FOCUSED COUNTRY EVALUATIONS - IRAN HIV EVALUATION

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Evaluation Plan:
2017-2023, Iran
Evaluation Type:
Final Project
Planned End Date:
09/2020
Completion Date:
09/2020
Status:
Completed
Management Response:
Yes
Evaluation Budget(US $):
40,000

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Title FOCUSED COUNTRY EVALUATIONS - IRAN HIV EVALUATION
Atlas Project Number: 00040048
Evaluation Plan: 2017-2023, Iran
Evaluation Type: Final Project
Status: Completed
Completion Date: 09/2020
Planned End Date: 09/2020
Management Response: Yes
Focus Area:
  • 1. Governance
  • 2. Others
Corporate Outcome and Output (UNDP Strategic Plan 2018-2021)
  • 1. Output 1.2.1 Capacities at national and sub-national levels strengthened to promote inclusive local economic development and deliver basic services including HIV and related services
SDG Goal
  • Goal 3. Ensure healthy lives and promote well-being for all at all ages
SDG Target
  • 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases
Evaluation Budget(US $): 40,000
Source of Funding: Global Fund
Evaluation Expenditure(US $): 40,000
Joint Programme: No
Joint Evaluation: No
Evaluation Team members:
Name Title Nationality
Aram Manukyan Evaluation Lead ARMENIA
Vira Ameli International Team Member
GEF Evaluation: No
Key Stakeholders:
Countries: IRAN (ISLAMIC REPUBLIC OF)
Lessons
Findings
Recommendations
1

Despite the existing economic situation, the country should ensure its transition plan and roadmap are integrated into the planning and budget for the 5th NSP. A gradual increase of domestic resources should be reflected in the new document. Due to floods, sanctions and COVID-19, the assumptions in current transition planning may need to be revisited: a transition preparedness reassessment will reveal the gaps that should be addressed while planning transition.

- It should also be ensured that the NSP budget incorporates expenditures for National HIV implementation of the M&E plan.

- The NSP and transition preparedness reassessment should also ensure the inclusion of HIV sub-accounts in annual National Health Accounts to allow the capture of the total expenditure on HIV/AIDS and monitoring of finances from public, private and external sectors.

2

Address enabling environment factors:
•       HIV stigma is one of the major contributing factors in failing to achieve 90-90-90 goals. The S&D strategy should significantly contribute to HIV service provision. Technical groups and stakeholders should ensure proper budgeting of S&D strategy in 5th NSP. The data collected through PLHIV Stigma Index 2 must be used to design activities aimed at S&D elimination. 

•  Efforts advocating changes in punitive laws for KPs should be intensified as much as possible. Some progress has been observed in recent years but not sufficient to significantly reduce legal barriers to HIV services.

•  The initiation of dialogue with clergy at various levels and their gradual involvement in some activities (e.g. stigma elimination or awareness raising related to harm of drug use) can be considered for involving them in BCC and HIV awareness raising campaigns. The perspective of their involvement in 5th NSP development and including them as implementers of some activities of NSP should be discussed.

3

Core HIV prevention services for organizations working under MoHME, MEHSAD and WO, to some extent, are providing overlapping services. Improvements in mapping of services, creation of online and interactive maps are desirable. Field workers of these organizations should have a clear knowledge of facilities working in the same geographic area and of the services provided by them.

•  Urgent activities aimed at defining the HIV prevalence among VM are required to adequately plan and scale-up HIV prevention activities within this population.

•  Task shifting - the scope of work for outreach workers should be expanded and reconsidered. For example, outreach workers can provide rapid HIV RD testing in the field. Expanding HIV testing services to trained lay providers working in the community may help to increase access to these services and their acceptability to people from key populations and other priority groups. Improvements would also be needed in the client registration system, and appropriate trainings should be provided to the personnel on regular basis. 

•  During some interviews the evaluators were informed that KP representatives - peers/leaders reach more effectively the target audience, so the model of including one peer-staff in each outreach team is useful, but it would be beneficial to increase the proportion of peers within team structures to increase the reach. 

4

Train and retrain Primary Health Care providers to: 

•  Minimize stigma and discrimination against PLHIV within general healthcare infrastructure.

•  Raise awareness among physicians and increase awareness of general population via reach of the general medical community.

•  Increase coverage and testing at earlier stages by providing more HIV testing at primary health centers, in addition to VCT Centers.

•  Increase access to treatment provision and reduce losses to follow up. 

Provide text messaging interventions through PHCs and Positive Clubs in order to increase linkage to care, from the onset of diagnosis, and further reduce losses to follow up and improve adherence.Consider use of digital platforms and interventions such as video-based information, messages and counselling where feasible like in high-volume clinics withsuboptimal HTS coverage. These platforms can be particularly appealing to adolescents, young people and key populations. This approach should be piloted in PHC clinics.

 

 

5

The recent BBS and PSE data significantly differ from the previous studies and cannot be compared due to various sampling methods. At this moment triangulation is seen as a most valuable and feasible approach to validate the results of these studies, particularly HIV prevalence among PWID.

6

Despite the negative attempts in introducing the Unique Identification Code (UIC) system for KPs, Iran must consider and seek for the new evidence-based approaches to introduce a UIC system for KPs receiving the HIV prevention and harm reduction services. 

1. Recommendation:

Despite the existing economic situation, the country should ensure its transition plan and roadmap are integrated into the planning and budget for the 5th NSP. A gradual increase of domestic resources should be reflected in the new document. Due to floods, sanctions and COVID-19, the assumptions in current transition planning may need to be revisited: a transition preparedness reassessment will reveal the gaps that should be addressed while planning transition.

- It should also be ensured that the NSP budget incorporates expenditures for National HIV implementation of the M&E plan.

- The NSP and transition preparedness reassessment should also ensure the inclusion of HIV sub-accounts in annual National Health Accounts to allow the capture of the total expenditure on HIV/AIDS and monitoring of finances from public, private and external sectors.

Management Response: [Added: 2021/06/26]

Management has acknowledged this recommendation. 

Key Actions:

Key Action Responsible DueDate Status Comments Documents
The 5th NSP was approved by the Supreme Council of Health and Food Security. This intersectoral council is headed by President, and this council's approvals are considered law and are binding. The topic of emergencies has also been included in the NSP under disaster management. 
[Added: 2021/06/26]
CDC 2020/12 Completed
NSP budget already incorporated expenditures for National HIV implementation of the M&E plan. In a separate meeting in the Supreme Council of Health and Food Security M& E plan and budgets were reviewed and approved. 
[Added: 2021/06/26]
CDC 2020/12 Completed
The 5th NSP has been developed in collaboration with all the relevant partners. In the detailed budgeting plan of the NSP, the role and contribution of all organizations have been included. This includes all the services, prevention, testing, care and treatment, harm reduction, and support.
[Added: 2021/06/26]
CDC 2020/12 Completed
2. Recommendation:

Address enabling environment factors:
•       HIV stigma is one of the major contributing factors in failing to achieve 90-90-90 goals. The S&D strategy should significantly contribute to HIV service provision. Technical groups and stakeholders should ensure proper budgeting of S&D strategy in 5th NSP. The data collected through PLHIV Stigma Index 2 must be used to design activities aimed at S&D elimination. 

•  Efforts advocating changes in punitive laws for KPs should be intensified as much as possible. Some progress has been observed in recent years but not sufficient to significantly reduce legal barriers to HIV services.

•  The initiation of dialogue with clergy at various levels and their gradual involvement in some activities (e.g. stigma elimination or awareness raising related to harm of drug use) can be considered for involving them in BCC and HIV awareness raising campaigns. The perspective of their involvement in 5th NSP development and including them as implementers of some activities of NSP should be discussed.

Management Response: [Added: 2021/06/26]

This recommendation is acknowledged. 

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Iran has joined the global partnership for action to eliminate all forms of HIV-related stigma and discrimination. In the first phase, the country has prioritized three areas: health care, Communities and households, and emergency and humanitarian settings. This topic has also been thoroughly included in the 5th NSP.
[Added: 2021/06/26]
CDC 2020/12 Completed
The challenges still exist. Different strategies have been applied in collaboration with UNADIS and partners including the study of stigma index 2, ethical framework in NSP, and some other community-based initiatives.
[Added: 2021/06/26] [Last Updated: 2021/12/14]
CDC 2021/12 Completed Stigma index 2 has almost been finalized. The first draft of the report was reviewed by UNAIDs and GNP+ and the overall idea was that some of the key populations were not well represented and more FGDs were held in response to this recommendation. It is expected the final report to be finalized in near future. In response to the finalized findings, MOH has formed “core training groups” at provincial levels who are responsible for the training of health service providers as a component of the “comprehensive training approach”. Regarding ethical framework, the study was completed, and findings were shared with the NSP writing team. The national response has planned to include some training courses for service providers in “Behavioral Diseases Counseling Centers” and other service delivery points to improve the quality of the services and make them more compatible with the ethical framework of service provision to key populations. History
This is a part of the NSP and the role of clergies has been included in the activities. However, because of the COVID-19 pandemic, the actual implementation might be delayed.
[Added: 2021/06/26] [Last Updated: 2021/12/14]
CDC 2021/12 No Longer Applicable [Justification: Considering the new changes in the Government, there are some concerns about the sensitivities/challenges this topic may raise. This decision can be reconsidered after a few years given the context of the country. ]
History
3. Recommendation:

Core HIV prevention services for organizations working under MoHME, MEHSAD and WO, to some extent, are providing overlapping services. Improvements in mapping of services, creation of online and interactive maps are desirable. Field workers of these organizations should have a clear knowledge of facilities working in the same geographic area and of the services provided by them.

•  Urgent activities aimed at defining the HIV prevalence among VM are required to adequately plan and scale-up HIV prevention activities within this population.

•  Task shifting - the scope of work for outreach workers should be expanded and reconsidered. For example, outreach workers can provide rapid HIV RD testing in the field. Expanding HIV testing services to trained lay providers working in the community may help to increase access to these services and their acceptability to people from key populations and other priority groups. Improvements would also be needed in the client registration system, and appropriate trainings should be provided to the personnel on regular basis. 

•  During some interviews the evaluators were informed that KP representatives - peers/leaders reach more effectively the target audience, so the model of including one peer-staff in each outreach team is useful, but it would be beneficial to increase the proportion of peers within team structures to increase the reach. 

Management Response: [Added: 2021/06/26]

Acknowledged

Key Actions:

Key Action Responsible DueDate Status Comments Documents
As per the national plan, by the end of 2021, the outreach teams will participate in training workshops and learn how to do the counseling and testing. Afterward, they will be equipped with Rapid Diagnostic Kits. 
[Added: 2021/06/26] [Last Updated: 2021/12/14]
CDC 2022/12 Initiated This had been initiated but in recent months has been delayed because of the COVID-19 pandemic. At the first step, training materials were developed, and TOT (training of trainers) workshops have been started but not done in all provinces. This is one of the priorities of the national response for 2022. History
This has already been addressed by applying different approaches. To have an updated map of the key population, different experts from every province have already been trained on "how to conduct risk-mapping". They are assigned to do the risk mapping regularly. Locating centers (just mobile centers) and outreach workers' activities will be organized by using these maps. In addition, MEHSHAD is planning to equip all the outreach workers with tablets. These tablets will have an application for organizing and supervising the outreach work.
[Added: 2021/06/26]
CDC 2020/12 Completed
Currently, there are 4 active centers in the cities with the highest concentration of High-Risk Behavioral Men Affected by HIV (HRBM). The relevant indicators have been included in the GF grant. The services will be expanded as per the 5th NSP. The size estimation exercise for HRMB is completed.
[Added: 2021/06/26]
CDC 2020/12 Completed
Outreach workers are peers of the key population and provide harm reduction services to key populations. All of them are working for CSOs or the private sector.
[Added: 2021/06/26]
CDC 2020/12 Completed
4. Recommendation:

Train and retrain Primary Health Care providers to: 

•  Minimize stigma and discrimination against PLHIV within general healthcare infrastructure.

•  Raise awareness among physicians and increase awareness of general population via reach of the general medical community.

•  Increase coverage and testing at earlier stages by providing more HIV testing at primary health centers, in addition to VCT Centers.

•  Increase access to treatment provision and reduce losses to follow up. 

Provide text messaging interventions through PHCs and Positive Clubs in order to increase linkage to care, from the onset of diagnosis, and further reduce losses to follow up and improve adherence.Consider use of digital platforms and interventions such as video-based information, messages and counselling where feasible like in high-volume clinics withsuboptimal HTS coverage. These platforms can be particularly appealing to adolescents, young people and key populations. This approach should be piloted in PHC clinics.

 

 

Management Response: [Added: 2021/06/26]

Acknowledged

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Different interventions have already been planned/implemented. 1. SIP (Supervising Implementation of the Programme) committee which is an intersectoral committee has planned a process evaluation step for testing, care and treatment procedures. Reviewing the process of service delivery is one of the components. This is supposed to be investigated during these process. Hence, health services providers are also being monitored about stigma and descrimination.  2. Development of an interactive programme to educate medical and health students on S&D using Gamification; Redxir: This project supported by UNAIDS targets medical and health students and aims to increase the knowledge of future health service providers. 3. In general testing and case finding has been affected by COVID-19 pandemic more than other aspects of HIV response programme. The national response is planning to strengthen case fining by different approaches including mobile centers, outreach workers and improving the quality of services. 4. Management of Loss to Follow up (LFTU) has been enhanced by using the MIS. The recent experience in the COVID-19 pandemic was very positive and the adherence rate was more than 90%. 5. There are plans for using digital platforms and applications in MOH and WO. The required infrastructure needs to be procured which is an ongoing process.
[Added: 2021/06/26] [Last Updated: 2021/12/14]
CDC 2021/12 Completed 1. This has been done and inter-sectoral committee has been formed, relevant forms and guidelines have been developed and process evaluation occurs regularly. The process has been completely explained in the national monitoring and evaluation plan for the 5th NSP. The action is completed. 2. UNAIDS worked with relevant authorities and had different meetings to address stigma and discrimination among medical and health students. The action is completed. 3. The national response operationalized the “HIV testing scale-up” plan. In addition, different approaches have been started to improve the access to and utilization of HIV testing services for example mobile centers and the recent 20-20-20 campaign. The action is completed. 4. This has been done and by using the MIS and follow-up mechanisms at service delivery points, even during the COVID-19 pandemic, the loss to follow up among linked PLHIV was around 10% which is very optimal. The action is completed 5. Currently, all the data is collated in the MIS system. This has helped the national system to have updated and accurate data about the project progress. All the main stakeholders review the data every three months. The action is completed. History
5. Recommendation:

The recent BBS and PSE data significantly differ from the previous studies and cannot be compared due to various sampling methods. At this moment triangulation is seen as a most valuable and feasible approach to validate the results of these studies, particularly HIV prevalence among PWID.

Management Response: [Added: 2021/06/26]

Accepted

Key Actions:

Key Action Responsible DueDate Status Comments Documents
This has already been discussed in detail in MOH and with other stakeholders. There is a technical committee that supervises the Population Size Estimation (PSE) and Biobehavioral Surveillance Studies (BSS). As per the applied methodology, appropriate weightings have been used before sharing the data to address this challenge and make them comparable. This is valid about all the recent studies conducted in 2019-20. 
[Added: 2021/06/26]
CDC 2020/12 Completed
6. Recommendation:

Despite the negative attempts in introducing the Unique Identification Code (UIC) system for KPs, Iran must consider and seek for the new evidence-based approaches to introduce a UIC system for KPs receiving the HIV prevention and harm reduction services. 

Management Response: [Added: 2021/06/26]

Accepted 

Key Actions:

Key Action Responsible DueDate Status Comments Documents
MEHSHAD will provide the outreach workers with tablets for data collection. This intervention will ensure creating UIC (Unique Identification Codes) onsite. Welfare Organization (WO) is also working on a similar procedure but has not been finalized yet. Furthermore, all the main implementing partner are connecting their data collection system in both harm reduction and care and treatment to a unified system. This provides an opportunity for creating a harmonized UIC system.  
[Added: 2021/06/26] [Last Updated: 2021/12/14]
CDC 2022/12 Initiated The process in MEHSHAD would be a pilot study and planned to be started in 2022. For WO the process has not been started and negotiations are ongoing about the infrastructures. The final decision about expansion will be made by the relevant partners after finalizing the pilot phase. History

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