Central America (2013), Assessment of Quality of Service Provision to Most-at-Risk Populations by Private Sector Providers in Central America

The HIV/AIDS epidemic in Central America remains concentrated among MARPs, primarily in and around networks of men who have sex with men (MSM). Throughout the region, the HIV prevalence among MSM is approximately 10% (UNAIDS 2009). Sexual transmission accounts for the vast majority of HIV infections in the region. Other populations with a notable burden of infection include transgender populations (Trans), male and female sex workers (SW) and their clients, and certain mobile and ethnic groups (e.g., migrants, uniformed services, individuals of Afro-Caribbean descent). Social stigma, however, has kept many of these epidemics hidden and unacknowledged (UNAIDS 2010). In 2010, PSI/PASMO, together with partners IPPF/WHR, Cicatelli Associates and Milk'an Cookies, was awarded a grant from USAID to implement the HIV Combination Prevention Program for MARPs in Central America and Mexico (2010-15) beginning on October 1, 2010. The program uses a combination prevention approach, which comprises a mixture of behavioral, structural and biomedical interventions and is based on scientifically-derived evidence and ownership of communities. The program's approach has been developed with guidance from the U.S. Government's Partnership Framewo rk Document to Support Implementation of the Central American Regional HIV/AIDS Response (March 2010) and embodies several key principles from that document, including using evidence-based approaches to decision making, prioritizing interventions targeting MARPs, involving MARPs more actively in programming, considering gender, increasing local capacity to mount an effective response, increase coordination among stakeholders and implementing agencies, and sharing best practices widely and actively (PSI/PASMO). Over the period 2010-15, the program seeks to achieve the following results: Result 1: Reduced prevalence of high-risk behaviors among MARPs and PLHIV. Result 2: Increased effective interventions implemented to decrease hostility in social environments that foment and tolerate homophobia and stigma and discrimination attitudes related to sexual orientation, occupation or status. Result 3: Increased access by MARPs to a minimum package of essential prevention and health services , that includes but is not limited to access to condoms, VCT services and STI diagnosis and treatment, emphasizing in the involvement of private health providers. Result 4: Strategic information obtained through the research and monitoring process, being used to design or modify prevention activities. As part of Results 2 and 3, the Program aims not only to increase access by MARPs to essential health services but also to ensure that these populations receive high-quality care, free of stigma and discrimination, beginning with private-sector facilities participating in the Program. In program monitoring and evaluation, including in the area of HIV/STI/AIDS health service provision, mystery clients have been used to identify and monitor areas for improvement (Center for Population Studies, Zimbabwe 2003; Family Health International 2007; Sarma and Oliveras 2011). Mystery clients provide a way to gather information about the service delivery process while minimizing bias that could result from potential modification of provider behavior when direct observation of patient-provider interaction is used (Pathfinder International 2006). In addition, this method allows program staff to capture the perspective and voice of the client, which is an important component of ensuring quality of care, particularly when serving vulnerable and hidden populations, whose perspectives are often unsolicited or unacknowledged. As such, beginning in the second year of the HIV Combination Prevention Program (2011-12), the Program team proposes to evaluate the quality of service provision at participating facilities on an annual basis employing mystery clients. Participating facilities include i) clinics of IPPF/WHR Member Associations in six countries in Central America (Belize, Costa Rica, El Salvador, Guatemala, Nicaragua and Panama) and ii) other private-sector facilities that offer VCT services (e.g., laboratories). The annual assessment will be used to identify areas for improvement in service provision to MARPs at each participating facility and the results will be used as a basis for discussion with and to make recommendations to facility managers and providers regarding potential changes.