Presentation by Sharon Weir on the Priorities for Local AIDS Control Efforts Method (PLACE).

1. The Priorities for Local AIDS Control Efforts Method
PLACE: An Overview
Sharon Weir
Carolina Population Center & Department of Epidemiology
University of North Carolina, Chapel Hill NC USA
Email: sharon weir @unc.edu

2. PLACE Counties: Past and Present
Kazakhstan
Karaganda
Almaty
Russia
Kyrgyzstan Saratov-Engels
Samara China
Uzbekistan Osh Liuzhou
St. Petersburg
Tashkent
Mexico
Chetumal
Ciudad Hidalgo Burkina Faso India
Banfora Bhubaneswar
DR Congo
Haiti Tenkodogo
Jamaica Carrefour Burundi Rwanda
All parishes
All 12 provinces
Guyana Uganda
Kenya
All 8 provinces
St. Lucia Ghana Tanzania
Castries All 10 regions Angola Magu
Malawi
Gros Islet Luanda Madagascar
Anse la Raye
Zimbabwe 7 cities
Zambia Hwange District
Mongu
Kapiri Mposhi
South Africa Lesotho
2 townships in Port Elizabeth Ficksburg, Maseru, Maputsoe, La
East London dybrand, Fouriesburg, Butha
1 Township in Cape Town Buthe

3. Global Recommendation
for PLACE
―Use innovative methods (PLACE,
key informant interviews) to
estimate the size and location of
relevant key populations by
country.‖
Key Population Working Group
Presentation to PEPFAR’s
Scientific Advisory Board
Washington, DC, October 2-3,
2012
Mead Over, Center for Global
Development

4. Problem Addressed by PLACE:
Preventing HIV transmission at the local
level
∆ The PLACE method addresses the need for
rapidly available information to strategically target
and monitor local AIDS prevention.

5. PLACE Argument
∆ The HIV pandemic is worldwide but transmission occurs in
local epidemics
∆ Prevention should focus in geographic areas where HIV
incidence is highest
∆ No two local HIV epidemics are the same. Each local HIV
epidemic reflects its unique underlying pattern of new and
concurrent sexual and needle sharing partnerships. National
and provincial data may hide local epidemics.
∆ In the absence of empiric data on the geographic distribution
of HIV incidence and number of new infections, national
stakeholders can thoughtfully interpret available information to
identify where HIV incidence is high.

6. PLACE Argument
∆ Interrupting HIV transmission requires focusing on people with
high rates of new sexual or needle sharing contacts.
∆ Effective prevention among these individuals must be multi-
level, using tailored ―combination prevention‖ to reduce their
partnership rates, increase testing, treatment, referral and
counseling for HIV/STI, and condom use.
∆ The PLACE method identifies venues and events where local
intervention programs can reach the most important sexual and
injecting drug use networks.
∆ Although outreach to these places can be expensive, outreach
is cost-effective if chains of transmission are broken.

7. Epidemiologic Model: R= c * B * D
∆ In a population where everyone initially is uninfected, the epidemic potential for the
population can be defined in terms of the average number of new infections ―R‖ that
would be sparked per each infected case over a specific time period after one new
infection was randomly seeded into the population.
∆ If each infected person infects > 1, the epidemic is increasing. If each infected person
infects < 1 person, the epidemic will gradually die. What determines if R is going to be
greater than one or less than one?
– C The rate of new sexual partnerships. The more new partners an infected
person has, the more people will be exposed to the infection. The more partners
an uninfected person has, the more likely he or she will be exposed to a partner
who is infected.
– B The probability of transmission during a contact between an infected and
uninfected person. Not using a condom, anal sex, high viral load (due to primary
infection for example) and untreated STI increase the probability of transmission.
– D How long a person is infectious. In HIV, infectiousness is considered lifelong.
∆ PLACE aims to identify those with the highest rates of ―c‖ and reduce their probability
of transmission per contact through STD treatment and condom use so that R is
reduced.

8. Theoretical Framework:
Proximate Determinants of HIV Transmission
Underlying Proximate Biological Health Demographic
determinants determinants determinants outcome outcome
New Partner C Rate of
Acquisition Contact of
Context Mixing patterns susceptible
Socio-economic Concurrency to infected HIV
Socio-cultural Abstinence persons incidence
Intervention Condom use Mortality
Programs Concurrent STI B Efficiency of
CT Risky sexual transmission
STD control practices per contact
Condom Chemotherapy STI
promotion incidence
Treatment D Duration of
infectivity
Boerma JT, Weir SS. Integrating demographic and epidemiologic approaches to research on
HIV/AIDS: the proximate determinants framework. Jour Inf Dis 2005;191(Suppl 1):S61-S67.

9. PLACE Overview
∆ Define PLACE strategy to meet country needs and adapt protocol
∆ Identify and select priority prevention areas where HIV incidence is high
∆ In each area, interview community informants to systematically list verifiable public
places where people with high rates of new sexual or needle sharing partnerships meet
new partners and could be reached with prevention services.
∆ Visit all reported places, assess each for on-site prevention program messages and
coverage, and map.
∆ Construct a sampling frame of places based on the data and select a representative
sample of people at the places during peak attendance hours.
∆ Interview these persons re demographics, risk behaviors, and exposure to
prevention. If possible, obtain biomarker samples.
∆ Use results to describe the place-based population and the characteristics of those
with highest partnership rates.
∆ Work with local stakeholders to identify actionable gaps in prevention and produce
coverage maps.

10. PLACE Protocol Overview: The 5 Steps
1. Establish a PLACE steering committee
2. In high incidence areas: Identify venues where people meet
new partners
3. Visit, characterize, map venues
4. Interview and test venue patrons & workers
5. Use results to improve programs

11. Step 1: Establish PLACE Steering Committee
∆ Convene a meeting of experts and review data and
contextual factors to identify areas of country where
HIV incidence is likely to be high
∆ Adapt protocol to country / Obtain IRB approval
– Define package of interventions to be assessed with coverage
indicators
– Identify key populations for any oversampling
– Identify indicators required
– Gain support of organizations providing prevention and linkage
to care
– Identify what testing will be done

12. Example: Selection of High Incidence
Areas in Madagascar
∆ The National AIDS Commission identified 7 areas based
primarily on contextual information:
– Antsiribe: 2nd largest city, transportation crossroads, tourism
– Tsiromandidy: Semi-urban, large cattle market
– Ilakaka: New sapphire mining area
– Morondava: Port city, tourism, hiv prevalence ^
– Fort Dauphin: Port city, mining industry, tourism
– Mananjary: Port City, tourism, cultural center
– Taolagnaro: Economic center, tourism

13. District HIV stakeholders
identified trading
centers, fishing posts, night
life hot spots, rapid growth
areas, and highway
stopovers at in this
Tanzania region.

14. Step 2: Within High Incidence Areas, Ask Community
Informants: Where do people meet new partners?
∆ Probe based on strata of interest for mixing
∆ Young women and older men
∆ Commercial sex workers
∆ Mobile and resident
∆ Military and civilian
∆ People who inject drugs
∆ Ask until no new venues are found
∆ Output: List of venues with number times reported

15. Township, South Africa Venues
∆ In the first PLACE
study, 297 community
informants identified 234
venues that interviewers
visited and characterized
within 3 weeks.
∆ We expected 50-60 venues

16. Step 3: Visit, characterize and map places
∆ Places include where people meet new sexual partners
and where people who inject drugs can be reached.
∆ Reported places are visited and mapped. An interview is
conducted with a knowledgeable person on-venue to
obtain characteristics of the place
∆ A place can be an establishment such as a bar, an
outdoor site such as a park or street, an event such as a
community festival, an internet site, or a phone number—
such as for escort services.
∆ Mapping can be done by hand, onto an aerial photo, or
using GPS

17. Characteristics of places / venues
Obtained from interviewing a knowledgeable person at the venue
To Gauge Prevention To describe patrons of venues
Program Coverage and
Potential at Venues ∆ Male:female ratio
∆ Type of venue ∆ Regular patrons
∆ Condom availability ∆ Where patrons reside
∆ Evidence of AIDS ∆ Whether patrons include
prevention commercial sex
∆ Busy times workers, gay, military, mobile,
∆ Maximum occupancy
youth, locals, unemployed, ID
∆ Number of staff U
∆ Venue stability ∆ Whether people meet new
partners at venue

18. Venue-based indicators from Step 3
Township, South Africa
– Venues where new partners are met 234
– % with condoms always available 5%
– % with condoms never available 80%
– % willing to have AIDS program 92%
– % with alcohol consumption at venue 88%
– % with over 100 patrons at once 10%
– % with student patrons 27%

19. Mapping Risk Venues using the PLACE method in
Luanda, Angola identified risk venues without prevention
outreach
Area with
clusters of
venues but no
prevention
program.
Weir et al, Results of the application of the PLACE approach to Rocha Pinto, Angola

21. Step 4: Interview and test people at
places
∆ Opinion: ∆ Socio-demographic &
– Do other people behavioral characteristics
come here to meet – Number of new and
new partners? total partners in the
past four weeks, year
∆ Behavior: – Condom use
– Have YOU ever met – Exposure to intervention
a new partner at this
venue?
– Have YOU ever ∆ Test for HIV & other STI
injected?

22. Interviews with patrons: Example of
Sampling Strategy
∆ Interviews at busy times at 40 venues
∆ An interval sampling strategy with probability of
selection proportional to size is used to select 40
venues where interviews with patrons will occur
∆ At each selected venue, approximately 24 male and
female patrons were systematically selected and
interviewed
∆ All workers at selected venues also interviewed
∆ Total of 960 patron interviews + worker interviews
NOTE: Actual sample size, sampling strategy developed
in consultation with Steering Committee and sampling
statisticians

23. Onsite Testing of Patrons and Workers:
The following tests have been used with PLACE:
∆ HIV (multiple tests used)
∆ Syphilis Testing (multiple tests used)
∆ Gonorrhea from urine sample (Gen-Probe)
∆ Chlamydia from urine sample (Gen-Probe)
∆ Trichomoniasis from urine sample (Gen-Probe)
∆ New in summer of 2013: Malaria, anemia, dengue fever

24. Percentage of Patrons Who Have Ever Met a New
Sexual Partner at the Venue: Findings from 6
PLACE Studies in Africa including 4 in South Africa
70
These findings
60 confirmed that
PLACE found
50 persons at risk.
40
30
20
10
0
CT Twp EL Twp PE Twp PE CBD Area in Banfora,
Kampala Burkina
Men Women Faso

25. Even though people reported meeting new
sex partners at these venues, few venues
reported commercial sex onsite People with many
35 sex partners often
do not self identify
30 as sex workers
25 and the venues do
not report
20 commercial sex
onsite.
15
10
5
0
CT Twp EL Twp PE Twp PE CBD Area in Banfora,
Kampala Burkina
4 Areas in South Africa Faso

26. Step 5: Use results to improve programs
∆ Maps can be shared with condom distributors to
ensure that condoms reach risk venue.
∆ Sub-group analysis can be used to provide
reportable M&E indicators for key populations
including sex workers, MSM, persons who inject
drugs, youth
∆ Coverage indicators for the package of
interventions for key populations can be
assessed and portrayed on maps

27. Additional options
∆ PLACE protocol can be adapted to estimate size of
risk populations.
∆ PLACE protocol can be adapted to provide
information for MOT analysis.
∆ PLACE can be used to promote MC
∆ PLACE protocol can be adapted to collect
biomarkers.

28. STEP 5
Inform interventions
Maps can show where
condoms are needed

29. Impact of PLACE in Jamaica after 10
years of implementation
∆ Improved Surveillance of MARPS
– Identified staff and patrons at venues as high risk via PLACE
– Showed the continued high prevalence of other STIs
– Improved the tracking of HIV & risk factors among MARPs
∆ Improved interventions
– Significantly increased access & outreach to MARPs
– Developed the scope and expertise of our outreach staff
– Spearheaded outreach HIV and STI testing/ youth
∆ Increased used of data to guide planning & interventions
– Helped us to refine our outreach interventions
– Convinced policy makers of need to retain field staff
– Showed the importance of social vulnerability
– Improved monitoring & evaluation
∆ Helped to reduce HIV prevalence among sex workers from 9% to 4.5%

30. The PLACE method Sex Work At Venues
identifies the gaps in HIV
prevention in
Iringa, Tanzania?
44% of villages and neighborhoods did NOT
have recognizable presence of HIV prevention
Most male patrons
were buying sex
Some male
patrons buying
sex
Percentage of Villages and Mtaa With
Recognizable Prevention Outreach by District No male patrons
Study included representative sample of Mtaa and villages buying sex

31. PLACE can help…
∆ Provide understanding of the sexual networks and
mixing patterns in a community
∆ Identify intervention venues
∆ Provide indicators for monitoring prevention
∆ Provide estimates of HIV/ STI prevalence among
workers and patrons of venues
∆ Sub-group analysis can provide estimates for sex
workers, MSM other groups

32. How does PLACE differ from
Demographic and Health Surveys (DHS)?
∆ DHS is a very large and expensive household survey that obtains
information on a range of health topics including HIV.
– PLACE focuses on HIV and is implemented within priority prevention
areas at a fraction of the cost of the DHS.
∆ DHS provides national-level health indicators using population-based data.
It does not provide local estimates.
– PLACE data are not representative of the general population.
Instead, PLACE monitors the local HIV response in key target areas
among persons most likely to acquire and transmit HIV.
∆ Since it is a household survey, DHS may miss mobile populations, under-
represent young men, and be conducted in a setting where people are less
likely to report extra-marital partnerships.
– PLACE interviews persons who are socializing at venues identified as
places where people meet new sexual partners and thus often includes
a large number of sexually active youth and mobile populations. PLACE
can miss persons who do not visit public venues.

33. How does PLACE differ from Targeted
Risk Group Surveys?
∆ Targeted risk-group surveys require operational definitions of target groups
to develop the sampling frame.
– PLACE avoids having to define ―men who have sex with men‖ or ―sex
workers‖ during data collection because it samples from all venues
where any persons meet sexual partners. Indicators for particular
groups can be obtained during the analysis phase.
∆ Results from targeted risk group surveys are usually specific to the defined
target group.
– PLACE data allows generalization to the population that visits venues
where people meet new sexual partners and allows examination of the
overlap between groups.
∆ Targeted surveys often aim to get national estimates for key populations
and indicators for national level reporting.
– PLACE results serve local programs immediately by providing maps of
program coverage and identify priority venues where AIDS prevention
programs are needed.

34. How does PLACE differ from respondent driven
sampling?
∆ Respondent driven sampling often is a strategy to sample sex workers or
MSM and uses peer recruitment to identify a sample of people meeting the
definition of the population.
– PLACE does not recruit individuals with particular behaviors. It identifies
risk venues and characterizes those persons at the venue regardless of
whether they meet the study definition of sex worker or MSM.
Consequently, RDS is often more efficient at getting a large sample of a
specific type of person. PLACE provides a broader picture of persons at
risk.
– RDS usually requires participants to go to a study office for interview.
PLACE does not require that a participant go anywhere.
– RDS can reach people who are not at risk venues. PLACE can reach
people at risk venues who will not go to an RDS study office.
– See also
• Weir SS, Merli MG, et al. Comparison of Venue-based and respondent driven sampling of sex
workers, in press, Sexually Transmitted Infection 2012 Dec 88 (Suppl 2), i95-i101

35. How does PLACE differ from respondent driven
sampling and time-location sampling?
∆ PLACE is a type of TLS.
∆ Usually TLS is implemented among specific types of venues (such as MSM
venues or sex worker venues.) PLACE is implemented at a wide variety of
places reported as places where people meet new partners or where IDU
can be reached.
∆ TLS often screens persons for participation and limits to people meeting
certain criteria such as those who report sex work. PLACE casts a wide net
and has few exclusion criteria.
∆ TLS samples from peak and non-peak times at a venue. PLACE samples
from venues at peak times.
∆ Often TLS is implemented as part of surveillance and to obtain indicators.
PLACE obtains indicators but has a focus on local use of data and
development of action plans and use of the maps for outreach.

36. The research presented here has been supported by the
President’s Emergency Plan for AIDS Relief (PEPFAR)
through the United States Agency for International
Development (USAID) under the terms of MEASURE
Evaluation cooperative agreement GHA-A-00-08-00003-
00. Views expressed are not necessarily those of
PEPFAR, USAID or the United States government.
MEASURE Evaluation is implemented by the Carolina
Population Center at the University of North Carolina at
Chapel Hill in partnership with Futures Group, ICF
International, John Snow, Inc., Management Sciences for
Health, and Tulane University.