Led by Dr. Sharon Weir, MEASURE Evaluation, and Professor Peter Figueroa, University of the West Indies, Jamaica. Presentation on the PLACE method and how it has been used for HIV/STI surveillance, behavioral surveillance, program monitoring, size estimation of most-at-risk populations, and program planning.

1. Using the PLACE Method to
Inform Decision Making
Sharon S Weir, University of North Carolina
J Peter Figueroa, University of the West Indies, Jamaica

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4. Agenda
• Welcome and introductions
• The importance of data-informed decision
making
• Overview of the PLACE approach
• PLACE in Jamaica
• Questions and answers
• Wrap up

5. Why data-informed decision
making?
Pressing need to target health
policies, strategies, & interventions
to the populations that need them
the most

6. “… without information, things are done
arbitrarily and one becomes unsure of
whether a policy or program will fail or
succeed. If we allow our policies to be guided
by empirical facts and data, there will be a
noticeable change in the impact of what we
do.”
National-level Policymaker, Nigeria

7. Using the PLACE Method to
Inform Decision Making
Sharon S Weir, University of North Carolina
J Peter Figueroa, University of the West Indies, Jamaica

8. PLACE Countries: Past and Present
Kazakhstan
Karaganda
Almaty
Russia
Kyrgyzstan Saratov-Engels
Samara China
Uzbekistan Osh Liuzhou
St. Petersburg
Tashkent
Mexico
Chetumal
Ciudad Hidalgo Burkina Faso India
Banfora Bhubaneswar
DR Congo
Haiti Tenkodogo
Jamaica Carrefour Burundi Rwanda
All parishes
All 12 provinces
Guyana Uganda
Kenya
All 8 provinces
St. Lucia Ghana Tanzania
Castries All 10 regions Angola Magu
Malawi
Gros Islet Luanda Madagascar
Anse la Raye
Zimbabwe 7 cities
Zambia Hwange District
Mongu
Kapiri Mposhi
South Africa Lesotho
2 townships in Port Elizabeth Ficksburg, Maseru, Maputsoe,
East London Ladybrand, Fouriesburg, Butha
1 Township in Cape Town Buthe

9. Global Recommendation
for PLACE
“Use innovative methods (PLACE,
key informant interviews) to
estimate the size and location of
relevant key populations by
country.”
Key Population Working Group
Presentation to PEPFAR’s
Scientific Advisory Board
Washington, DC, October 2-3,
2012
Mead Over, Center for Global
Development

10. Problem Addressed by PLACE:
Preventing HIV transmission at the
local level
 The PLACE method addresses the need for
rapidly available information to target and monitor
local AIDS prevention strategically.

11. PLACE Argument
 The HIV pandemic is worldwide but transmission occurs in
local epidemics
 Prevention should focus in geographic areas where HIV
incidence is highest
 No two local HIV epidemics are the same. Each local HIV
epidemic reflects its unique underlying pattern of new and
concurrent sexual and needle sharing partnerships. National
and provincial data may hide local epidemics.
 In the absence of empiric data on the geographic distribution
of HIV incidence and number of new infections, national
stakeholders can thoughtfully interpret available information to
identify where HIV incidence is high.

12. PLACE Argument
 Interrupting HIV transmission requires focusing on people with
high rates of new sexual or needle sharing contacts.
 Effective prevention among these individuals must be multi-
level, using tailored “combination prevention” to reduce their
partnership rates, increase testing, treatment, referral and
counseling for HIV/STI, and condom use.
 The PLACE method identifies venues and events where local
intervention programs can reach the most important sexual and
injecting drug use networks.
 Although outreach to these places can be expensive, outreach
is cost-effective if chains of transmission are broken.

13. PLACE protocol overview: The 5
Steps
1 Using available data, identify geographic areas likely
to have high incidence of HIV infection
2- 4 Conduct rapid assessment in each area
2 Identify venues where people meet new partners
3 Visit, characterize, map venues
4 Assess risk behavior & estimate prevalence
though interviews/testing of venue patrons & workers
5 Use results to improve programs

14. Step 2: Within High Incidence Areas,
Ask Community Informants: Where do people
meet new partners?
 Probe based on strata of interest for mixing
 Young women and older men
 Commercial sex workers
 Mobile and resident populations
 Military and civilian
 Ask until no new venues are found
 Output: List of venues with number times
reported

15. Step 3: Visit, characterize and map
places
 Reported places are visited and mapped. An interview is
conducted with a knowledgeable person on-venue to
obtain characteristics of the place
 A place can be an establishment such as a bar, an
outdoor site such as a park or street, an event such as a
community festival, an internet site, or a phone number—
such as for escort services.
 Mapping can be done by hand, onto an aerial photo, or
using GPS

16. Characteristics of places / venues
Obtained from interviewing a knowledgeable person at the venue
To Gauge Prevention To describe patrons of venues
Program Coverage and
Potential at Venues  Male:female ratio
 Type of venue  Regular patrons
 Condom availability  Where patrons reside
 Evidence of AIDS  Whether patrons include
prevention commercial sex workers, gay,
 Busy times military, mobile, youth, locals,
 Maximum occupancy unemployed
 Number of staff  Whether people meet new
partners at venue
 Venue stability

17. Step 4: Interview and test people
at places
 Opinion:  Socio-demographic &
behavioral characteristics
 Do other people
come here to meet  Number of new and
new partners? total partners in the
past four weeks, year
 Behavior:  Condom use
 Have YOU ever met  Exposure to
a new partner at this intervention
venue?
 Have YOU ever  Test for HIV & other STI
injected?

18. STEP 5
Inform interventions
Maps can show where
condoms are needed

19. Collaboration re PLACE in Jamaica
2002 PLACE Montego Bay
2003 PLACE roll out Kingston, Negril
2005-06 PLACE RCT Kingston
2006 PLACE roll out island wide
Caribbean study tour
Technical assistance to St Lucia
2008 PLACE Survey
2012 PLACE Survey

20. Impact of PLACE in Jamaica
 Improved Surveillance of MARPS
 Identified staff and patrons at venues as high risk via PLACE
 Showed the continued high prevalence of other STIs
 Improved the tracking of HIV & risk factors among MARPs
 Improved interventions
 Significantly increased access & outreach to MARPs
 Developed the scope and expertise of our outreach staff
 Spearheaded outreach HIV and STI testing/ youth
 Increased used of data to guide planning & interventions
 Helped us to refine our outreach interventions
 Convinced policy makers of need to retain field staff
 Showed the importance of social vulnerability
 Improved monitoring & evaluation
 Helped to reduce HIV prevalence among sex workers from 9% to 4.5%

22. Method Adapted to Jamaica’s
Needs
 Survey questions developed to meet program
needs, to meet global reporting requirements, to
parallel questions asked previously and
questions asked in national KAPB survey, and to
meet requests from stakeholders (to extent
possible)
 HIV+ persons enrolled in national treatment and
care program
 STI treated at no charge to participants

23. HIV and STI Infections Measured
 HIV (rapid tests)
 Syphilis Testing (multiple tests used)
 Gonorrhea
 Chlamydia
 Trichomoniasis Gen-Probe laboratory equipment
 Women: urine or vaginal swab (acceptability)

24. Data Use: PLACE provided prevention indicators for
female sex workers
Indicator 2011
Condom use at last sex with a 91%
client
Knowledge of how to prevent HIV 38%
(5 questions)
Knowledge of how to prevent HIV 52%
omitting one faithful partner option
Reached with prevention program 92%
HIV tested in past 12 months and 75%
know result
24

25. Future Needs
 Complete Institutionalization of PLACE in the Ministry & Health Regions in
Jamaica
 Consolidate the outreach intervention approaches
 Follow-up the cohorts of MSM and sex workers
 Need to use anal swabs with MSM
 Develop & evaluate more effective interventions for MSM
 Additional analyses and publications
 Review the Modes of Transmission model & HIV treatment cascade
 Need to address other STIs especially among the youth
 Maintain STI testing capacity using GenProbe
 Gonorrhoea sensitivity testing
 Share these methods, approaches and lessons with other Caribbean countries

26. Questions and Answers

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28. Presenter Contact Information
 Dr. Sharon Weir sharon_weir@unc.edu
 Prof. Figueroa figueroa10@gmail.com

29. The research presented here has been supported by the
President’s Emergency Plan for AIDS Relief (PEPFAR)
through the United States Agency for International
Development (USAID) under the terms of MEASURE
Evaluation cooperative agreement GHA-A-00-08-00003-
00. Views expressed are not necessarily those of
PEPFAR, USAID or the United States government.
MEASURE Evaluation is implemented by the Carolina
Population Center at the University of North Carolina at
Chapel Hill in partnership with Futures Group, ICF
International, John Snow, Inc., Management Sciences for
Health, and Tulane University.