Belize (2012): Assessment of Quality of Service Provision to Most-at-Risk Population by Private Sector Providers in Central America.

Abstract In Central America, HIV/AIDS is remains concentrated among most-at-risk populations (MARPs), primarily in and around networks of men who have sex with men (MSM), transgender populations, male and female sex workers (SW), and certain mobile and ethnic groups (e.g., migrants, uniformed services, individuals of Afro-Caribbean descent). A USAID-funded HIV Combination Prevention Program for MARPs in Central America and Mexico is being implemented by PSI/PASMO, together with partners IPPF/WHR, Cicatelli Associates and Milk and Cookies in the period 2010-15, which aims to i) reduce prevalence of high-risk behaviors among MARPs and people living with HIV, ii) decrease homophobia, stigma and discrimination related to sexual orientation, occupation or HIV status, iii) increase access by MARPs to a minimum package of essential health services, and iv) use strategic information to design or modify prevention activities. As part of the Program, we plan to assess the quality of service provision to MARPs at health facilities participating in the program with the goal of ensuring that these populations receive high-quality care, free of stigma and discrimination. Our descriptive study will use mystery clients to collect data. Our findings will provide guidance to participating facilities on improving services to MARPs. Introduction and Rationale 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 prev alence 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 and 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 œPartnership Framework 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. Objectives The specific objectives of this evaluation are to: 1. Assess the quality of service provision to MARPs by private-sector health-service providers participating in the HIV Combination Prevention Program for MARPs funded by USAID in Central America (Belize, Costa Rica, El Salvador, Guatemala, Nicaragua and Panama). 2. Compare the quality of services provided to MARPs to the quality of services provided to the general population by private-sector health-service providers participating in the Program in the countries of interest. 3. Identify areas for improvement in service provision to MARPs at participating facilities and provide recommendations. Study Design This is a descriptive, mystery client study that will be conducted annually over the course...摘要：在中美洲地区，艾滋病（HIV/AIDS）的传播仍集中于高风险人群（most-at-risk populations, MARPs），主要分布在男男性行为者（men who have sex with men, MSM）社群及其周边，此外还包括跨性别人群、男女性工作者（sex workers, SW）以及部分流动群体与少数族裔（如移民、军警人员、非裔加勒比裔人群）。由美国国际开发署（USAID）资助的针对中美洲及墨西哥高风险人群的艾滋病综合预防项目，由PSI/PASMO联合合作伙伴IPPF/WHR、Cicatelli Associates及Milk and Cookies于2010-2015年期间实施，项目目标包括：1）降低高风险人群及艾滋病病毒感染者的高危行为流行率；2）减少针对性取向、职业或艾滋病感染状况的恐同情绪、污名化与歧视行为；3）提高高风险人群获取基本卫生服务包的可及性；4）利用战略信息设计或优化预防活动。作为本项目的组成部分，我们计划对参与项目的医疗卫生机构为高风险人群提供的服务质量进行评估，旨在确保该人群能够获得无污名化、无歧视的高质量医疗服务。本描述性研究将采用神秘顾客法收集数据，研究结果将为参与项目的医疗机构优化针对高风险人群的服务提供参考依据。 引言与研究依据：中美洲地区的艾滋病疫情仍集中于高风险人群，主要以男男性行为者社群为核心。联合国艾滋病规划署（UNAIDS）2009年数据显示，该地区男男性行为者的艾滋病病毒感染率约为10%。性传播是该地区绝大多数艾滋病病毒感染的途径。其他感染负担较重的人群还包括跨性别人群（transgender, Trans）、男女性工作者及其客户，以及部分流动群体与少数族裔（如移民、军警人员、非裔加勒比裔人群）。然而，社会污名化使得这类艾滋病传播疫情大多处于隐蔽且未被正视的状态（联合国艾滋病规划署，2010年）。2010年，PSI/PASMO联合合作伙伴IPPF/WHR、Cicatelli Associates及Milk and Cookies获得了美国国际开发署（USAID）的资助，于2010年10月1日启动为期2010-2015年的中美洲及墨西哥高风险人群艾滋病综合预防项目。本项目采用综合预防策略，整合行为干预、结构干预与生物医学干预手段，其设计基于科学实证依据与社区主体地位。本项目的方案制定参考了美国政府《支持落实中美洲区域艾滋病应对工作的伙伴关系框架文件（2010年3月）》的指导，并体现了该文件中的多项核心原则，包括采用循证决策方法、优先针对高风险人群开展干预、推动高风险人群更积极地参与项目规划、纳入性别视角、提升本地有效应对能力、加强利益相关方与执行机构间的协调、广泛且主动地分享最佳实践（PSI/PASMO）。在2010-2015年实施期间，本项目旨在达成以下目标：目标1：降低高风险人群及艾滋病病毒感染者的高危行为流行率。目标2：加强有效干预措施的实施，以改善助长并容忍针对性取向、职业或感染状况的恐同情绪、污名化与歧视态度的社会环境。目标3：提高高风险人群获取基本预防与卫生服务包的可及性，服务内容包括但不限于安全套获取、艾滋病病毒自愿咨询检测（VCT）以及性传播感染的诊断与治疗，同时强调动员私立医疗卫生机构参与其中。目标4：通过研究与监测过程获取战略信息，用于设计或优化预防活动。作为目标2与目标3的组成部分，本项目不仅旨在提高高风险人群获取基本卫生服务的可及性，还致力于确保该人群能够获得无污名化、无歧视的高质量医疗服务，本次评估将从参与项目的私立医疗机构入手。 评估目标：本评估的具体目标如下：1. 评估参与美国国际开发署（USAID）资助的中美洲（伯利兹、哥斯达黎加、萨尔瓦多、危地马拉、尼加拉瓜及巴拿马）高风险人群艾滋病综合预防项目的私立医疗卫生服务机构为高风险人群提供的服务质量。2. 对比参与本项目的私立医疗卫生服务机构为高风险人群提供的服务质量与为普通人群提供的服务质量。3. 识别参与机构在为高风险人群提供服务过程中有待改进的领域，并提出针对性改进建议。 研究设计：本研究为描述性研究，将采用神秘顾客法开展，计划在项目周期内每年进行一次……