive cre from helth-cre workers who hve the clinicl knowledge to meet their specific needs. Idelly, ll minstrem sexul nd reproductive helth services should meet key popultion sensitiztion stndrds. Accordingly, in mny countries trgets of 100% my e pproprite for indictors SRH 1f nd SRH 1g. Countries should then set out mitious ut relistic time frmes for scling up sexul nd reproductive helth services to rech these trgets. These time frmes should e sed on n ssessment of the logisticl issues nd the resources required to roll-out sexul helth services to key popultion-focused progrmmes nd key popultion sensitiztion trining nd procedures to minstrem services tht provide sexul nd reproductive helth services.

65 61 SRH 2 AVAILABILITY: Key popultion reporting sexul helth services re ccessile Percentge in smple of key popultion who nswer yes to oth these questions: Behviourl survey Do you know where you cn go for STI/sexul helth check-up? Would you e comfortle using this service if you wnted to hve n STI/sexul helth check-up? SRH 2 provides some indiction of the ccessiility of STI/sexul helth services to people from key popultions. SRH 2 gives some indiction of the cceptility of the service to people from the key popultion, which directly ffects ccessiility. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for this indictor. Countries cn set trgets for increses ginst seline levels nd time frme for their chievement. SRH 3 Progrmme dt COVERAGE: Key popultion ttending sexul helth services Numer of people from key popultion ttending sexul helth services t key popultion-focused progrmmes over the specified reporting period (e.g. the lst 1, 3, 6 or 12 months) If key popultion-specific dt re lso ville from minstrem progrmmes, these cn lso e included in this indictor. Different time periods my e selected when mesuring this indictor. See pge 15 for further informtion on this type of coverge indictor. Setting trgets: The seline level should first e mesured. Countries should then set n mitious ut relistic trget nd time frme for scling up sexul helth services for people from key popultions to increse the numer of people from key popultions receiving sexul helth consulttions. The time frme nd trget should e sed on n ssessment of the logisticl issues nd the resources required to rollout sexul helth services to key popultion-focused progrmmes. SRH 4 Behviourl survey COVERAGE: Key popultion reporting they hve een tested for STIs Percentge in smple of key popultion who nswer yes to the question: Hve you een tested for STIs in the lst 12 months? See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for this indictor. Countries cn then set trget nd time frme for its chievement.

66 62 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Comined pckge of interventions PKG 1 c AVAILABILITY: Sites providing defined pckge of helth sector interventions Numer of sites where key popultion-focused progrmmes provide defined suset of interventions from the evidence-sed pckge Totl numer of sites where key popultion-focused progrmmes re offered [] x 100 = [] Fcility-sed ssessment/progrmme dt Percentge of key popultion-focused progrmme sites providing defined suset of interventions from the evidence-sed pckge This indictor ttempts to mesure the extent to which multiple interventions re provided t the sme loction in n integrted model of service delivery. For most countries, it would e unusul for single site to provide ll the interventions in the evidence-sed pckge. It is more useful, for the purpose of this indictor, to select suset of these interventions nd identify sites where they re ll present. This suset could include some or ll of these interventions: legl support to people from key popultions pproprite medicl, psychologicl nd legl support for those who hve experienced violence distriution of condoms nd comptile luricnt ehviourl interventions for sexul risk reduction rief intervention counselling for prolemtic drug nd lcohol use HIV testing nd counselling sexul nd reproductive helth services HIV tretment needle nd syringe distriution opioid sustitution therpy heptitis B vccintion. The selection of interventions to e included in this suset could e sed on vrious rtionles such s dt vilility or the priority of specific interventions in prticulr context. The interventions included must e clerly indicted when reporting this indictor. Site definitions used should lso e documented. Sites might include fixed-site services nd loctions where outrech nd moile services operte. See pge 15 for further informtion on this type of indictor. Setting trgets: When scling up interventions for key popultions, it is useful to trck the totl numer of key popultion-focused sites providing multiple or comined interventions to people from key popultions (PKG 1). Countries cn set trgets for increses in the totl numer of sites providing comined interventions over specific time period. An increse in the totl numer of sites does not necessrily correlte with incresed ccessiility, however (see pge 11 for further discussion). As noted in preceding indictors on the vilility of ech intervention, not every site where key popultion-focused progrmmes operte will e pproprite for providing ll the interventions included in the evidence-sed pckge or even prticulr suset of interventions. Countries should set n mitious ut relistic trget nd time frme for scling up more progrmmes to provide comined interventions so s to rech these trgets. This time frme should e sed on n ssessment of the logisticl issues nd the resources required to roll-out dditionl interventions to key popultion-focused progrmmes.

67 63 PKG 2 COVERAGE: Key popultion reporting they hve received comined set of helth sector interventions Percentge in smple of key popultion who nswer yes to ll of the following questions (including [f] if smple of people who use drugs): c d e f Behviourl survey In the lst [X months], hve you een given condoms? (e.g. through n outrech service, drop-in centre or sexul helth clinic.) [CCP 5] In the lst [X months], hve you een given schets (or other continers) of luricnt? (e.g. through n outrech service, drop-in centre or sexul helth clinic.) [CCP 5] In the lst [X months], hve you received informtion on condom use nd sfe sex? (e.g. through n outrech service, drop-in centre or sexul helth clinic.) Hve you een tested for HIV in the lst [X months]? [HTC 2] I don t wnt to know the results, ut did you receive the results of tht test? [HTC 2] Hve you een tested for STIs in the lst [X months]? [SRH 4] In the lst [X months], hve you een given clen needles or syringes? (e.g. y n outrech worker or through needle nd syringe progrm.) [NSP 5] This indictor gives sense of how mny within the key popultion hve received multiple helth sector interventions within the specified time periods. At the progrmme or service provider level, it my e possile to report, using progrmmtic dt, on the numer of people who hve received ll components of this set of helth sector interventions. (The Glol Fund recommends reporting such indictors on the progrmmes it funds (31)). This my e difficult t the ntionl level, however, s it requires ll service sites to use common unique identifier system nd for dt to e disggregted y key popultion group. As discussed on pges 15 nd 17, when multiple service providers offer interventions, including some which might not e specific to key popultion, comprle dt will not typiclly e ville. For this reson, in mny settings the percentge of key popultion receiving comined set of helth sector interventions my e more redily estimted through ehviourl surveys thn from progrmme dt. See pge 17 for further informtion on gthering dt from ehviourl surveys. Setting trgets: The results of n initil survey cn e used to set seline for this indictor. Countries cn then set trget nd time frme for its chievement.

68 64 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions Outcome nd impct indictors O 1 Infection incidence mong key popultion c Estimted incidence of HIV mong key popultion Estimted incidence of heptitis C mong key popultion Incidence of STIs mong key popultion, including: Neisseri gonorrhoe Chlmydi trchomtis syphilis heptitis B Notifiction from sentinel sites Registries Longitudinl cohort studies Prevlence mong young memers of key popultion Projection modelling Recent infection testing lgorithms (RITA) for HIV Chnges in incidence cn e n indiction of the impct of prevention efforts, ut re difficult to mesure directly. See pge 20 for further informtion on how to mesure nd interpret estimtes of incidence. Setting trgets: When setting ntionl trgets for reductions in new HIV infections, countries should consider relevnt glol trgets nd commitments. The 2011 Politicl Declrtion on HIV/AIDS included the commitment y Memer Sttes to reduce sexul trnsmission of HIV y 50% nd to hlve the trnsmission of HIV mong people who inject drugs y 2015 (14). In 2014, UNAIDS lunched Fst-Trck Trgets to moilize glol efforts nd resources in order to end the AIDS epidemic y 2030, including: reducing the numer of new HIV infections mong dults in low nd middle income countries to 500,000 per yer y 2020, nd to 200,000 per yer y 2030 (15). O 2 Incidence of AIDS-relted mortlity Numer of AIDS-relted deths mong key popultion in the pst 12 months Projection modelling ART registries nd deth registries (linked dt fcilities) Longitudinl cohort studies Aville dt my hve significnt limittions. Ntionl mortlity dt re unlikely to include informtion on the key popultion. This indictor my e more esily reported if there is dt linkge etween HIV/AIDS registries nd mortlity records; in mny countries, however, tht will e unlikely. If cohorts of the key popultion re followed, dt from these studies my lso e useful, ut representtiveness nd potentil is need to e considered.

69 65 O 3 Infection prevlence mong key popultion c Prevlence of HIV mong key popultion Prevlence of STIs mong key popultion Prevlence of HCV mong key popultion Integrted io-ehviourl surveys Limittions of smpling strtegies used, ssocited is nd likely representtiveness of the smple should e considered when interpreting results. Seril mesurements of prevlence over time should e interpreted with cution; see pge 21 for further informtion. Prevlence dt my e used in mthemticl models to project incidence. O 4 Prevlence of risk ehviours nd knowledge round HIV c d e f g h i j k l m n o Percentge of sex workers in smple who report using condom with their most recent client Percentge of sex workers in smple who report lwys using condom with ll sex work clients during the pst 1 month Percentge of sex workers in smple who report using condom during lst sex with non-commercil prtner Percentge of sex workers in smple who report lwys using condom with ll non-commercil prtners during the pst 6 months Percentge of men who hve sex with men in smple who report using condom the lst time they hd nl sex Percentge of men who hve sex with men in smple who report lwys using condom with ll nl sex prtners in the pst 6 months Percentge of trnsgender people in smple who report using condom the lst time they hd nl or vginl sex Percentge of trnsgender people in smple who report lwys using condom with ll nl or vginl sex prtners in the pst 6 months Percentge of people who inject drugs in smple who report using condom the lst time they hd nl or vginl sex Percentge of people who inject drugs in smple who report lwys using condom with ll nl or vginl sex prtners in the pst 6 months Percentge of people in prisons or other closed settings in smple who report using condom the lst time they hd nl or vginl sex Percentge of people in prisons or other closed settings in smple who report lwys using condom with ll nl or vginl sex prtners in the pst 6 months Percentge of key popultion in smple who inject drugs nd who report using sterile injecting equipment the lst time they injected drugs Percentge of key popultion in smple who inject drugs who report lwys using sterile injecting equipment every time they injected drugs in the pst 6 months Percentge of key popultion in smple le to correctly identify wys to prevent HIV nd who reject common misconceptions Behviourl surveys Limittions of smpling strtegies used, ssocited is nd likely representtiveness of the smple should e considered when interpreting results.

70 66 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions O 5 Stigm nd discrimintion experienced y key popultion Percentge of smple from key popultion reporting stigm nd discrimintion Behviourl survey including relevnt items from the People Living with HIV Stigm Index The People Living with HIV Stigm Index includes items relevnt to memers of key popultions, including those who re HIV-negtive. The Interntionl Plnned Prenthood Federtion ( cn provide guidnce to countries wishing to implement the Index nd cn provide ccess to the questionnire. O 6 Attitudes towrds key popultion held y service providers Percentge of service providers surveyed responding tht they gree or strongly gree to the following sttements (responses on five-point scle: strongly disgree / disgree / neutrl / gree / strongly gree ): c d e I would prefer not to provide services to men who hve sex with men. I would prefer not to provide services to sex workers. I would prefer not to provide services to trnsgender people. I would prefer not to provide services to people who inject drugs. For those nswering tht they gree or strongly gree, sk: Do you gree or strongly gree ecuse: They put me t higher risk for disese? This group engges in immorl ehviour? I hve not received trining to work with this group? I m worried tht people will think I m prt of this group? Survey of service provider stff. Include medicl nd government socil service stff. When reporting these dt, results should e disggregted y different types of stff nd services providers. These questionnire items re tken from: Stngl AL, Brdy L, Fritz K. Mesuring HIV stigm nd discrimintion technicl rief. London School of Hygiene nd Tropicl Medicine, Interntionl Centre for Reserch on Women, 2012 (32). It should e noted tht the 2011 Politicl Declrtion on HIV/AIDS included the commitment y Memer Sttes to eliminte HIV-relted stigm, discrimintion, punitive lws nd prctices y 2015 (14).

71 67 REFERENCES 1. World Helth Orgniztion. Consolidted guidelines on HIV prevention, dignosis, tretment nd cre for key popultions. Genev, World Helth Orgniztion, World Helth Orgniztion, United Ntions Office on Drugs nd Crime, Joint United Ntions Progrmme on HIV/AIDS. Technicl guide for countries to set trgets for universl ccess to HIV prevention, tretment nd cre for injecting drug users 2012 revision. Genev, WHO, Fmily Helth Interntionl. Behviourl Surveillnce Surveys BSS: Guidelines for Repeted Behviourl Surveys in Popultions t Risk of HIV Joint United Ntions Progrmme on HIV/AIDS. Addressing HIV-relted lw t ntionl level guidnce note. Genev, UNAIDS, VnWey LK et l. Confidentility nd sptilly explicit dt: Concerns nd chllenges. Proceedings of the Ntionl Acdemy of Sciences of the United Sttes of Americ, 2005, 102(43): Joint United Ntions Progrmme on HIV/AIDS. Interim guidelines on protecting the confidentility nd security of HIV informtion: proceedings from workshop My 2006, Genev, Switzerlnd. Genev, UNAIDS, The Glol Fund to Fight AIDS Tuerculosis nd Mlri. Hrm reduction for people who use drugs: informtion note. Genev, The Glol Fund to Fight AIDS, Tuerculosis nd Mlri, The U.S. President s Emergency Pln for AIDS Relief. Comprehensive HIV prevention for people who inject drugs, revised guidnce. Wshington D.C., The U.S. President s Emergency Pln for AIDS Relief (PEPFAR), United Ntions Office on Drugs nd Crime. Estimting Prevlence: Indirect Methods for Estimting the Size of the Drug Prolem. UNODC, Hickmn M et l. Estimting the prevlence of prolemtic drug use: review of methods nd their ppliction. UN Bulletin on Nrcotics, 2002, (54): UNAIDS/WHO Working Group on Glol HIV/AIDS nd STI Surveillnce. When nd how to use ssys for recent infection to estimte HIV incidence t popultion level. Genev, World Helth Orgniztion, World Helth Orgniztion. Prevention nd tretment of HIV nd other sexully trnsmitted infections for sex workers in low- nd middle-income countries: recommendtions for pulic helth pproch. Genev, World Helth Orgniztion, United Ntions Office on Drugs nd Crime et l. Policy rief. HIV prevention, tretment nd cre in prisons nd other closed settings: A comprehensive pckge of interventions. Vienn, UNODC, United Ntions Generl Assemly. Generl Assemly Resolution 65/277 Politicl Declrtion on HIV/AIDS: Intensifying our Efforts to Eliminte HIV/AIDS. New York, United Ntions, Joint United Ntions Progrmme on HIV/AIDS. Fst-Trck: ending the AIDS epidemic y Genev, UNAIDS, Ktz I, Wong W, Altmn D. Trget setting of HIV services. Wshington DC, USAID, Opertionl guidelines for monitoring nd evlution of HIV progrmmes for people who inject drugs: Monitoring nd evlution t the service delivery level. Genev, UNAIDS, Opertionl guidelines for monitoring nd evlution of HIV progrmmes for sex workers, men who hve sex with men nd trnsgender people. Genev, UNAIDS, Joint United Ntions Progrmme on HIV/AIDS. Glol AIDS response progress reporting 2012: guidelines construction of core indictors for monitoring the 2011 Politicl Declrtion on HIV/AIDS. Genev, Joint United Ntions Progrmme on HIV/AIDS, Joint United Ntions Progrmme on HIV/AIDS. Glol AIDS response progress reporting 2014: construction of core indictors for monitoring the 2011 United Ntions Politicl Declrtion on HIV nd AIDS. Genev, Joint United Ntions Progrmme on HIV/AIDS, Vickermn P et l. Model projections on the required coverge of syringe distriution to prevent HIV epidemics mong injecting drug users. Journl of Acquired Immune Deficiency Syndromes: JAIDS, 2006, 42(3): Heimer R. Community coverge nd HIV prevention: ssessing metrics for estimting HIV incidence through syringe exchnge. Interntionl Journl on Drug Policy, 2008, 19 Suppl 1:S65-73.

72 68 TOOL FOR SETTING AND MONITORING TARGETS Supplement to the 2014 Consolidted Guidelines for HIV prevention, dignosis, tretment nd cre for key popultions 23. Des Jrlis DC, Friedmn SR. Fifteen yers of reserch on preventing HIV infection mong injecting drug users: wht we hve lerned, wht we hve not lerned, wht we hve done, wht we hve not done. Pulic Helth Reports, 1998, 113 Suppl 1: Boshev GV, Zule WA. Modeling the effect of high ded spce syringes on the humn immunodeficiency virus (HIV) epidemic mong injecting drug users. Addiction, 2010, 105(8): Zule WA, Boshev G. High ded-spce syringes nd the risk of HIV nd HCV infection mong injecting drug users. Drug nd Alcohol Dependence, 2009, 100(3): World Helth Orgniztion. Guide for monitoring nd evluting ntionl HIV testing nd counselling (HTC) progrmmes: field-test version. Genev, WHO, World Helth Orgniztion. A hndook for improving HIV testing nd counselling services: field-test version. Genev, World Helth Orgniztion, United Ntions Office on Drugs nd Crime, Joint United Ntions Progrmme on HIV/AIDS, World Helth Orgniztion. HIV testing nd counselling in prisons nd other closed settings. Vienn, UNODC, Joint United Ntions Progrmme on HIV/AIDS. Amitious tretment trgets: writing the finl chpter of the AIDS epidemic. Genev, UNAIDS, World Helth Orgniztion. Consolidted guidelines on the use of ntiretrovirl drugs for treting nd preventing HIV infection. Genev, WHO, The Glol Fund to Fight AIDS Tuerculosis nd Mlri. Monitoring nd evlution toolkit: HIV, Tuerculosis, mlri nd helth nd community systems strengthening. Prt 5: helth nd community systems strengthening. Genev, Glol Fund, Stngl AL, Brdy L, Fritz K. Mesuring HIV stigm nd discrimintion technicl rief. London, London School of Hygiene nd Tropicl Medicine, Interntionl Centre for Reserch on Women, 2012.

73 Notes

74 Notes

75

76 For more informtion, contct: World Helth Orgniztion Deprtment of HIV/AIDS 20, venue Appi 1211 Genev 27 Switzerlnd E-mil: ISBN Empowered lives. Resilient ntions.