AIDSTAR-One Case Study: Avahan-India HIV/AIDS Initiative
AIDSTAR-One Case Study: Avahan-India HIV/AIDS Initiative
AIDSTAR-One Case Study: Avahan-India HIV/AIDS Initiative
March 2011
n an old schoolhouse on the outskirts of Chennai, the scene is hectic at midday. The rehabbed building is now home to a local HIV prevention program, with a busy sexually transmitted infection clinic, drop-in counseling facilities, and a safe house for victims of violence. At one large table sits a group of peer educators, all womenmost of them poor and illiterate reviewing data they have gathered in the neighborhoods where they conduct HIV prevention activities for other sex workers. Dressed in bright saris of every color, their self-confidence and pride in their achievements could not be more evident as they discuss their work. These women, like thousands of other peer educators who work with the Avahan-India AIDS Initiative, play a critical role on the front lines of Indias epidemic. Avahan means a call to action in Sanskrit. It is a fitting name for one of the largest and most promising HIV prevention programs in the world. Launched in 2003 with funding from the Bill & Melinda Gates Foundation, this major HIV prevention program stretches over six of the Indian states most affected by HIV, as well as key trucking routes. Now in a second phase, Avahan1 works in partnership with the Indian government, which will take over most of the programs activities by 2014. Over its short life, Avahan has become a global model for achieving multiple goals that many prevention programs find challenging. First, it has successfully built a comprehensive prevention program that combines the most effective responses to the multiple and complex needs of mostat-risk populations (MARPs). Second, its activist peer educatorswhose responsibilities include ongoing data collection and analysis and some
By Bill Rau
AIDSTAR-One
John Snow, Inc. 1616 North Ft. Myer Drive, 11th Floor Arlington, VA 22209 USA Tel.: +1 703-528-7474 Fax: +1 703-528-7480 www.aidstar-one.com
Throughout this case study, Avahan refers to the program as a whole, including its numerous partners.
This publication was produced by the AIDS Support and Technical Assistance Resources (AIDSTAR-One) Project, Sector 1, Task Order 1. USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008.
Disclaimer: The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Avahan has achieved nearly unprecedented levels of scale-up that have made a real impact on the epidemic in the regions where it works.
monthly prevention services to more than 220,000 female sex workers, 80,000 high-risk MSM and transgendered people, 18,000 IDUs, and 5 million men working in the trucking industry. In addition to Indias National AIDS Control Organization (NACO) and the state government AIDS Control Societies, Avahan partners with nine lead implementing grantees, 134 local nongovernmental organizations (NGOs), and hundreds of formal and informal community-based groups (CBGs), as well as 5,700 peer educators and outreach workers. Avahans current interventions reflect the key elements of combination HIV prevention programming for MARPs: Peer-led outreach to promote behavior change Clinical services to treat STIs Condom social marketing and distribution of free condoms Distribution of clean needles and syringes Support for community mobilization Advocacy to reduce structural barriers to safer sexual practices. These elements combine standard components of a minimum package of services for MARPs with community mobilization and efforts to address structural barriers to risk reduction. To tie these components together, Avahan has strong management and capacity-building structures at many levels throughout its operations. For example, Avahans peer educators not only carry out extensive outreach but
The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics
assistant. The STI clinics also provide referrals for tuberculosis (TB) diagnosis and HIV testing, care, and treatment. Avahans condom program includes both social marketing and distribution of free condoms by peer educators and at STI clinics. In conjunction with the government, Avahan has intensified the advertising and distribution of socially marketed condoms in more than 100 sexual hot spots along trucking routes. Currently, free and Avahan-supported commercial outlets distribute nearly 20 million condoms monthly. Condoms are also available from many other outlets across India. Altering the structures of risk: One of the key findings from the mapping exercises was that in addition to harassment, female sex workers and MSM experience police and gang violence, which can discourage them from using condoms or changing risky behaviors. For example, police often suspect women found with condoms of being sex workers; the women may be forced to pay a bribe to avoid arrest, or coerced into providing a sexual favor. In health care settings, sex workers and MSM face stigma and discrimination from staff, who often deny them services. Fearful of such treatment, many simply forgo accessing basic health care.
The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics
Avahans management relies on the large amount of output data the program generates at all levels, starting with contacts made by peer educators.
Monitoring and evaluation: Avahans management relies on the large amount of output data the program generates at all levels, starting with contacts made by peer educators. Peer educators keep daily records of their contacts and their interactions with their peers, identifying highly vulnerable peers for extra attention. These records are consolidated into weekly summaries of contacts. Implementing NGOs work with the peer educators to analyze these data and plan outreach to ensure maximum coverage and clinic attendance. They then forward output data to the lead agencies in each state to help monitor progress and identify areas for improvement or added attention. Avahan also monitors outcomes. STI rates at clinics are followed closely, as is condom distribution at various sources. Avahan funded two rounds (200607 and 200910) of an Integrated Behavior and Biological Assessment to collect behavior and biological data from a representative sample of the targeted at-risk populations in selected districts. Sample data elements included knowledge, attitudes, and practices related to safer sex; and HIV, STI, and/or hepatitis infection. NACO generates annual estimates of Indias population living withHIV to focus attention on districts with emerging epidemics, and conducts biannual behavioral surveys. Along with its own data, Avahan uses data from NACOs behavior surveys and estimates of people living with HIV to further monitor its own progress and to look for gaps in its districts.
Recently, peer educators were trained to identify basic TB symptoms and to escort symptomatic peers to clinics for diagnosis, in some cases arranging for TB treatment monitoring. Some of the CBOs that have sprung from the work of the peer educators also help people living with HIV register for government treatment services. Avahans approach to peer education is intensive, both for the peer educators and the supervisory outreach workers of the implementing NGOs. Extensive planning helped establish a viable system of identifying and selecting peer educators, providing initial and follow-up training, and sustaining their interests and skills with close supervision. Drop-in centers offer a supportive place for peer educators to meet, discuss, plan, and offer services to peers. As peer educators began to expand their work and organize themselves, Avahan found it needed further planning to manage and incorporate those community groups. Crisis intervention is a high-profile service of the peer educator system. A peer-led and NGOsupported rapid response network with access to
Peer educators have multiple responsibilities that take advantage of their knowledge and skills.
The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics
Program Results
In Avahans first phase, the project was able to quickly go to scale through its massive peer education activities, which resulted in uptake in STI services and condom distribution and a decrease in STI rates, including HIV. In addition to the service delivery outcomes, the program contributed to greater social cohesion and community ownership of HIV prevention programs. Finally, the donor investments in Avahan helped to spur increased
The dedication of peer educators to their work is one reason Avahan was able to quickly scale-up its program across 82 districts in six states.
The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics
One unexpected but welcome outcome has been a blossoming of community solidarity between female sex workers and MSM.
themselves are assuming ever greater control of the process and outcomes of community mobilization. In many situations where individuals have united around common interests, both informal and formal organizations have appeared. Two aspects of the growth and influence of constituent control and ownership within Avahan are noteworthy. First, the peer educators and their communities are at the forefront of HIV prevention at the local levels, at a scale never before seen in HIV prevention work. Second, the program management has, for the most part, not felt threatened by the growth of community activism and ownership. With the exception of some NGO staff concerned about their jobs, the management at all levels does not worry that community groups are taking over their roles. In fact, the state implementing agencies actively encourage the consolidation of community groups into registered CBOs, with elected officers and committees. In Tamil Nadu, the CBOs have been linked into a registered federation. Some CBOs are also linking with established CBOs and NGOs that deal with microfinance and other areas of advocacy and rights. Cost and affordability: The Bill & Melinda Gates Foundations investment of U.S.$258 million over the first 5 years of the 10-year program is substantial. About $215 million of that amount was actually spent (an average of $48 million per year). As of mid-2009, the Foundation had committed $330 million to Avahan. By comparison, Indias initial budget for NACP-III, to run from 2007 to
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When structural interventions and community mobilization are added to a mix of prevention services, the synergy achieved with combination HIV prevention is evident.
Working with volunteers: Peer educators join Avahan as volunteers. However, Avahan provides a monthly stipend equivalent of between $10 and $20 each. The stipend is an important supplement for women and men who live very marginally; many are in debt. However, when they describe their motivation for becoming peer educators, they talk not about the extra income but about the sense of accomplishment and self-fulfillment they feel. Removing structural obstacles to HIV prevention: To counter local-level harassment by police of female sex workers and MSM, Avahan launched sensitivity training, peer advocacy, and rapid responses to individual cases of harassment or violence. As relations between the police and MARPs improve, it becomes easier for targeted populations to practice safer sex and to seek care. As confidence has grown within CBGs, other structural impediments have been addressed: peer community members have now acquired ration cards, access to public health facilities, and, for some, health insuranceall services long denied to marginalized groups. Authentic community ownership: The active involvement of target audiences has been critical in building community involvement and ownership throughout Avahan. Not all community groups organized under the Avahan umbrella will survive, but many will, and they will become more powerful in representing their constituents in the process. Stakeholder learning from and with Avahan: Avahan adds value to the governments HIV prevention program as it broadens and
Challenges
There is wide acknowledgment by the Indian National AIDS Control Organization, SACS, Avahans state partners, and most participants that the program has generally worked well. However, there are several areas where program weaknesses have been encountered, and these provide lessons for other large, focused HIV prevention programs. Sustainability: The Avahan program has several more years to run. In 2009, Avahan began to hand over district-level program activities to SACS; such transfers will be completed in 2014. The financial sustainability of the Avahan approach is assured by the governments very substantial budget for HIV and AIDS work and its commitment to communitydriven programming. Yet not all are convinced that the Government of Indias resources can maintain the Avahan program at current operating costs. In addition, Avahans partners are concerned that the support given for CBGs will wane as the government takes over programs. Partners also fear potential
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The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics
seeking a greater role in running their own affairs. But it also means that the strong coordination features of the Avahan program will begin to loosen to accommodate diverse local interests and methods. Replication: Avahans combination HIV prevention approach appears to be very replicable in countries with concentrated HIV epidemics and likely replicable where there are mixed epidemics. Replication will require a good, but not necessarily perfect, set of epidemiological and behavioral data, good planning, and a sound management structure at all levels. Any replication of the Avahan model should reflect local realities and organizational experiences. The financial and human resources needed to build such a program are, in most cases, within the reach of HIV and AIDS budgets in many countriesif donors, governments, and implementing agencies can agree to work on a common program. Even countries that lack an adequate budget or consensus on focusing resources on the main drivers of the epidemic can learn from the Avahan model and replicate some of its elements. Three of those elements stand out. First, use available data to identify the main drivers, most-at-risk, or underserved groups in the epidemic and put adequate resources toward reaching them. Second, focus on building and sustaining community buy-in and an active role in program development. Third, address the structural barriers that make it difficult for individuals to practice risk reduction. Monitoring qualitative and emotive aspects of the program: Although Avahan has systems to regularly collect and use large amounts of data, it has been slow to develop methods for monitoring the effects of advocacy efforts at all levels, measuring levels of violence against MSM and female sex workers (other than police violence), quantifying expanded access to non-program services (such as food ration cards) for high-risk people, and capturing information about community mobilization. The programs initial emphasis on
RESOURCES
Avahan has produced several publications that describe aspects of the program. These can be found on the programs website: www.gatesfoundation .org/avahan/Pages/overview.aspx. Avahans state partners also maintain websites that provide information on their involvement. For Tamil Nadu, see www.taivhs.org/ For Andhra Pradesh, see http://www.hlfppt.org/ andhrapradesh.htm For more information on the APAC project, please visit www.apacvhs.com. In addition, the following publications were useful in preparing this case study: Avahan. 2008. Managing HIV Prevention from the Ground Up: Peer Led Outreach at Scale in India. New Delhi: Avahan. Cornish, Flora, and Catherine Campbell. 2009. The Social Conditions for Successful Peer Education: A Comparison of Two HIV Prevention Programs Run by Sex Workers in India and South Africa. American Journal of Community Psychology 44(1-2):12335. Jana, S., et al. 2004. The Sonagachi Project: a sustainable community intervention program. AIDS Education and Prevention 16:40514. Kenya National AIDS Control Council. 2009. Kenya HIV Prevention Response and Modes of Transmission Analysis: Final Report. Nairobi: NACO.
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The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics
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