Step 1: PLACE Strategy

Objective

To convene a PLACE Steering Committee that determines the PLACE strategy, adapts the PLACE protocol to the local context and plans implementation

Methods

1.1    Establish a PLACE Steering Committee

1.2    Convene a workshop to prioritize areas for a PLACE assessment

1.3    Adapt and finalize the PLACE protocol and indicators and field test questionnaires

1.4    Plan dissemination of results and data use

1.5    Plan study implementation and logistics

1.6    Compile and document the PLACE Strategy

Expected Outputs:

• A National Steering Committee has been established

• The PLACE strategy has been written

• Priority Prevention Areas have been identified and prioritized for PLACE

• The protocol has been adapted and questionnaires translated and field tested

• The protocol has been approved by an ethical review committee

• PLACE teams in the initial implementation areas have been identified

• A timeframe has been developed for field work, feedback workshops, and dissemination of results

• A budget has been developed and funding secured

• A map identifying areas where PLACE will be implemented has been printed

1.1 Establish a PLACE Steering Committee

The PLACE method comes alive when a committee of thoughtful people-- the PLACE Steering Committee-- reviews the status of the HIV/AIDS epidemic in their borders and reaches consensus on a PLACE strategy that ensures that the findings will be used to improve programs that will prevent new infections. The PLACE Steering Committee is comprised of decision makers and people with strong ties to AIDS prevention programs. Members could include Ministry of Health officials, an epidemiologist, a demographer or social scientist, and representatives from intervention groups.

Although the steering committee is usually convened at a national level, representatives from the local areas where PLACE assessments are conducted should be invited to join the committee as soon as the specific local areas are identified.

The functions of the Steering Committee are to:

• Determine the PLACE strategy

• Specify the geographic scope of the PLACE Strategy

• Lead a national workshop to identify Priority Prevention Areas where PLACE will be implemented

• Adapt the PLACE protocol

• Commission a field test of the protocol and questionnaires

• Obtain ethical review and approval of the protocol

• Secure funding

• Ensure that the results are used to improve prevention programs

• Ensure confidentiality of data

• Identify PLACE Field Coordinators in each area where PLACE is implemented

• Respond to any problems that arise.

1.2 Convene a national workshop to identify Priority Prevention Areas for PLACE implementation

Geographic Scope

Prior to the workshop, the Steering Committee should determine the geographic scope of the PLACE Strategy. The geographic scope of the PLACE strategy is the entire area under consideration when identifying Priority Prevention Areas and choosing where to implement PLACE. The geographic scope is usually a country, but it could be a province, a district, city, or a region of interest including several countries, cities, or border crossings.

Workshop Objectives

A national 1 day workshop is held to identify and select areas where PLACE will be implemented. Participants include the Steering Committee members and key stakeholders. PLACE should be implemented in the areas where there is a great potential for programs to prevent new infections.

The specific objectives of the workshop are to:

1. Review available epidemiologic and surveillance data, reports, and maps to facilitate identification of areas in the country where new adult HIV infections are likely to cluster and where prevention efforts are most needed

2. To nominate areas for a PLACE assessment, locate each area on a country map, and describe the characteristics of each area that make it particularly vulnerable to increased HIV transmission

3. Based on feasibility of implementation, resources available, and intervention potential, to reach a consensus on which areas are the highest priority for a PLACE assessment and which are the lowest priority

Workshop Objective 1

To review epidemiologic data, reports and maps to identify areas where new adult infections are likely to cluster

At the workshop, presentations should be made that review and synthesize relevant epidemiologic and contextual information in order to highlight the state of the epidemic in the geographic scope of the PLACE initiative and to summarize in broad stokes the known information about factors underlying the epidemic and their geographic distribution. The proximate determinants framework can be used as a guide to identifying factors that determine the size and pattern of the HIV epidemic. In order to facilitate discussion at the workshop, information is most usefully summarized on maps. The areas covered in the review should include:

Trends in HIV Prevalence

Valid estimates of geographic trends in HIV incidence are rarely available. Trends in HIV prevalence among 18-24 year old women tested at antenatal care clinics as part of a national surveillance program are often available, however, and useful for identifying where incidence may be increasing. In some cases, there may be a plethora of surveillance data that are not organized to facilitate the identification of areas with the highest incidence of HIV transmission. In these cases, it is extremely useful to identify clinics where surveillance has been conducted at least three times and to identify the specific clinics where prevalence among the 18-24 year old women has consistently increased over time.

Socio-Economic, Cultural and Contextual Factors Affecting HIV Transmission

Decisions about where to implement PLACE often rely extensively on socio-economic, cultural and contextual factors. The geographic distributions of key socio-economic, cultural and contextual factors affecting HIV transmission are often very useful in identifying areas where PLACE should be implemented. These are often most effectively presented as maps and can include maps of population density, migration patterns, poverty, major transportation routes and commercial centers, migrant worker locations, health indicators, health care availability, locations of areas with high prevalence of tuberculosis and other infectious diseases, high crime areas, drug trafficking routes, and the location of cultural festivals.

Current Prevention Programs

A review of the major prevention programs in the country, their objectives, and where they are located is also useful for identifying where program resources may be available and where program gaps occur.

Workshop Objective 2

Identification of Priority Prevention Areas, and Prioritization for PLACE

After the review of the maps and information highlighting the geographic distribution of factors affecting HIV transmission in the country, workshop participants discuss the findings and nominate geographic areas in the country where the available evidence suggests prevention programs are most likely to prevent new infections. So far, seven types of priority prevention areas have emerged (See below). Each represents the geographic convergence of economic, demographic, and health factors associated with vulnerability to HIV/AIDS transmission.

Types of Priority Prevention Areas

Workshop Objective 3

Prioritization of Areas for PLACE

A brief description of the health, population, and infrastructure of each selected Priority Prevention Area should be written based on available information and reports. The workshop ends with a discussion to reach consensus on which of the nominated areas are the highest priority for a PLACE assessment and which are the lowest priority, based on feasibility of implementation, resources available, and intervention potential for preventing new infections.

1.3 Adapt PLACE protocol and specify PLACE indicators

The PLACE Protocol must be adapted for use in each country and, within each country, must be appropriate for each Priority Prevention Area where it will be implemented. The major decisions required in order to adapt the protocol are described below.

For which programs will coverage estimates be obtained?

One of the most important decisions is the range of programs for which program coverage estimates will be obtained. The standard protocol obtains program coverage estimates for condom availability, STI treatment, and voluntary counseling and testing programs (VCT). Other programs could be included, however, such as specific mass media campaigns or messages (radio, television, billboards) and special programs for key populations, such as peer education for commercial sex workers, sexually transmitted disease treatment for migrant workers, or harm reduction programs for injecting drug users. Indicators of program coverage will include maps, site-level indicators of program coverage, and indicators of exposure to programs among people socializing at sites.

For which key populations are separate descriptions required?

PLACE provides information about the population socializing at sites where people meet new sexual partners and/or sites where injecting drug users can be found. This population may be comprised of a diverse group of individuals including people who are young, mobile, who engage in transactional sex, and/or who inject drugs. The PLACE strategy should specify whether there are any key populations (e.g. sex workers, clients of sex workers, injecting drug users, and youth) for whom separate indicators of behavior or program coverage are required. The strategy should also specify whether additional funds should be spent if additional data collection is required in order to obtain a sample of sufficient size for describing the behavior and characteristics of the key populations.

What are the Summary PLACE indicators?

The usual summary indicators provided by the PLACE method are listed below. Additional indicators can be specified.

Summary PLACE indicators

• Number of venues reported where people meet new sexual partners

• Types of venues most frequently identified

• Percent of venues:

  • where sex workers solicit

  • where IDUs socialize

  • where youth 15-19 socialize and alcohol is consumed

  • where condoms were never available in the past year

  • where condoms were available and seen during PLACE visit

  • willing to have onsite AIDS prevention program

• Characteristics of Venue Patrons

  • Number of male and female patrons attending venue during the past week

  • Percent of patrons aged 15-24

• Percent of patrons (by gender, and separately for youth aged 15-24) who:

  • live in the area

  • are students

  • are unemployed

  • visit the venue daily

  • have met a sexual partner at the venue

  • have ever had sex

  • have ever used a condom

  • used a condom at most recent coitus

  • had a symptom of an STI in the past 4 weeks

    • of these, percent who sought treatment from a clinic or hospital

  • injected drugs in the past 12 months

  • have been tested for HIV in the past 12 months

  • have heard an AIDS program on the radio

  Partnerships

  • have had one sexual partner in the past 12 months

  • have had more than one sexual partner in the past 12 months

  • have had a new sexual partner in the past 12 months

  • have had a new sexual partner in the past four weeks

  • gave or exchanged money for sex in the past 4 weeks

  • had sex with a man (MSM) in the past 4 weeks (men only)

• Maps

  • Condom availability at sites

  • Priority sites for prevention programs

1.4 Plan dissemination of results and data use

Ensuring that the PLACE findings are used to improve programs is an integral step of the PLACE method. Reports, maps, and presentations are shared at meetings that are strategically planned to maximize the usefulness of the PLACE assessments. Typically, the meetings include the following:

A local participatory feedback and action plan workshop

At this workshop, local stakeholders discuss the PLACE results and their implications for current local HIV/AIDS prevention program strategies. Each participating intervention group is asked to identify immediate steps that the intervention group can take to improve their programs based on the results. These participatory workshops are an important means of informing key stakeholders and community members of intervention gaps and facilitating ownership by the community of the results. Getting feedback from intervention groups about the results has proven essential for interpreting findings.

A district or city-wide presentation of results

A formal presentation of results at a higher administrative level than the local feedback workshop is often held. This presentation is targeted to national or city-level officials and policy makers. In addition, members of the community where the PLACE assessment was conducted are invited to comment on the findings. The results are presented by the chair of the steering committee.

A data use workshop

A data use workshop for community members engaged in monitoring local HIV/AIDS prevention programs enables people to use the data to monitor their own programs. Armed with the capacity to revisit the results, the intervention team can generate new lists of priority sites to receive prevention programming. As coverage of previously identified priority sites is achieved, or priorities change, new sites for intervention can be identified.

A meeting to plan follow-up PLACE assessments and "roll-out" assessments

The PLACE method is an effective means of monitoring programs. To examine change over time, subsequent assessments are necessary. Developing a plan for a follow-up assessment will help structure a timeline for site-based interventions. Likewise, "rolling out" PLACE to other areas will help target prevention programs in a broader geographic area.

1.5 Plan PLACE Implementation

Organization of PLACE Team

In planning a PLACE implementation in multiple areas, it is useful to have a chart identifying the major components of the PLACE assessment team and to develop a budget to cover all activities. The figure below illustrates a typical PLACE assessment team.

Budget

The total cost of the study will depend on the area and intended sample size. The following items should be considered when creating a budget:

Study Preparation

1. Translation and back translation of questionnaires into local language

2. Pre-testing and revision of questionnaires

3. Duplication of questionnaires, interview guide, and any other field supplies

4. Purchase of Digital maps and/or air photos

5. Field Work supplies (pens, clipboards, etc)

6. Meeting with local stakeholders, intervention groups, community groups, etc.

Field Work: Personnel and Data Collection

1. Local Principal Investigator Salary

2. PLACE Coordinator Salary

3. Field Coordinator Salary

4. Interviewer Salary

5. Interviewer daily transport allowance

6. Communication costs

7. Transportation costs

8. Training costs, including rental of space

9. Data Entry

10. Data Analyst

11. Mapping Specialist

Presentations and Reporting

1. Feedback workshop to community and stakeholders

2. Debriefing session

3. Report Dissemination

4. Workshops and Meeting costs

1.6 Compile and Document the PLACE Strategy

The PLACE Strategy is a 10-15 page document with 3-4 appendices and follows the format below.

Planning for Step 1

Exercises

Exercise 3

Objective

To understand the characteristics of Priority Prevention Areas (PPAs) for HIV and be able to recognize potential PPAs.

Identifying PPAs is a very important part of the PLACE strategy because PPAs are the areas where there is the most potential for preventing new infections. One of the most accurate ways to locate PPAs would be to find areas with the fastest growing HIV seroprevalence measured by national population-based seroprevalence surveys. However, such data is almost never available and the location of PPAs must instead be determined using the best available data. It is entirely possible that identification of PPAs based on the best available information may miss important PPAs with higher incidence of HIV infection. The PLACE method uses current information to make the best judgments about the location of PPAs. If new information becomes available that points to PPAs of greater importance, the PLACE team must be ready to modify its country strategy as appropriate.

Instructions

In this exercise, you will use the best information available to locate possible PPAs in the fictional country of Chackarona. Maps with information on the topography, transportation system, population density, and HIV sentinel surveillance of Chackarona are provided to help you determine where HIV is most likely to be transmitted.

First, familiarize yourself with the three maps of Chackarona provided below. You may want to print them out so that you can write on them. Review the characteristics and types of PPAs described above in section 1.3. Then, answer the following questions.

1. Roughly how large is Chackarona? Where are the most densely populated areas of the country? Where are the urban areas?

2. Describe the major transportation routes.

3. How many antenatal care clinics (ANC) are there in Chackarona? How are they distributed throughout the country? Identify areas of the country with the highest prevalence of HIV among pregnant women surveyed at these sites.

4. Which areas of Chackarona do you think have the most uneven male-to-female ratio? Why do you think an uneven male-to-female ratio is of concern?

5. Which area do you think should be chosen as the PPA area to be targeted by the PLACE team? Justify your choice by citing characteristics that you think make this area a PPA. Note: there is more that one possible PPA. Pick one and justify your choice.

1. Topography

2. Transportation

3. Population density/HIV prevalence

Answers

Exercise 3

1. Roughly how large is Chackarona? Where are the most densely populated areas of the country? Where are the urban areas?

   Chackarona is a small country of approximately 5600 square kilometers. Most people live along the central coast, and very few people live in the western mountains or in the northeast and northwest corners of Chackarona. The areas with the highest population density are a mining town in the center of northern Chackarona, a border town in the south, and a port city in the center of the eastern coast.

2. Describe the major transportation routes.

   Roads and railways connect each of the three urban areas and connect Chackarona to its neighboring countries. The railroads form fairly straight links between each city, unlike the roads which are not direct. Rivers close to the mining and border towns may also provide transportation connecting these areas to the ocean in the east.

3. How many antenatal care clinics (ANC) are there in Chackarona? How are they distributed throughout the country? Identify areas of the country with the highest prevalence of HIV among pregnant women surveyed at these sites.

   The 11 ANC are found everywhere in the country except for in the mountainous west. Four of the clinics are in the three major urban areas, one clinic is on the outskirts of the mining town, and most of the other clinics are near major roadways. Extremely high HIV prevalence of at least 30 percent was reported at the antenatal clinic in the border town and at the ANC in the port city. The ANC on the outskirts of the mining town also reported a high HIV prevalence of between 20 and 30 percent.

4. Which areas of Chackarona do you think have the most uneven male-to-female ratio? Why do you think an uneven male-to-female ratio is of concern?

   There are several areas that could have an uneven sex ratio. If migrant laborers are hired to work in the mining town, it is likely that the mining town has the most uneven male-to-female sex ratio with more males than females. Is it also possible that uneven sex ratios with more females than males occur in rural areas where many men are away from home working as migrant laborers. The border town could have a relatively uneven ratio if there are many male migrants there from neighboring countries. Lastly, the port city could have an uneven ratio if there are large numbers of male sailors taking shore leave from the ships that employ them.

   An uneven sex ratio is of concern because it is one of many factors which may encourage sex work and thereby increase the number of new sexual partnerships formed in a population.

5. Which area do you think should be chosen as the PPA area to be targeted by the PLACE team? Justify your choice by citing characteristics that you think make this area a PPA. Note: there is more that one possible PPA. Pick one and justify your choice.

   There are three possible areas that could be chosen as the PPA, given the available data. Below are three possible answers; all are correct. We have arbitrarily selected the port city as the PPA to be used in subsequent exercises.

• The mining town: There are many characteristics of the mining town that are associated with PPAs. To begin with, the mining town has a relatively high population density. It is also at the intersection of major railway lines and roadways. The mining town probably has an uneven male to female sex ratio, with more males than females, because of male migrant labor in the mines. It is possible that many new sexual partnerships are formed here between male migrant workers and female sex workers.

  A high HIV prevalence of between 20 and 29.9 percent was measured among pregnant women attending the antenatal clinic on the outskirts of the mining town. Women attending the antenatal clinic within the mining town had an HIV prevalence of between 1 and 9.9 percent.

  Choosing the mining town as the PPA where PLACE should be implemented is based on currently available data only. It is possible that a higher priority area with higher transmission exists which cannot be identified using the available data.

• The port city/capital: The port city/capital is likely to be a PPA for several reasons. The main reason is that it is at the intersection of railway lines as well as major roadways. The port may act as a hub for international shipping traffic, drawing sailors from all over the world. In addition, tourism may be an important industry here. All of these factors indicate that there may be a high rate of new sexual partner acquisition in the port city.

  One of the two highest HIV prevalence rates in the country of over 30 percent was measured among pregnant women attending the antenatal clinic in the southern part of the city. The other antenatal clinic had a prevalence of between 10 and 19.9 percent.

  Choosing the port city as the PPA where PLACE should be implemented is based on currently available data only. It is possible that a higher priority area with higher transmission exists which cannot be identified using the available data.

• The border town: The border town may be experiencing rapid and uncontrolled population growth, particularly if migrants from neighboring countries are settling in Chackarona in large numbers. Rapid and uncontrolled population growth is known to be a characteristic of PPAs. If there are more male migrants than female migrants, many new sexual partnerships may be formed here between male migrant workers and female sex workers. The border town also contains the intersection of two major railway lines that connect it to the mining town and the port city. The fact that the town is on a major transport route, and the fact that it is a border town, make it likely to be a PPA.

  Lastly, one of the two highest HIV prevalence rates in the country of over 30 percent was measured among pregnant women attending the antenatal clinic in the border town.

  Choosing the border town as the PPA where PLACE should be implemented is based on currently available data only. It is possible that a higher priority area with higher transmission exists which cannot be identified using the available data.