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.

中美洲的艾滋病（HIV/AIDS）疫情仍集中在高风险人群（Most At-Risk Populations, MARPs）中，主要集中在男男性行为者（Men Who Have Sex with Men, MSM）群体及其周边网络内。整个区域内，男男性行为者的HIV感染率约为10%（联合国艾滋病规划署，2009年）。性传播是该地区绝大多数HIV感染的途径。其他感染负担较重的人群包括跨性别群体（Transgender, Trans）、男女性工作者（Sex Workers, SW）及其客户，以及部分流动群体和族群（如移民、制服服务人员、非裔加勒比裔个体）。然而，社会耻辱感使得许多此类疫情被掩盖且未被正视（联合国艾滋病规划署，2010年）。
2010年，PSI/PASMO与合作伙伴IPPF/WHR、Cicatelli Associates及Milk'an Cookies一同获得美国国际开发署（USAID）的拨款，于2010年10月1日启动针对中美洲及墨西哥高风险人群（Most At-Risk Populations, MARPs）的HIV综合预防项目（2010-2015年）。该项目采用综合预防策略，融合行为、结构与生物医学干预手段，基于科学实证及社区主体性开展工作。该项目的策略依据美国政府《支持落实中美洲地区艾滋病应对工作的伙伴关系框架文件》（2010年3月）制定，吸纳了该文件中的多项核心原则，包括采用循证决策方法、优先开展针对高风险人群的干预、推动高风险人群更积极地参与项目规划、纳入性别视角、提升当地开展有效应对的能力、加强利益相关方与执行机构间的协调，以及广泛主动地分享最佳实践（PSI/PASMO）。
2010-2015年期间，该项目力求达成以下结果：
结果1：降低高风险人群及艾滋病毒感染者（People Living with HIV, PLHIV）的高危行为发生率。
结果2：增加有效干预措施的实施，以改善助长并容忍基于性取向、职业或身份的恐同行为、耻辱感及歧视态度的社会环境，减少其中的敌意氛围。
结果3：提升高风险人群获取基本预防与医疗服务包的机会，该服务包包括但不限于安全套获取、艾滋病病毒咨询与检测（Voluntary Counseling and Testing, VCT）服务以及性传播感染（Sexually Transmitted Infection, STI）的诊断与治疗，并强调纳入私立医疗服务提供者的参与。
结果4：将通过研究与监测流程获取的战略信息用于设计或优化预防活动。
作为结果2与结果3的组成部分，该项目不仅旨在提升高风险人群获取基本医疗服务的机会，还确保这些人群能够获得无耻辱感与歧视的高质量医疗服务，项目首先从参与其中的私立医疗机构入手。
在项目监测与评估环节，包括HIV/性传播感染/艾滋病医疗服务提供领域，项目已采用神秘顾客法识别并监测待改进的领域（津巴布韦人口研究中心，2003年；国际家庭健康组织，2007年；Sarma与Oliveras，2011年）。
神秘顾客法能够在收集服务提供流程相关信息的同时，最小化直接观察医患互动时可能出现的、因服务提供者行为改变而产生的偏倚（国际探路者组织，2006年）。
此外，该方法能够帮助项目人员收集服务对象的视角与心声，这是保障医疗服务质量的重要一环，尤其在服务脆弱且隐蔽的人群时，这类人群的视角往往未被主动征询或正视。
因此，在HIV综合预防项目的第二年（2011-2012年）起，项目团队计划每年采用神秘顾客法对参与机构的服务提供质量开展评估。
参与机构包括：①中美洲六国（伯利兹、哥斯达黎加、萨尔瓦多、危地马拉、尼加拉瓜及巴拿马）的IPPF/WHR成员协会诊所；②其他提供艾滋病病毒咨询与检测服务的私立机构（如实验室）。
年度评估将用于识别各参与机构针对高风险人群的服务提供环节中待改进的领域，评估结果将作为与机构管理者及服务提供者开展讨论的依据，并针对潜在改进方向提出建议。