Avahan - The India AIDS Initiative: The Business of HIV Prevention at Scale

This 40-page publication explores the strategies undergirding the 10-year HIV prevention programme Avahan, which the Bill and Melinda Gates Foundation launched in 2003 (under the title "the India AIDS Initiative") in an effort to curtail the spread of HIV in India. The publication describes the Avahan initiative and provides an overview of the evolution of the Avahan strategy and its implementation; a description of the key elements of the programme and how Avahan achieved its first goal of rapidly rolling out services to a large and hard-to-reach population across a large geographic area; how Avahan monitors and evaluates the initiative; the preliminary results and learnings; and its plans for the future.

As outlined here, the following are key strategic choices made in the initial design and subsequent evolution of Avahan:

1. Focusing prevention efforts on high-risk groups: female sex workers, high-risk men who have sex with men, transgenders known as hijra, injecting drug users, and clients of sex workers;
2. Concentrating efforts on the 6 states with the majority of HIV cases (83%) at the time (2002): Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra, Nagaland, and Manipur;
3. Basing the initiative on global best practices in HIV prevention;
4. Scaling services across intervention geographies rapidly to contain the spread of the epidemic;
5. Creating an in-country office to facilitate rapid scale-up;
6. Investing in knowledge-building, evaluation, and dissemination; and
7. Articulating an explicit goal to transfer the funding and management of the programme to "natural owners", including government and communities.

The Avahan programme elements for high-risk groups incorporate a variety of communication strategies, including:

1. Peer-led outreach education - Peer educators identify those among their social network who are at greatest risk and provide support and information that are designed to help improve their ability to negotiate condom use and their attendance at sexually transmitted infection (STI) clinics and self-help programmes. These educators gather detailed, multi-faceted information from "hotspots" (high-risk venues where commercial sex is solicited) to understand the nature of intervention needed. This is followed by systematic, ongoing outreach to the high-risk groups in these venues. Peer educators manage and monitor 25-50 peer members in their assigned group and work about 4 hours per day. Their activities include sharing prevention information with their colleagues, distributing condoms (and, as appropriate, needles and syringes), making referrals to clinics and other services, and gathering information on each individual's risk profile, including their vulnerability to violence and their ability to access services. Data are recorded with low-literacy tools. Their micro-planning records are discussed during weekly meetings with peer supervisors or field officers who monitor performance, provide additional training, and help the peer educators prioritise their workloads. The purpose of this strategy is to empower members of the communities and prepare the ground for the community to eventually take over management of components of the programme itself. It is also designed to foster leadership among individuals who can go on to advocate for the wider rights of these groups.
2. Programme-supported clinical services to treat STIs other than HIV through a combination of presumptive treatment, syndromic management, and regular screening. Avahan's peer educators help drive attendance at the clinics, encourage sex workers and others to promote utilisation, reinforce condom use, and facilitate follow-up and partner treatment. Avahan partners in the states and grassroots non-governmental organisations (NGOs) adapt service delivery approaches to meet the needs of the high-risk communities in their areas.
3. Promoting and distributing free condoms for sex workers and needle and syringe exchange for injecting drug users - NGOs and their peer educators estimate the number of condoms needed by high-risk groups based on the number of commercial partners. These condoms are in turn distributed by peer educators within their network.
4. Facilitating community mobilisation and capacity for community ownership of the programme - This process began with the recruitment of community guides to map the high-risk populations in each of the Avahan districts. In addition to involving interested and skilled individuals to serve as peer educators (as described above), the programme made a concerted effort to recruit people from the high-risk communities to work in clinics, run drop-in centres, and oversee outreach. Organisers believe that, in addition to strengthening the skills and confidence of those who participated, this strategy "created a platform for increasing numbers of community members to interact with each other. They started coalescing and expressing greater interest in directly engaging with issues of major importance to them, such as stigma (of HIV and of belonging to marginalised groups). Some community members began forming their own self-help groups. The programme also instituted formal skills training for community members in areas such as media handling, advocacy, and legal literacy. With the support of the programme, community members increasingly started shaping local advocacy efforts and leading activities such as negotiations with local power structures (e.g., the police).

The prevention package for men at risk (including men congregating at sex solicitation venues ("hotspots") and long-distance truckers) include:

1. Enhanced distribution and social marketing of condoms, complemented by mass media to promote the use of condoms. Avahan created non-traditional outlets for condom distribution including tea and pan shops (tobacco and cigarette shops), roadside restaurants, local all-purpose grocery stores, vending machines at truck stops, and health clinics. This effort is supported by promoting condom normalisation through a combination of active mid-media efforts (street theatre, retailer promotions) and mass media campaigns (television, radio, movies, billboards).
2. Behaviour change communication activities using interpersonal, mid-, and mass media - In hotspots or in transshipment locations along the national highways, one-on-one and one-to-group interpersonal communication sessions are held. A variety of different mid-media activities such as drama, street theatre, entertainment shows, and competitions are also used to provide education on HIV, STI symptoms and treatment, safe sex, and condoms.
3. STI treatment, either through clinical services provided in truck stops or through a franchised network of private STI providers - The clinics were established by identifying physicians who were already seeing a high volume of STI cases; they were then given training on STI management, and the clinics were branded uniformly. The clinics were promoted through mass media and local promotions at the hotspots. Pre-packaged STI syndromic treatment kits containing antibiotics, condoms, instructions, and partner referral cards were also developed.

This core implementation programme has been complemented by advocacy to increase funding and political support for HIV prevention, and to encourage greater dialogue around the issues of HIV and AIDS. Other advocacy endeavours include efforts to alter police practices that harm HIV prevention programming (e.g., the arrest of sex workers for carrying condoms). High-risk groups are also educated about their legal rights, to prevent such abuses of power against them. A major effort has also been underway to improve the quality and quantity of HIV media coverage in vernacular papers across the 6 Avahan focus states. Avahan partners conduct wider public education and mass media outreach addressing the stigma faced by people infected with HIV. Avahan collaborates with national film celebrities, sports stars, and business leaders to create public service announcements (PSAs). These efforts attempt to address societal perceptions that lead to stigmatisation of HIV and high-risk communities.

The following section of the publication explores strategies that Avahan used in its rapid scale-up of infrastructure and services (At the end of two years of implementation, 83% of the enumerated high-risk population had been contacted by a peer outreach worker at least once.) Avahan's approach to scaling up across intervention geographies was based on the principles of: designing for scale, organising for scale, and executing and managing for scale.

Next, Avahan's evaluation framework is outlined, in order to provide context for the preliminary results reported in the document. For example, data show a broad programmatic footprint, increasing depth and intensity of service delivery, rising levels of condom use, and decreasing curable STI prevalence among female sex workers. A series of lessons learned emerge from the evaluation process, and are detailed here. Amongst the communication-centred insights are: the importance of increasing the programme ownership by communities, in part because this "bodes well for the development of an active, aware, and articulate set of customers for HIV prevention services, which is a key consideration for the long term." Meeting future programme challenges, such as transferring the custodianship to "natural owners" in India, will involve strategies such as working closely with national- and state-level HIV programmes; in this regard, organisers stress the importance of building in processes that explicitly foster cross-sharing of experiences between partners.