The aim of this CA was to bring together researchers who are active in the assessment field, make an initial appraisal of the results of AIDS prevention efforts in various population groups in Europe and develop an assessment methodology. Five areas of study were selected for the CA:
- general population,
- males who have sexual relations with other males;
-intravenous drug users,
monitoring of sexually transmitted diseases (STD) to determine changes in behavior.
The main weapon in the struggle against acquired immune deficiency syndrome (AIDS) is prevention. Most European countries have set up national or regional prevention campaigns and programmes which are either aimed at target groups and use a community approach or involve measures of individual counselling. An assessment of these prevention programmes has been made from which problems have been defined and corrective measures are proposed.
Major disparities in prevention strategies have been noted which concern the timing of the first measures, the scale and continuity of the measures and the diversity of the target populations. In particular, migrant populations and ethnic minorities have not been given sufficient attention. There appears to be a slowing down of prevention efforts in certain countries. Most of the assessments performed have been focussed on specific programmes and diverse methods and tools are used for the assessments making international comparisons difficult. However, there is evidence that the prevention measures are effective. This evidence concerns primarily the population subgroups (ie homo bisexual men, intravenous drug users).
International studies aimed at the same target populations and using the same methods are required for making valid comparisons between countries and interpreting the results of disparate existing studies. Measures aimed at certain population groups need to be evaluated. Additional knowledge is required about the correlations between the epidemiology of sexual behaviour in a given population and the epidemiology of the different sexually transmitted diseases and the hypothesis that prevention efforts are slackening off should be studied since the consequences of any such slowdown could be serious in a few years time.
Primary prevention programs for HIV/AIDS have been implemented in most countries. Broadly speaking, three levels of intervention can be identified:
- Nation-wide campaigns directed at the population as a whole. Most of these are multiphase campaigns aimed at providing information about HIV transmission and protective behavior. They use the various mass media as channels and are directed mainly at modifying sexual behavior.
- Community-based interventions aimed at various target populations. These populations will have been selected because of their high risk of infection (gay men and prostitutes) and because their members are difficult to reach (intravenous drug users).
-Individual counselling, often supported by public funds or large non-governmental organizations, but also conducted by health professionals or community leaders in their day-to-day work.
In terms of human resources and financial support, major efforts have gone into developing and implementing these preventive programs. In most countries, however, less energy has perhaps been put into the evaluation of these campaigns. As far as evaluation methods are concerned, three main steps are involved:
- During the development of the intervention program, a short-term assessment is made to check on the feasibility of planned prevention programs and/or provide for rapid feed-back to the promoters of the program so that they can make any necessary adjustments to the messages delivered by the campaign. This kind of evaluation, which is sometimes designated a formative evaluation, is carried out to inform and to guide the most effective initiatives, which are, typically, undertaken by advertising agencies, and it is already a regular feature of most existing campaigns.
- The second type of evaluation is typically performed during the campaign and is focused mainly on the way the program is actually functioning. This process evaluation therefore tends to be concerned with questions regarding the types of preventive service actually delivered during the program (e.g. number of condoms or syringes distributed or sold) and the proportion of the population actually covered by the intervention.
The third type of evaluation is concerned with the impact of the intervention, and endeavours to answer the very basic question of whether the intervention makes any difference. This outcome evaluation is a major part of the evaluation process, but, since it necessarily presupposes the full development of the preventive program, it comes relatively late. Although HIV seroprevalence is the 'final' outcome indicator of any preventive program in this field, it is, as an indicator, both too general and too distant. Intermediate and surrogate outcome indicators have therefore been developed. These are aimed mainly at collecting information on knowledge, risk behavior and protective behavior.
Application of this evaluation framework and related methods to the field of HIV/AIDS prevention has revealed substantial problems of research design. However, experience in several countries shows that assessment of HIV/AIDS prevention can be carried out successfully if carefully planned and adequately funded.