Planning frameworks and targets

Efficacy evidence and the theoretical framework behind interventions are not the only considerations taken into account when public health bodies commission services. It is important, at this stage, to draw together from the available evidence a planning framework that:

• explains the implications of the available evidence, synthesising knowledge of the HIV and health risks that affect the population it covers and how interventions could modify these
• explains where evidence is lacking
• explains the theoretical basis behind behaviour changes and/or sets out which theory of social change and behaviour change will guide the planning process
• sets out a list of modifiable risks that HIV-prevention programmes can aim to influence
• sets out measurable targets that can show if interventions are effective in reducing these risks.

In the UK, the most influential planning-framework documents have been ones written by the organisations involved in prevention activities themselves. In the UK, CHAPS, a partnership of organisations involved in HIV prevention, issued its collaborative planning framework, Making it Count, initially in 1998 and more recently, for its fourth edition, in 2011.¹

In the fourth edition, the CHAPS partners set out a number of strategic goals, aims and objectives. The tripartite distinction between ‘goals’, ‘aims’ and ‘objectives’ is influenced by the theoretical framework underpinning Making it Count (MiC), which is an adaptation of the Information/Motivation/Behavioural Skills model (see ‘Theoretical Models of Behaviour Change’ below) that MiC called ‘benefits-driven change’. The key concept behind this idea is to concentrate on the ‘upside’ of protection, or on the belief that men who have sex with men (MSM) “can experience both an improvement in their sex lives and a reduction in the harm arising from their sex lives”.

The strategic aimis to increase the motivation and power that enable men to make precautionary choices. As a result of more men making such choices, the aim is for there to be:

• a reduction in the average length of time between HIV infection and diagnosis, and the proportion of MSM with HIV who are in fully suppressive HIV therapy
• a reduction in the average number of partners MSM have, especially casual partners, and the number of times they have unprotected sex with partners of unknown HIV status
• a reduction in both the relative amount of anal sex within sexual encounters and the amount that does not feature the use of condoms
• a reduction in unprotected sex with ejaculation generally, both oral and anal
• a reduction in poppers (nitrite) use during anal sex.

MiC then, using a social-cognitive theoretical framework, lists a number of ‘choices’ MSM may make in deciding whether to adopt behaviours that protect them from HIV, lists reasons why they may or may not make that choice, and lists interventions that could help them make health-affirming choices.

The strategic objectives include research into the attitudes of MSM towards HIV infection and reasons for avoiding it, and a commitment to increase gay men’s awareness of the consequences of infection and their motivation for making health-affirming choices. They also aim to address the information needs and skills gaps of MSM and, for the first time, to do research into, and work with, the trusted partners and valued friends of gay men to pass on HIV-protective positive attitudes, thus acknowledging the importance of peer-group reinforcement.

The task of a strategic-planning framework like MiC is, therefore, not to prescribe specific HIV interventions, or even to list them in a hierarchy of evidence, but to outline the reasoning that might go into deciding on a particular intervention and suggest benchmarks for measuring their effectiveness.

The National African HIV Prevention Programme (NAHIP) partnership has issued a similar strategic-planning framework document, The Knowledge, the Will and the Power, to meet the HIV-prevention needs of the other main at-risk population in the UK.² Its strategic behavioural aims are to:

• reduce the length of time between HIV infection and diagnosis
• reduce the number of HIV-serodiscordant unprotected-intercourse events by increasing the number of times that sex is deferred or declined, by choosing non-penetrative sex and by using male and female condoms
• reduce the number of condom-failure events by increasing correct use of condoms
• reduce ejaculation and the presence of other STIs when exposure occurs by increasing withdrawal and STI testing
• increase post-exposure prophylaxis in people sexually exposed to HIV.

As well as listing behavioural aims and the possible informational, motivational and skills needs of clients, it also discusses the structural and resource needs of agencies that will need to be met in order to achieve these aims.