PSI RESEARCH & METRICS TOOLKIT

Transcription

1 Building Research Capacity Studies: TRaC, Condom Sales and the Disability-Adjusted-Life-Year (DALY) Calculator PSI s Core Values Bottom Line Health Impact Private Sector Speed and Efficiency Decentralization, Innovation, and Entrepreneurship Long-term Commitment to the People We Serve

2 Research & Metrics Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C Studies: TRaC, Condom Sales and the Disability-Adjusted-Life-Year (DALY) Calculator PSI Research & Metrics 2007 Population Services International, 2007 Contact Information: Hongmei Yang Steven Chapman th Street, N.W. #600 Washington, DC

3 TRAC, CONDOM SALES AND THE DALY CALCULATOR LEARNING OBJECTIVES: By the end of this chapter, the reader will be able to: 1. Describe why linking TRaC and condom sales to the DALY calculator is important 2. Include up to 17 risk related questions into a TRaC survey 3. If interested, review how TRaC survey results produce a DALY. BACKGROUND This PSI Research Toolkit gives step-by-step instructions to PSI social marketers and researchers on how to use TRaC surveys to generate the HIV risk profile of PSI condom users. 1 This risk profile shows the extent to which a PSI country program is targeting those most at risk of HIV transmission and infection. The annex 3 of this paper demonstrates how this information is processed in PSI s DALY calculator the tool we use to estimate Bottom Line Health Impact, one of PSI s most important Core Values. DALY stands for Disability-Adjusted Life Year, a measure of the number of years of healthy life lost due to disease or what is generally called the burden of disease. 2 PSI s health impact is measured in terms of a DALY gained how many healthy life years are gained as a result of PSI s intervention. Here is an example to demonstrate the importance of linking TRaC, condom sales and the DALY calculator: Let s say there are two neighboring PSI country programs, both of which have populations with HIV prevalence of four percent. Country A s condom social marketing intervention sells one million condoms per month to a population at very high risk of HIV infection or transmission, such as sex workers. Country B s intervention also sells one million condoms per month but to a population who are at much lower risk, such as men who have exclusively regular partners. Without TRaC information on the HIV risk profile of PSI condom users, the DALY calculator will estimate the health impact of these two very different interventions to be the same. Each 1 TRaC surveys (Tracking Results Continuously) are repeated cross sectional surveys whose purpose is to produce actionable information relating to segmentation, monitoring and evaluation. 2 World Bank/ WHO, 2006, 1

4 country s distribution of one million condoms is calculated to avert 58 cases of AIDS and 1614 DALYs. 3 See Box 1 to read an example of how DALYs and DALYs-Gained are calculated. BOX ONE: HOW ARE DALYS CALCULATED? Box 1: How are DALYs Calculated? A DALY is an estimate of the total years of life lost to death from a disease like AIDS, plus years of life lived with disability due to HIV and AIDS. One easy way to think of a DALY is in terms of dying young. Imagine that life expectancy is 80 years, and a person dies at age 50. In general terms, the person has lost 30 years of expected life or 30 DALYs (without considering future year discounting). Further, imagine that the person had AIDS at age 48, and was sick from that time until death. Then his DALYs are 30 (from dying young) plus an upward adjustment for the two years the person spent with AIDS. Let s say that AIDS reduces quality of life by 50%, so two years living with AIDS equals one year of healthy life. Thus, the person s AIDS infection and premature death contributes 31 DALYs (without considering future year discounting). Clearly, this is not accurate. Country A is averting many more transmissions and infections than Country B. In social marketing terms, Country A is targeting the process of allocating resources and achieving results among those with the highest need or vulnerability better than Country B. When this targeting effect is taken into account, Country A is found to be gaining nearly ten times as many cases of AIDS and DALYs as Country B. TRaC surveys improve the accuracy of the DALY calculator by creating an HIV risk profile of PSI condom users, and estimating sales volume by level of risk. PSI Research can then insert this information into the PSI DALY calculator, resulting in credit for more effective targeting and higher levels of health impact. HOW-TO-STEPS Research managers have three simple steps to follow to produce TRaC information that generates a HIV risk profile of PSI condom users. In short, conduct TRaC surveys among the risk groups described below, insert 17 questions in that TRaC survey or 15 questions if it is a survey among sex workers, and then send these data to Hongmei Yang at PSI Research. STEP ONE: CONDUCT TRAC SURVEYS Condoms are assumed to be used by consumers in one of five risk categories, ranging from high to low. The risk categories are largely based on the individual s total number of partners, type of partners and number of sex acts with each partner type. A TRaC survey among a representative sample of condom users must be conducted to determine which risk categories PSI s condoms users fall into. 3 This example depends on assumptions about HIV prevalence across risk groups and a baseline assumption about the risk profile of users as explained in the appendix. Note that one million condoms translates into this number of cases of AIDS averted and DALYs gained only when these assumptions are the same. 2

5 Among what population? To accurately determine the risk profile(s) of the consumers using the PSI condoms, one TRaC survey among the general population is required. This is true even in countries that target highrisk populations. Ideally, the TRaC survey among the general population should be conducted with men and women of reproductive age (i.e., 15-49). At a minimum, a survey among males aged (or 15-29) is required. Males are the selected set since it is typically the male who buys condoms and remembers the brand names. Data from females could provide additional market insight but is not sufficient on its own. Fifteen to twenty-four is the minimum age range likely to work for most countries. In countries where sexual debut occurs relatively late in life (e.g., in early twenties), may serve as the minimum request on age range. Keep in mind that surveys among people with broader age ranges are welcome. Where? In a country where PSI condoms are promoted nationwide, a nationally representative sample of the general population is preferred. In a country where PSI condoms are promoted only in a couple of provinces or regions, such survey should be conducted in those provinces or regions. But what if I work only with high-risk groups? Since the vast majority of PSI condoms are distributed through commercial channels, it is difficult to know who ultimately purchases and uses our branded product. So, even though your work may be highly focused, a general population survey is required to ascertain whether the consumers purchasing your condoms fall exclusively into the targeted population or into others as well. If you cannot do a general population survey, a study among the high-risk groups you target can be used to estimate the proportion of PSI condoms used by that group IF you can also provide estimates of the size of their population using the multiplier method (please see Annex 2 for detail) or estimates from report or literature review. Any volume sales not accounted for by the condom usage rates reported by the target group are assumed to be used by lower-risk groups and will be allocated accordingly. STEP TWO: INSERT THE FOLLOWING QUESTIONS INTO YOUR TRAC SURVEY These questions are designed for males. To some extent, questions can be modified for other populations or to accommodate cultural sensitivities. Please work with your research backstopper if this is required. Questions for a survey among FSWs can be found in the attached Annex 1 (page 10). INSTRUCTIONS: 1. The following questions can serve as a starting point when you develop your own questionnaires. They tell you what information needs to be covered and how. You are welcome to make your own questions more culturally specific by changing the time frame and/or types of partners which are highlighted in grey. 3

6 2. Types of partners: How to classify partners into different types depends on the target population s sexual and condom use behavior with different partners. In a country where the target population usually uses condoms with their commercial partners but seldom uses one with their spouse or regular partner and uses condoms at a rate somewhere in between when they have sex with other partners, you may consider to categorize their partners into three groups (e.g., regular, casual, and commercial). Then, you need to select a term to identify each type of partners. It is advisable to use your local language to summarize each type of partner during questionnaire development and data collection. The key to making a good classification of partner types is to make sure all the types that you identify and define are mutually exclusive (i.e., no overlap among types) and completely exhaustive (i.e., these types cover all kinds of partners). 3. Time frame or Recall period: The time frame for number of sexual acts may vary from country to country. The key is to make sure it is short enough so that respondents remember experiences (i.e., to minimize recall bias) but it is not too short so that the representiveness is adequate. For populations in which individuals have more coital frequency, the recall period may be set shorter, say one week for sex workers, to assure an accurate recall. BOX TWO: QUESTIONS 0 Have you ever had sex? 1 With how many people have you had sex in the past 12 months? [Prompt: please consider all types of partners, including spouse(s), cohabitating partner(s), girlfriend(s), sweetheart(s), one-night lover(s), sex worker(s), etc.] 2 Among these partners, how many are your regular sexual partners? Regular partners are a spouse or a cohabitating partner. [Note: We break down partners into three categories: regular, casual, and commercial. The definitions of the three partners are subject to change to be culturally specific. But keep in mind that the categories should cover all sexual relationships in the universe and be exclusive to each other.] 3 How many are commercial partners? A commercial partner is a partner with whom you exchange money for sex or vise versa. [Note: see note for question two] 4 Calculate and confirm that the other partners are casual partners, partners that are not a spouse, a cohabitating partner, or a commercial partner. [Note: see note for question two.] Yes or No 4

7 5 Thinking back over the past month, how many times did you have sex (either vaginal or anal) with all your regular partner(s)? [Note: Here we need a total number of sexual contacts with all regular partners that they had. So If one person had two regular partners and had sex 1 time with partner A and twice with partner B, we need to record 3 here.] 5a If zero to question 5, ask you did not have sex with regular partners in the last month but you had regular partners in the last year, could you please tell me how many times you had sex (either vaginal or anal) with all your regular partner(s) in the past year? 6 You say you have had sex times with your regular partner(s) during the past month (or year). How many times did you use a condom with your regular partner(s)? [note: the time period in this question can be past month or past year. For those who had sex with regular partners in the past month, it refers to past month. For those who had sex with regular partners in the past year but did not in the past month, it refers to past year ]. 7 You say you used a condom times with your regular partner(s). How many of those condoms were this brand [show picture of PSI brand(s)]? number or percent estimate. 8 Thinking back over the past month, how many times did you have sex (either vaginal or anal) with all your commercial sex partner(s)? [Note: Here we need a total number of sexual contacts with all commercial partners that they had. So If one person had two commercial partners and had sex 1 time with partner A and twice with partner B, we need to record 3 here.] 8a If zero to the question 8, ask you did not have sex with commercial partners in the last month but you had commercial partners in the last year, could you please tell me how many times you had sex (either vaginal or anal) with all your commercial partner(s) in the past year? 9 You say you have had sex times with commercial partner(s) during the past month (or year). How many times did you use a condom with your commercial partner(s)? [note: the time period in this question can be past month or past year. For those who had sex with commercial partners in the past month, it refers to past month. For those who had sex with commercial partners in the past year but did not in the past month, it refers to past year ]. Or don t know what brand was used 888 5

8 10 You say you used a condom times with your commercial partner(s). How many of those condoms were this brand [show picture of PSI brand(s)]? number or percent estimate. Or don t know what brand was used Thinking back over the past month, how many times did you have sex (either vaginal or anal) with all your casual partner(s)? [Note: Here we need a total number of sexual contacts with all casual partners that they had. So If one person had two casual partners and had sex 1 time with partner A and twice with partner B, we need to record 3 here.] 11a If zero to the question 11, ask you did not have sex with casual partners in the last month but you had casual partners in the last year, could you please tell me how many times you had sex (either vaginal or anal) with all your casual partner(s) in the past year? 12 You say you had sex times with your casual partner(s) during the past month (or year). How many times did you use a condom with your casual partner(s)? [note: the time period in this question can be past month or past year. For those who had sex with casual partners in the past month, it refers to past month. For those who had sex with casual partners in the past year but did not in the past month, it refers to past year ]. 13 You say you used a condom times with your casual partner(s). How many of those condoms were this brand [show picture of PSI brand(s)]? number or percent estimate. Or don t know what brand was used Have you had or suspected yourself having any STD or STI in the past 12 months? If yes, how many times did you have symptoms? 15 During the past 12 months, have you had an abnormal genital discharge (prompt: color, smell, property, etc. not as usual)? If yes, how many episodes started in the last 12 months? Yes or No Yes or No 6

9 16 During the past 12 months, have you had a genital sore or ulcer? If yes, how many episodes started in the last 12 months? Yes or No 17 [Males only]. Are you circumcised? Yes or No STEP THREE: SEND FOLLOWING DATA TO HONGMEI YANG, PSI RESEARCH. HYANG@PSI.ORG Please send in the following documents: 1. Cleaned data sets of TRaC surveys among the target populations; 2. Corresponding questionnaires; 3. Study design or report if it is ready; 4. Prevalence of HIV and STD among general male, female, and FSWs in your country or the study area. Please also specify the source of the information. 5. Prevalence of male circumcision in your country. Please also specify the source of the information. 6. Proportion of each study population among total population in your country. For example, if PSI condoms are delivered through social marketing outlets in your country and you have conducted TRaC surveys among reproductive men and women and FSWs. Please provide information of the proportion of each target population, say, Males (15-49) account for 20% of the total population in your country; Females (15-49) account for another 20%; and FSWs account for 2%. Please also specify the source of the information. I. When should we apply targeting data? TRaC data collected and submitted before September 30: Once approved by Research & Metrics, it will be applied retroactively to the beginning of the year. TRaC data collected and submitted after September 30: Once approved by Research & Metrics, it will be applied at the beginning of the following year. II. For how long should we apply TRaC data? Consistent with our minimum standards discussions/decisions, TRaC data should be used/applied for 3 years from the time it is submitted. After 3 years and absent another TRaC survey, we will revert to using the default estimates for targeting 7

10 At this time, PSI Country Programs do not need to conduct further analysis on this data. In the future, we expect to decentralize the additional steps below, but for now PSI Research will conduct the analysis. Interested in how this is done? See Annex 3! CASE EXAMPLES AND LESSONS LEARNED This Toolkit has no case examples and lessons learned, to date. We expect that we will have case studies about how to modify these questions or the methods we demonstrate in the annex 3 to produce targeting information. QUALITY IMPROVEMENT CHECKLIST FIGURE FOUR: CHECKLIST FOR TRaC STUDY DESIGN (USE THIS Have COLOR, the 17 FONT questions SIZE, been AND included CAPS) in (WRITE your TRaC THE Survey? STANDARDS The exact ON statements THE of these questions i are CHECKLIST subject to change IN THE in order FORM to A be QUESTION) culture-specific. If you do not have a survey of males or believe modifications of the questions are required, have you contacted your regional researcher or Hongmei Yang? REFERENCES 1. Definition of regular and casual partner: Partner relationship was divided on the basis of cohabitation and marriage. Sex with any non-cohabiting, non-marital partner is considered to be higher risk than sex with a cohabiting partner. (HIV/AIDS Survey Indicator Database, available at: last visit: July 18, 2006) 2. First question: Demographic and Health Survey, Survey, Questionnaires and Modules, Core Questionnaire Library, Phase 5, available at: Feb06WithRationale.pdf, last visit: July 18, Time period for number of sexual partner: usually use the past year (or 12 months) Time period for number of sexual acts: The UNAIDS/MEASURE Evaluation HIV/AIDS Prevention Indicator Survey uses the past 3 months as recall period when asking how many times respondents had sex with a partner (see Q309, available at: ). 5. Self-reported STD infection: Questions may ask if respondents have experienced any of the following symptoms in a specified time period. These questions may investigate symptoms of 8

11 genital pain, sores, or discharge. The recall period varies, but the last 12 months is most commonly used ( The two STD symptom questions were drawn from DHS AIDS Module- Macro International, Inc. Available at: last visit: July 25, ANNEX 1 EXAMPLE QUESTIONS FOR SURVEYS AMONG FSWS: Questions: 1 How many stable (or regular) sexual partners do you have in the past 12 months? [Prompt: a stable partner is a man with whom you have a sexual relationship for at least 3 months and/or with whom you have sex regularly. A stable partner is also a man whom you are not willing to view as a client even if you get money/gifts/accommodation/etc. from him. This category may include spouse(s), cohabitating partner(s), boyfriend(s), long-term stable clients, etc.] 2 How many casual sexual partners do you have in the past 12 months? [Prompt: a casual partner is not your client but a man with whom you have a sexual relationship for less than 3 months and/or with whom you have sex occasionally. This category may include one-night affair, etc.] 3 Usually, how many clients (note: exclude the long-term stable client; Prompt: a client is a man with whom you have sex just for money or other stuff) do you have sex with per week during the past 12 months? 4 Thinking back over the past month, how many times did you have sex (either vaginal or anal) with your stable partner(s)? [Note: Here we need a total number of sexual contacts with all stable partners that they had. So If one person had two stable partners and had sex 1 time with partner A and twice with partner B, we need to record 3 here.] 5 You say you have had sex times with your stable partner(s) during the past month. How many times did you use a condom with your stable partner(s)? 9

12 6 You say you used a condom times with your stable partner(s). How many of those condoms were these brands [show picture of PSI brands at the same time or one by one, whichever works better]? PSI Brands number or percent estimate. If don t know what brand was used, put 888 (a) Jeito (b) Trust Studded (c) Femidom (female condom) (d) Generic (free condom) Note: Here we use condoms sold in Mozambique as an example to show how to collect such information by brand. Please make changes to reflect condom names promoted in your country. Important Note: If all PSI brands have the same market, there is no need to collect this information by brands. That is to say the breakdown table can be taken out. 7 Thinking back over the past month, how many times did you have sex (either vaginal or anal) with your casual (but not commercial) sex partner(s)? [Note: Here we need a total number of sexual contacts with all casual partners that they had. So If one person had two casual partners and had sex 1 time with partner A and twice with partner B, we need to record 3 here.] 8 You say you have had sex times with your casual (but not commercial) partner(s) during the past month. How many times did you use a condom with the casual (but not commercial) partner(s)? 9 10 number. You say you used a condom times with the casual (but not commercial) partner(s). How many of those condoms were these brands [show picture of PSI brands at the same time or one by one, whichever works better]? PSI Brands number or percent estimate. If don t know what brand was used, put 888 (a) Jeito (b) Trust Studded (c) Femidom (female condom) (d) Generic (free condom) Note: Here we use condoms sold in Mozambique as an example to show how to collect such information by brand. Please make changes to reflect condom names promoted in your country. Important Note: If all PSI brands have the same market, there is no need to collect this information by brands. That is to say the breakdown table can be taken out. Thinking back over the past week, how many times did you have sex (either vaginal or anal) with your clients (note: exclude the long-term stable client)? [Note: Here we need a total number of sexual contacts with all clients they had. So If one person had two clients and had sex 1 time with client A and twice with client B, we need to record 3 here.] 11 You say you had sex times with your clients (note: exclude the long-term stable client) during the past month. How many times did you use a condom with your casual partner(s)? number. 10

13 12 You say you used a condom times with your casual partner(s). How many of those condoms were these brands [show picture of PSI brands at the same time or one by one, whichever works better]? PSI Brands (a) Jeito (b) Trust Studded (c) Femidom (female condom) (d) Generic (free condom) number or percent estimate. If don t know what brand was used, put 888 Note: Here we use condoms sold in Mozambique as an example to show how to collect such information by brand. Please make changes to reflect condom names promoted in your country. Important Note: If all PSI brands have the same market, there is no need to collect this information by brands. That is to say the breakdown table can be taken out. 13 Have you had or suspected yourself having any STD or STI in the past 12 months? If yes, how many times did you have symptoms? 14 During the past 12 months, have you had an abnormal genital discharge (prompt: color, smell, property, etc. not as ususal)? If yes, how many episodes started in the last 12 months? 15 During the past 12 months, have you had a genital sore or ulcer? If yes, how many episodes started in the last 12 months? Yes or No Yes or No Yes or No ANNEX 2 MULTIPLIER METHOD FOR ESTIMATING POPULATION SIZE: If you can't obtain an estimate of the target population that you are comfortable with from literature, we would suggest you do the following... Suppose the target population is IDUs. Contact all methadone centers and obtain monthly records for the number of IDUs in treatment. Then during the next tracking survey, ask how many study respondents have participated in methdone treatment at those centers in 11

14 the last month. Then aggregate the numbers and get a better estimate of the number of IDU. Example: In January, all methadone clinics in Bangkok treated 1,000 different IDUs. During the next tracking survey, 20% of IDUs interviewed report seeking methadone treatment in January. We can assume that 1,000 is 20% of the total IDU population. Then we divide 1,000 by 20% = 5,000 which is the estimated number of IDUs in Bangkok 12

15 ANNEX 3 HOW TRAC AND CONDOM SALES MODIFY THE DALY CALCULATOR Linking TRaC, sales and the DALY calculator requires the information in Table 1. TABLE 1: DATA INPUTS TO DALY CALCULATOR A. TRaC Data B. Data from Literature [A1] Coital frequency per year [B1]. Risk of HIV transmission during window period [A2]. Number of partners by type of partner [B2]. Risk of transmission during non-window period [A3]. Number of sexual acts with each type of [B3]. Length of window period partner [A4]. GUD infection [B4]. Protective effect of male circumcision [A5]. Circumcision [B5]. Protective effect of male condom [A6]. Percent of sexual acts with a condom by type [B6]. Duration of HIV infection without symptoms of partner [A7]. Sex with a PSI condom [B7]. Duration of AIDS [A8]. PSI condoms sold [B9]. Country-specific proportion of study population in the total population [A9]. Age of HIV infection onset (average age of [B10]. Country-specific HIV prevalence among study population each risk group: low-, medium-, high, very high, and highest) PSI Research follows a four step process to link TRaC, condom sales, and the DALY Calculator. This is shown in Figure 1: 13

16 FIGURE 1: FOUR STEP PROCESS TO LINK TRAC, CONDOM SALES AND THE DALY CALCULATOR Step 1: Calculate Net Probability of Infection How to Read the DALY-Gained Formula Place Figures 2-5 in a backwards L shape, in the following order. Step 2: Transform Net Probability of Infection into Reduction in HIV Infection Probability Per Condom Step 3: Transform Target Pop. by Risk Level into Sales Volume by Risk Level Step 4: Transform Sales Volume by Risk Level into DALY-Gained Step 1 of the four-step process is to calculate the net probability of infection. See Figure 2. 14

17 = PSI RESEARCH & METRICS TOOLKIT FIGURE 2: CALCULATING THE NET PROBABILITY OF INFECTION 1 Person Coital Frequency Per Year (A1) Sex Act = HIV Prev. (B10) = Casual At Risk Acts (A2/A3) At Risk Acts Regular At Risk Acts GUD (A4) Non-GUD GUD Non-GUD Window Period (B1/B3) Non-window Period (B2) Window Period (B1/B3) Non-window Period (B2) Window Period (B1/B3) Non-window Period (B2) Window Period (B1/B3) Non-window Period (B2) X % X % X % X % X % X % X % X % = Sum of Infection Probabilit PE of 1 { Circumcision (B4) Prevalence of Circumcision (A5) Net Probability of Infection Go to Step 2 Risk of Infection (RoI) Step 1: Calculate Net Probability of Infection Information collected and calculated from TRaC, such as number of partners (e.g., regular, casual, and commercial), number of sexual contacts with each partner type in the past year, and proportion of sexual contacts protected by a (PSI) condom is combined with information collected from secondary sources, such as HIV prevalence, the length of the window period of infection, and the protective efficacy of circumcision to determine the net probability of infection. Step 2 of the four step process transforms net probability of infection into the reduction in HIV prevalence probability per condom. Information from TRaC includes the percentage of sexual contacts with condoms, and the percentage of those contacts in which PSI condoms are used. Information from secondary sources is the protective efficacy of condom use. The DALY calculator then calculates the reduction in HIV infection probability per condom. 15

18 = = PSI RESEARCH & METRICS TOOLKIT FIGURE 3: TRANSFORM NET PROBABILITY OF INFECTION INTO REDUCTION IN HIV INFECTION PROBABILITY PER CONDOM Step 2: Transform Net Probability of Infection into Reduction in HIV Infection Probability per Condom Net Probability of Infection % of Sex Acts with Condoms (A6) % of PSI Condoms Used (A7) PE of Condom Use (B5) Reduction in HIV infection Probability by use of PSI condoms per person Coital Freq. % of Sex Acts with Condoms % of PSI Condoms Used (A7) Reduction in HIV infection Probability per Condom (C8) Go to Step 3 Step 3 of the four step process begins with dividing the target population into risk groups. This is done based on number of total partner in the past year from the TRaC survey as follows: Low risk: having only 1 partner; Medium risk: 2 partners; High risk: 3-4 partners; Very high risk: 5-9 partners; Highest risk: 10+. This information starts Step 3, the transformation of target population by risk level into sales volume by risk level. Information from condom sales is combined with secondary information about the proportion of one or more target groups relative to the total population of the country. FIGURE 4: TRANSFORM TARGET POPULATION BY RISK LEVEL INTO SALES VOLUME BY RISK LEVEL 16

19 = PSI RESEARCH & METRICS TOOLKIT Prop. of 1 st Target Pop. By Risk Low: % Med: % High: % Very High: % Highest: % Prop. of 2 nd Target Pop. By Risk Low: % Med: % High: % Very High: % Highest: % + Proportion of 1 st Target Group in the country (B9) Proportion of 2 nd Target Group in the country (B9) Target Population by Risk Low: % Med: % High: % Very High: % Highest: % Target Population by Risk Low: % Med: % High: % Very High: % Highest: % SUM SUM SUM SUM SUM SUM SUM SUM SUM SUM Prop. of PSI condoms consumed Low: % Med: % High: % Very High: % Highest: % # of PSI condoms Prop. of PSI consumed condoms per year consumed Low: % Med: % High: % Very High: % Highest: % Total PSI Condoms Sold (A8) = Sales Volume Pop. 1 Low: % Med: % High: % Very High: % Highest: % Pop. 2 Low: % Med: % High: % Very High: % Highest: % SUM % of Sex Acts with Condoms Coital Freq. % of PSI Condoms Used (A7) Go to Step 4 Step 3: Transform Target Population by Risk Level into Sales Volume by Risk Level Step 4 and the final step is to combine information from Step 3, sales volume by risk level, with the outcome of Step 2, the reduction in HIV infection probability per condom, and secondary information about the average age of onset of HIV infection. That is done following the procedure in Table 2. TABLE 2: DALY CALCULATION ASSUMING ONE TARGET POPULATION AND ONE MILLION (10 6 ) CONDOMS -- FOUR-STEP PROCESS TO LINK TRAC, CONDOM SALES AND THE DALY CALCULATOR Table 2: DALY Calculation assuming one target population and one million (10 6 ) PSI condoms sold Risk Groups Prop. No. of PSI condom used in last year per person Prop. of PSI condom used =/ SUM() PSI condom consumption = 10 6 Reduction in probability of infection per condom Cases Averted = Low 70% 50 35/ Medium 10% 80 8/ High 10% / V. High 5% 120 6/ Highest 5% / DALY = (YLL+YLD) A1,A2, A1, A7 Calculation A8 A1 to A8, B1 to Calculation B6, B7, A9 17

20 A3, A4 B5, B10 In the Table 2 example, the target population is males aged years in Country A. Males are divided into five risk groups, which is here assumed to be: low, 70 percent, medium, 10 percent, high, 10 percent, very high, five percent, and highest, five percent according to their risk profile. Then, using the Cases of AIDS Averted model in the DALY calculator, the reduction in probability of infection due to PSI condoms per person for each risk group is estimated. That amount is transformed from the reduction in probability of infection due to PSI condoms per person into reduction in probability of infection per PSI condom (Column 6). The Cases of AIDS Averted is then calculated (Column 7) and finally the DALY is calculated (Column 8). The procedure for combining information for two TRaC surveys is similar and demonstrated in Table 3. TABLE 3: EXAMPLE ASSUMING TWO RISK GROUPS: MALES AGES (20 PERCENT OF THE TOTAL POPULATION) AND SEX WORKERS (ONE PERCENT) AND ONE MILLION CONDOMS SOLD Table 3: Example Assuming Two Risk Groups: Males Ages (20 percent of total population), and Sex Workers (one percent) and one million condoms sold. Risk Groups Prop. No. people New prop. =/ SUM() No. of PSI condom used in last year per person Prop. of PSI condom used = / SUM( ) Males, 15-49yrs: Low 70%.7.2tot 14/ Medium 10%.1.2tot 2/ High 10%.1.2tot 2/ V. High 5%.05.2tot 1/ Highest 5%.05.2tot 1/ FSWs: Low 5%.05.01tot.05/ Medium 5%.05.01tot.05/ High 20%.2.01tot.2/ V. High 30%.3.01tot.3/ Highest 40%.4.01tot.4/ A1,A2, A3, A4 B9 Calculation A1, A7 Calculation PSI condom consumption = 10 6 Reduction in probability of infection per unit Cases Averted = DALY = (YLL+YLD)

21 A8 A1 to A8, B1 to B5, B10 Calculation B6 to B7, A9 19