AIDSTAR-One | CASE STUDY SERIES                                                                                           ...
AIDSTAR-One | CASE STUDY SERIESaspects of program planning and management—experience true ownership of and commitment to  ...
AIDSTAR-One | CASE STUDY SERIESalso plan their activities. That planning feeds into a               (APAC) project, implem...
AIDSTAR-One | CASE STUDY SERIESFinally, Avahan is a learning model. Avahan must            with the highest HIV prevalence...
AIDSTAR-One | CASE STUDY SERIES                                                                                           ...
AIDSTAR-One | CASE STUDY SERIES    RESPONSIBILITIES OF                     Avahan’s management relies on the large amount ...
AIDSTAR-One | CASE STUDY SERIESdifference between living in deep poverty and havingthe means to work toward a more secure ...
AIDSTAR-One | CASE STUDY SERIESlawyers can respond within 24 hours to reports of         experience in community mobilizat...
AIDSTAR-One | CASE STUDY SERIESfunding by the state governments to adequately                        rates declined by abo...
AIDSTAR-One | CASE STUDY SERIESEmerging leadership: Avahan’s peer educatorshave benefited from shouldering significant    ...
AIDSTAR-One | CASE STUDY SERIES                                           2012, was set at over $1 billion, and has since ...
AIDSTAR-One | CASE STUDY SERIESThe Avahan project has been the subject of a                                       middle s...
AIDSTAR-One | CASE STUDY SERIES                                                                     strengthens a targeted...
AIDSTAR-One | CASE STUDY SERIESfunding disruptions, especially to local NGOs and       seeking a greater role in running t...
AIDSTAR-One | CASE STUDY SERIESquantitative indicators was not adequately followed                   implementation are mo...
AIDSTAR-One | CASE STUDY SERIESKim, Caron R., and Caroline Free. 2008. Recent              Pradesh, P. Shailaja and the st...
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AIDSTAR-One Case Study: Avahan-India HIV/AIDS Initiative


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Launched in 2003, the Avahan-India HIV prevention program has become a global model for combination HIV prevention programming that meets the complex and varied needs of most-at-risk populations. This case study describes Avahan’s behavioral, biomedical, and structural components and how the program was able to quickly scale up its activities across 82 districts in India. To view this and other combination HIV prevention resources:

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AIDSTAR-One Case Study: Avahan-India HIV/AIDS Initiative

  1. 1. AIDSTAR-One | CASE STUDY SERIES March 2011 The Avahan-India AIDS Initiative Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics I n an old schoolhouse on the outskirts of Chennai, the scene is hectic at midday. The rehabbed building is now home to a Prashant Panjiar for the Bill & local HIV prevention program, with a busy sexually transmitted Melinda Gates Foundation 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 women—most of them poor and illiterate— reviewing data they have gathered in the neighborhoods where they conduct HIV prevention activities for other sex workers.Drop-in center for groups at Dressed in bright saris of every color, their self-confidence andhighest risk in Mysore. 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 India’s 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 program’s 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 most- By Bill Rau at-risk populations (MARPs). Second, its activist peer educators—whose responsibilities include ongoing data collection and analysis and some 1 Throughout this case study, “Avahan” refers to the program as a whole, including its numerous partners. AIDSTAR-One John Snow, Inc. 1616 North Ft. Myer Drive, 11th Floor This publication was produced by the AIDS Support and Technical Assistance Resources Arlington, VA 22209 USA (AIDSTAR-One) Project, Sector 1, Task Order 1. Tel.: +1 703-528-7474 USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008. Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
  2. 2. AIDSTAR-One | CASE STUDY SERIESaspects of program planning and management—experience true ownership of and commitment to Avahan has achieved nearlythe program. Third, it successfully addresses difficult unprecedented levels of scale-upstructural issues that impede programs worldwide.Finally, Avahan has achieved nearly unprecedented that have made a real impact onlevels of scale-up that have made a real impact on the epidemic in the regions wherethe epidemic in the regions where it works. it works.Combination HIV Prevention monthly prevention services to more than 220,000 female sex workers, 80,000 high-risk MSM andAt first, Avahan offered a traditional mix of services: transgendered people, 18,000 IDUs, and 5 millionHIV behavior change messages delivered primarily men working in the trucking industry. In addition tothrough outreach workers and peer educators, India’s National AIDS Control Organization (NACO)condom promotion and distribution, and sexually and the state government AIDS Control Societies,transmitted infection (STI) treatment. After recruiting Avahan partners with nine lead implementinglocal partners and peer educators, it added grantees, 134 local nongovernmental organizationsstructural interventions designed to reduce police (NGOs), and hundreds of formal and informalharassment of and violence against high-risk groups community-based groups (CBGs), as well as 5,700and to expand national HIV prevention policies and peer educators and outreach engagement efforts. Avahan’s current interventions reflect theOver time, Avahan evolved into a combination HIV key elements of combination HIV preventionprevention program targeted to MARPs, a model programming for MARPs:that includes a mix of risk-reduction strategies based • Peer-led outreach to promote behavior changeon the latest epidemiological and programmaticevidence. Such programs target different populations • Clinical services to treat STIswith simultaneous behavioral, biomedical, and • Condom social marketing and distribution of freestructural interventions designed to address local condomsrealities. Avahan focuses on the region’s MARPs: • Distribution of clean needles and syringesfemale sex workers, men who have sex with men(MSM), transgender people, injecting drug users • Support for community mobilization(IDUs), and truckers and their helpers. • Advocacy to reduce structural barriers to safer sexual practices.Avahan’s overall goal is to work with existinggovernment interventions in six states (Andhra These elements combine standard components ofPradesh, Karnataka, Maharashtra, Tamil Nadu, a minimum package of services for MARPs withNagaland, and Manipur), where prevalence of HIV community mobilization and efforts to addressis highest among MARPs, to reach 80 percent of structural barriers to risk reduction. To tie theseMARPs with prevention services. These states components together, Avahan has strong managementaccounted for 83 percent of HIV infections in 2002, and capacity-building structures at many levelsand represent a geographic area and population size throughout its operations. For example, Avahan’s peersimilar to the United States. Avahan reports providing educators not only carry out extensive outreach but2 AIDSTAR-One | March 2011
  3. 3. AIDSTAR-One | CASE STUDY SERIESalso plan their activities. That planning feeds into a (APAC) project, implemented by the Voluntarymultilevel management structure that gives the program Health Services in Chennai, funded by USAID inadaptability and strong accountability. collaboration with the Government of India.Structural interventions—which address social, Avahan’s planners focused the bulk of the program’seconomic, and political issues that affect health at resources on targeted interventions in the sixthe individual, community, and societal levels—are states where the epidemiological data indicateda key element of Avahan. To address structural the prevalence rates were highest, saturating themproblems, Avahan advocates for policies, regulations, with far more intensive coverage of MARPs. Theselitigation, and enforcement of existing laws to interventions emphasized behavior change amongcreate an enabling legal and social environment for high-risk groups and sought to provide adequateprevention. The organization also supports local services for the sexual health of those groups.empowerment and antiviolence initiatives, as well asaccess to public health and food security programs. An EffectiveThe Origins of Avahan Management ModelWhen Avahan began, NACO was already operating Avahan reflects a data-driven business approach toa prevention program of national scope under its confronting the epidemic. Its senior managers comeNational AIDS Control Program (NACP-I and -II). from a business background and rely on data forInitial funding for this effort came from the national planning and monitoring of program outputs. Data aregovernment, the World Bank, and several bilateral used to target interventions, make adjustments in thedonors to support both state- and national-level program as needed, and measure progress towardactivities. Later, State AIDS Control Societies (SACS) program objectives. The managers recognize that thetook charge of some of the decisions related to search for perfect data never ends and thus makeselecting, funding, and monitoring local NGOs, which decisions based on the best available data rather thanimplemented targeted interventions to prevent HIV. wait for the next sample or a more refined analysis.As rates of HIV infection in India increased in the The program also followed business models tolate 1990s, many noted the potential for a much create a system of decentralized planning andlarger epidemic. Although epidemiologic estimates management that gives substantial responsibilities tofrom that time put the number of HIV-infected local organizations. Through its Common Minimumindividuals in India at 4 million, fears grew that Program (CMP), Avahan established a shared visionprevalence could reach 5 percent by 2005—some for its highly decentralized operations that set basic37 million people. The national program suffered standards for its NGO partners to ensure high-from uneven implementation, inadequate coverage quality services, while providing necessary guidance,of MARPs, and insufficient intensity of prevention training, and monitoring. The centrally definedefforts. However, there were also encouraging framework and standards are thus decentralizeddevelopments. By the time Avahan was being to the implementing organizations. A third aspectdesigned, initial reports from Tamil Nadu indicated of Avahan’s business approach is saturating targetthat prevalence in that state was declining in part audiences with adequate staff and services, a keyas a result of the AIDS Prevention and Control feature found in effective advertising. The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics 3
  4. 4. AIDSTAR-One | CASE STUDY SERIESFinally, Avahan is a learning model. Avahan must with the highest HIV prevalence and the largestadapt to respond to changing realities in the field in concentrations of MARPs within the six states.order to succeed. For example, the CMP was revised Avahan’s partners then undertook detailed mappingthree times in the project’s first phase, allowing for and size estimation exercises within districts andinnovations at the local level to be channeled back to subdistricts to determine where to establish servicesthe Avahan program level. Managers listen closely to and to use later to gauge progress. As part of thatstate implementing agencies and NGOs and adjust process, they carefully mapped solicitation hot spotstheir approaches and support when they hear that and sexual networks at local aspect of the program is not working optimally.Avahan’s state partners provide additional staff support These data made it possible to focus resources inand training to NGOs that slip in reaching their targets. each state on districts, subdistricts, and sections of up to 10 large cities and 100 towns with the highest HIV prevalence and concentrations of MARPs. TheAvahan’s Technical mapping generated estimates of 213,000 female sex workers, 76,000 transgender people and MSM,Approach and 25,000 IDUs in 82 districts across the six states.2 Target groups were further subdivided byAvahan’s technical approach involves the target demographic characteristics, behaviors, or workingcommunities to develop its interventions, using highly locales to allow for different outreach approaches.participatory approaches to identify hotspots and risk For example, female sex workers were identifiedgroups, to design a package of prevention services as home-based, as street-based, or as based inthat is relevant and accessible, and to address social brothels and lodges.factors that increase MARP marginalization andcreate barriers to prevention services. By investing in Building key services: Avahan provides amonitoring and evaluation activities, Avahan ensures package of prevention services on a large scalethat its interventions continue to effectively address across the six states. Condom promotion andthe evolving needs of its target populations. distribution as well as STI diagnosis and treatment are linked to behavior change communication—allPinpointing the epidemic: To assess where essential elements of combination HIV prevention. Tothe need for prevention services for MARPs is maintain high standards of quality in service delivery,most critical, Avahan began its planning process by the program actively monitors all activities at all levels.reviewing India’s extensive epidemiologic and sexualbehavioral data. These data showed that the six Most Avahan clinics are located in areas with highstates where Avahan is based had an estimated 83 concentrations of MARPs or where two or threepercent of all HIV infections in India. These states such groups tend to overlap. Avahan sponsors STIalso had a concentration of female sex workers, clinics at sites not covered by government clinics.MSM, and IDUs. Many are housed within the nearly 600 community drop-in centers the program has created. ClinicianMapping exercises further confirmed that these hours are posted, and each STI clinic also includes astates represent the core of the epidemic in India and counselor, a nurse/dispenser, and an administrativeuncovered even larger numbers of MARPs. First, 2 Estimates in subsequent years increased the number of female sex workers toAvahan state partners and NGOs—which both serve 221,000 and of most-at-risk MSM to 81,000, while decreasing the number of IDUsand are often staffed by MARPs—mapped areas to 18,000.4 AIDSTAR-One | March 2011
  5. 5. AIDSTAR-One | CASE STUDY SERIES In response, Avahan instituted sensitivity training for police. But Avahan’s peer educators and NGO partners also encourage female sex workers Prashant Panjiar for the Bill & Melinda Gates and MSM to proactively confront police who try to intimidate or marginalize them. This approach empowers MARPs to have greater control over their own sexual health and well-being, which is one of Avahan’s key goals. Largely at the initiative of the MARPs themselves, Foundation the program now actively fosters and supports a sense of community ownership to further counterPeer educators in Thane completing a hotspot map of marginalization and neglect. Avahan encouragestheir outreach area. NGOs to help create CBGs and to support formally registered community-based organizations (CBOs) for MARPs; CBGs and CBOs now operate in manyassistant. The STI clinics also provide referrals for of the districts covered by the program. In turn, thetuberculosis (TB) diagnosis and HIV testing, care, CBGs and CBOs have contributed to the programand treatment. by focusing on quality-of-life issues beyond HIVAvahan’s condom program includes both social prevention that are important to MARPs, suchmarketing and distribution of free condoms by peer as obtaining food ration cards, sensitizing healtheducators and at STI clinics. In conjunction with the providers to their needs, and expanding skills traininggovernment, Avahan has intensified the advertising and income-generating opportunities. Committeesand distribution of socially marketed condoms in within the CBOs monitor the quality and acceptabilitymore than 100 sexual hot spots along trucking of services at the Avahan STI clinics. In severalroutes. Currently, free and Avahan-supported cases, committees gained sufficient information tocommercial outlets distribute nearly 20 million insist on replacing clinicians with irregular attendancecondoms monthly. Condoms are also available from or judgmental attitudes.many other outlets across India. Prashant Panjiar for the Bill & Melinda Gates FoundationAltering the structures of risk: One of thekey findings from the mapping exercises was thatin addition to harassment, female sex workersand MSM experience police and gang violence,which can discourage them from using condoms orchanging risky behaviors. For example, police oftensuspect women found with condoms of being sexworkers; the women may be forced to pay a bribeto avoid arrest, or coerced into providing a sexualfavor. In health care settings, sex workers and MSMface stigma and discrimination from staff, who oftendeny them services. Fearful of such treatment, manysimply forgo accessing basic health care. Peers talking to police in Mysore. The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics 5
  6. 6. AIDSTAR-One | CASE STUDY SERIES RESPONSIBILITIES OF Avahan’s management relies on the large amount PEER EDUCATORS of output data the program generates at all levels, • Mapping peer sexual contact starting with contacts made by peer educators. locales and networks • Weekly contact with peers, Monitoring and evaluation: Avahan’s management relies on conveying a growing set of the large amount of output data the program generates at all levels, messages about safe sex starting with contacts made by peer educators. Peer educators keep • Condom promotion and daily records of their contacts and their interactions with their peers, distribution identifying highly vulnerable peers for extra attention. These records are • Weekly data summaries consolidated into weekly summaries of contacts. Implementing NGOs • Microplanning and revisions work with the peer educators to analyze these data and plan outreach to ensure maximum coverage and clinic attendance. They then forward • Referrals to STI clinics and output data to the lead agencies in each state to help monitor progress follow-up, as needed and identify areas for improvement or added attention. • TB screening and referrals; some accompaniment to clinic Avahan also monitors outcomes. STI rates at clinics are followed closely, as is condom distribution at various sources. Avahan funded two rounds • HIV testing referrals. (2006–07 and 2009–10) of an Integrated Behavior and Biological Assessment to collect behavior and biological data from a representative LEARNING FROM PEER sample of the targeted at-risk populations in selected districts. Sample EDUCATORS data elements included knowledge, attitudes, and practices related to safer sex; and HIV, STI, and/or hepatitis infection. NACO generates Peer educators feel they have annual estimates of India’s population living with HIV to focus attention demonstrated the following to on districts with emerging epidemics, and conducts biannual behavioral Avahan and its state partners. surveys. Along with its own data, Avahan uses data from NACO’s • There are many skills within behavior surveys and estimates of people living with HIV to further marginalized communities monitor its own progress and to look for gaps in its districts. • Communities can manage their problems • Communities can mobilize Peer Educators Within Avahan resources The use of peer educators is a well-established practice in HIV prevention. • Communities can take a leading But many peer educator projects have had limited results. Retention of role in running health and social peer educators, lack of message innovation and change, reliance on welfare programs. uncompensated volunteer peers, the short duration of many projects, and other factors have reduced the impact that such initiatives might have. Within Avahan, peer educators are the central focus of program operations. Peer educators have multiple responsibilities that take advantage of their knowledge and skills. They receive a small stipend that, for many, is the6 AIDSTAR-One | March 2011
  7. 7. AIDSTAR-One | CASE STUDY SERIESdifference between living in deep poverty and havingthe means to work toward a more secure future.While the stipend is important to peer educators, thecommitment to personal and community change is Prashant Panjiar for the Bill & Melinda Gates Foundationalso an important motivator. Moreover, the programwas structured to provide opportunities that allowedthem to develop new skills and positioned them forgreater responsibilities. These factors created astrategy to combat the high turnover rates typical inmost peer educator programs.Some peer educators help manage the program’sactivities with peer communities. As they documentinteractions with peers, they know the data theycollect are essential for their own planning, which iskey to the program’s overall implementation strategy. Peer educators in Pune.Avahan has developed non- and low-literacymaterials that peer educators use during training and Recently, peer educators were trained to identifyon the job. Many of the materials use pictures and basic TB symptoms and to escort symptomaticsymbols instead of text. Training includes topics on peers to clinics for diagnosis, in some casesself-esteem development, negotiation and facilitation arranging for TB treatment monitoring. Some of theskills, advocacy and leadership, and peer monitoring. CBOs that have sprung from the work of the peer educators also help people living with HIV registerPeer educators and service delivery: for government treatment services.Each peer educator has up to 50 clients, meetingwith each at least once a month and often more Avahan’s approach to peer education is intensive,frequently. During meetings, peer educators offer both for the peer educators and the supervisorysafer sex messages, provide condoms, and note outreach workers of the implementing NGOs.their clients’ visits to STI clinics. They serve as Extensive planning helped establish a viable systemthe primary and initial contacts for access to STI of identifying and selecting peer educators, providingservices at Avahan clinics, giving referral notes for initial and follow-up training, and sustaining theirdiagnosis and treatment services. They encourage interests and skills with close supervision. Drop-inand facilitate attendance, sometimes by escorting centers offer a supportive place for peer educatorsthe peer to the STI clinic, which also serves as a to meet, discuss, plan, and offer services to peers.referral point for HIV testing and treatment services. As peer educators began to expand their work and organize themselves, Avahan found it needed further planning to manage and incorporate those Peer educators have multiple community groups. responsibilities that take advantage Crisis intervention is a high-profile service of of their knowledge and skills. the peer educator system. A peer-led and NGO- supported rapid response network with access to The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics 7
  8. 8. AIDSTAR-One | CASE STUDY SERIESlawyers can respond within 24 hours to reports of experience in community mobilization to theirviolence by police or gangs, domestic violence, work. Rather than insisting on one model ofor other complaints. Negotiations are conducted community mobilization, Avahan senior managersat police stations, sometimes with senior officers. responded with one of the program’s coreDomestic violence has led some CBOs to establish features: flexibility to adapt based on changingsafe houses for women and their children; CBO circumstances and information. The willingnessmembers may also attempt to intervene with the of the program to learn from and with its partnershusband or partner to resolve issues. fostered a working collaboration that contributed to the rapid scale-up of program activities.The dedication of peer educators to their work isone reason Avahan was able to quickly scale-up Because scale-up began simultaneously inits program across 82 districts in six states. Most each state, the program had been establishedpeer educators have come to recognize that even in nearly 90 percent of the targeted locales, hadin a program this large, their individual inputs and recruited two-thirds of the projected number ofachievements contribute to the program’s objectives. peer educators, and was distributing 6 millionWeekly recordkeeping and biweekly data analysis condoms per month within two years after thewith outreach workers add to the peer educators’ program’s launch. Two years after that, Avahan andsense of responsibility and engagement. government-supported interventions covered about 95 percent of female sex workers and 90 percent ofScaling up: Working at a large scale was a MSM in the four southern states.primary program objective from the outset. Beginningin late 2003, Avahan moved quickly to expandservices sufficiently to cover 80 percent of identified Program ResultsMARPs in the states where it works. This involvedidentifying lead partner agencies in each of the six In Avahan’s first phase, the project was ablestates, one for work with truckers, and one for men to quickly go to scale through its massive peerat sex solicitation locales. Through the lead state education activities, which resulted in uptake in STIpartners, Avahan identified local NGOs to implement services and condom distribution and a decrease inthe work in districts with substantial MARPs. The STI rates, including HIV. In addition to the serviceNGOs received training about Avahan’s goals, delivery outcomes, the program contributed todata collection methods and standards, and peer greater social cohesion and community ownershipmanagement. of HIV prevention programs. Finally, the donorIt was not always a smooth or linear process, investments in Avahan helped to spur increasedespecially in developing an approach to communitymobilization. It took time to identify and recruitpeer educators, develop low-literacy (and non- The dedication of peer educatorsliteracy) materials, and provide training. An to their work is one reason Avahanearlier community mobilization model in India, thewell-known Sonagachi Project for sex workers, was able to quickly scale-up itsprovided useful lessons in what marginalized program across 82 districts in sixcommunities can achieve. In addition, Avahan’s states.state and NGO partners brought their extensive8 AIDSTAR-One | March 2011
  9. 9. AIDSTAR-One | CASE STUDY SERIESfunding by the state governments to adequately rates declined by about 80 percent during the sameaddress HIV. period in Tamil Nadu. Between 2003 and 2007, in the states where Avahan worked, governmentSTI and HIV prevention: In 2008, midway surveys showed small declines in HIV prevalence,through its 10-year program, Avahan has achieved its again adding to the impact of earlier interventions.goal of operating at a large scale in six Indian states. However, in 18 districts where Avahan’s effortsThe program has recruited and trained thousands of were most intense, HIV prevalence at antenatalpeer educators with a variety of STI/HIV prevention clinics declined from 1.5 percent to 0.6 percentmessages, providing them with a range of delivery between 2003 and 2007. While other factors maytools and techniques. Data collection and monitoring have played a part in the decline of STIs and HIV inmaterials were developed for use by low-literacy and these regions, it is clear that Avahan contributed tonon-literate peer educators. The program carried out reduction.a very extensive mapping exercise of sex hot spotsin 82 districts, along with estimations of the number In addition to STI management referrals, peerof sex workers, MSM, and IDUs in specific locales in educators added TB screening, HIV testing,those districts. Based on the monitoring system, peer and referrals for antiretroviral therapy to theireducators now account for 90 percent of all contacts responsibilities, which they recognized as importantwith the target populations. to the health and well-being of their peers. This reflects how peer educators, as they gained moreThe rapid increase in the number of condoms experience and confidence, came to understanddispensed or sold and increases in reported condom more fully the interconnectedness of HIV with otheruse are evidence of the effectiveness of peer health conditions.educator outreach efforts. By early 2006, more thanthree-quarters of sex contacts with clients of female Advocacy and community initiatives: Thesex workers involved condom use. Over the entire importance of access to adequate health care andproject, more than 80 percent of male clients of of human and civil rights emerged from the local-female sex workers reported condom use at last sex level advocacy practiced by peer educators andwith a sex worker; as of May 2007, that represents a the implementing NGOs. Peer educators and other35 percent increase from a year earlier. By late 2008, program staff target the police, both street-leveleach peer educator was distributing an average of patrols and officers, to stop harassment, coercion,38 condoms per month to most-at-risk individuals. and violence. Though during the early mapping exercises fewer than one-quarter of sex workersOf most-at-risk individuals contacted by the program, reported experiencing police harassment, police85 percent of female sex workers and 64 percent of interference with sex work (and with the ability of sexmost-at-risk MSM used the STI services. STI rates workers to practice safer sex) has been a concerndeclined after the implementation of Avahan. For for many sex workers and MSM.example, in the state of Tamil Nadu, where a large,well-established, USAID-funded HIV prevention The resistance by sex workers to police interferenceprogram implemented by APAC had already shown and the use of rapid crisis response teams tosignificant results, the added support of Avahan police and gang violence has resulted in changesbrought syphilis rates among female sex workers in working conditions for sex workers. From alldown by one-third between the end of 2003 (pre- anecdotal reports, police interference has fallen offAvahan start-up) and 2006. In addition, chlamydia dramatically. The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics 9
  10. 10. AIDSTAR-One | CASE STUDY SERIESEmerging leadership: Avahan’s peer educatorshave benefited from shouldering significant One unexpected but welcomeresponsibilities in addition to traditional peer education outcome has been a blossomingtasks. During the design and planning stages,they take charge of microplanning, which includes of community solidarity betweeninitial mapping of sexual solicitation and networking female sex workers and MSM.locales used by MARPs. Peer educators also playan important role in fostering community mobilizationand the development of CBGs and CBOs. These themselves are assuming ever greater control of theexperiences have created a sense of ownership of the process and outcomes of community mobilization.program and a commitment to creating environments In many situations where individuals have unitedconducive to reduced risk, leading to increased self- around common interests, both informal and formalconfidence and self-esteem. organizations have appeared.One unexpected but welcome outcome has been ablossoming of community solidarity between female Two aspects of the growth and influence ofsex workers and MSM. Avahan seemed to provide constituent control and ownership within Avahanan opportunity and space for these marginalized are noteworthy. First, the peer educators and theirgroups to create communities and organize communities are at the forefront of HIV prevention atthemselves to articulate their grievances against the local levels, at a scale never before seen in HIVsystems that marginalize them. prevention work. Second, the program management has, for the most part, not felt threatened by theSeveral peer educators are now working for growth of community activism and ownership. WithNGOs, many of them as outreach workers; others the exception of some NGO staff concerned aboutare studying or have acquired new skills, such as their jobs, the management at all levels does nothairdressing, that provide income. They recognize worry that community groups are taking over theirthemselves as role models for others, which in turn roles. In fact, the state implementing agenciesenhances the credibility of the safer sex messages actively encourage the consolidation of communitythey convey to others. groups into registered CBOs, with elected officers and committees. In Tamil Nadu, the CBOs have beenAn emphasis on community engagement has been linked into a registered federation. Some CBOs area key focus from the start of Avahan. The Sonagachi also linking with established CBOs and NGOs thatmodel for building sex worker ownership of a safer deal with microfinance and other areas of advocacysex environment—which proved to the world that and rights.programs can successfully engage MARPs—wasan important inspiration for Avahan. But Avahan staff Cost and affordability: The Bill & Melindaand peer educators have gone forward to create their Gates Foundation’s investment of U.S.$258 millionown mechanisms for broader community involvement over the first 5 years of the 10-year program isand ownership, built on the program’s experiences substantial. About $215 million of that amount wasand understanding of its target populations. actually spent (an average of $48 million per year). As of mid-2009, the Foundation had committedCommunity ownership: While Avahan has $330 million to Avahan. By comparison, India’sfostered community ownership, the communities initial budget for NACP-III, to run from 2007 to10 AIDSTAR-One | March 2011
  11. 11. AIDSTAR-One | CASE STUDY SERIES 2012, was set at over $1 billion, and has since grown to $1.7 billion,THE COST OF PEER using a loan from the World Bank, grants from other sources, andEDUCATOR STIPENDS: internal resources. (The Gates Foundation funding is included in theEVIDENCE FROM TAMIL country’s total budget for HIV.) About $350 million of the NACP-IIINADU budget is for programming for a broad spectrum of high-risk groups across the country. While Avahan covers six states and major truckingEach of about 1,725 peer routes, India’s national program covers the entire country, a larger andeducators connected to the more complex undertaking. Nonetheless, Avahan has demonstratedAvahan program in Tamil Nadu to the government what can be accomplished with well-targeted andreceive a stipend of about adequate resources.U.S.$10.50 per month. Thiscomes to just over $18,100per month for direct support to Limited data were available at the time of field visits about the cost-all the peer educators in that effectiveness of the Avahan program or its various components. Avahanstate. The annual cost comes to does have a subcontractor gathering data for costing analyses. One$217,200. Management support study puts the NGO-level cost of covering one beneficiary at an average(training, supervision, materials) of $48, although there are variations between states and not included in the figures. By While within the guidelines prepared by NACO, the cost is higher thancontrast, the monthly costs for the $40 of one state’s SACS. Another study found that there is a wideART drugs alone total about $22 variation in the costs of reaching high-risk individuals. The variationper patient. was explained by different approaches of implementing partners (both state partners and NGOs) and the number of beneficiaries contacted by individual NGOs. However, as scale expanded, the average costs declined. A breakout of financial distributions for program implementation by Avahan and its partners showed that about 41 percent went to prevention activities for female sex workers and MSM. Just over 20 percent went to prevention for high-risk males (e.g., clients of sex workers and potential clients such as truckers found in “hot spots”). The next largest segment was for capacity building for partners and government (14 percent). A small proportion, four percent, went to prevention activities for IDUs. The remainder was divided between advocacy, communications, monitoring and evaluation, and knowledge building. The population of the six Indian states where Avahan operates totals approximately 300 million people; Avahan’s annual cost averaged $33 million over its lifespan. Given the costs associated with even small increases in prevalence in India and the subsequent burden of treatment and care, Avahan’s contributions to reduce STI and HIV prevalence could be interpreted to represent a proportional investment in prevention efforts. For instance, a 0.1 percent increase in the six states would roughly translate to 100,000 people needing treatment at an annual cost of $24.6 million. The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics 11
  12. 12. AIDSTAR-One | CASE STUDY SERIESThe Avahan project has been the subject of a middle segment of management—between targetrecent ongoing debate regarding its perceived high audiences and senior project management—iscost structure and sustainability.3,4 As the transition the weak link, often filled by an implementingto NACO nears, concerns have been raised that NGO. In contrast, almost all of the NGOs originallyAvahan’s costs could hinder the Government of recruited by Avahan are performing well becauseIndia’s maintenance of program operations. Similarly, of a relatively simple program approach thatAvahan’s cost structure has implications for its maintains common standards, sets up an intensivereplication elsewhere. More specifically, concerns reporting system, and provides ongoing training andhave been raised over whether or not the Avahan interaction. Training and oversight have also beenmodel can be sustained if there is a continued stepped up to address any NGO weaknesses.expansion in the size of MARPs, for example, withan influx of sex workers from the surrounding region. Intensive use of human resources: The ability and willingness to work at a large scaleIn February 2010, a special peer-reviewed reflects Avahan’s commitment to placing humansupplement of the journal, Sexually Transmitted resources where they are most needed to reachInfections, evaluated results from Avahan from their target populations and consistently deliverdifferent angles, including cost.5 services to MARPs. Avahan’s ratio of peer educators to peers ranges from 1:35 to 1:50, much lower than in other peer education programs. Peer educatorsWhat Worked Well are also responsible for intensive data collection and analysis, including recording individual contacts andThe Avahan program demonstrates that a very large aggregating the data weekly.HIV prevention program can provide a combinationof services to multiple target groups at multiple levels Using, not just collecting, data: From thewith a flexible management structure. In addition, beginning, data have been used to identify keyearly planning to foster community ownership and drivers of the epidemic and to pinpoint areas withpromote structural interventions has added critical high levels of HIV infection. From the weekly reportsvalue to Avahan’s overall program. of peer educators, data work their way up through the management structure and are used at all levelsManaging with a clear set of goals and to monitor progress and to identify and addressstandards: To respond to changing conditions problems.and opportunities, Avahan’s management structureis both proactive and flexible. Avahan remains Peer education with multiplefocused on its objectives and personnel as it responsibilities: Avahan has demonstrated thatoperates at a very large scale, thereby gaining the peer educators can handle a range of behavioraltrust of its target groups. For many projects, the change topics, activities, and responsibilities. Through the microplanning process, peer educators3 Flock, Elizabeth. “How Bill Gates Blew $258 Million in India’s HIV Corridor.” become part of a whole team, rather than isolatedForbes India, June 5, 2009. Available at individuals. They build on the trust Avahanborder/how-bill-gates-blew-$258-million-in-indias-hiv-corridor/852/1. management places in them to stimulate solidarity4 Yamada, Tachi. “Bill & Melinda Gates Foundation Responds To Forbes Article.”Forbes, July 20, 2009. Available at within peer communities. It is useful to note that thefoundation-response-philanthropy-avahan_print.html turnover rate for peer educators working with Avahan5 Sexually Transmitted Infections. “Emerging Results from a Scaled HIV Preven-tion Program–Avahan, the India AIDS Initiative.” February 2010, Volume 86, Suppl is about 10 percent per year, a rate generally lower1. than most other peer educator programs.12 AIDSTAR-One | March 2011
  13. 13. AIDSTAR-One | CASE STUDY SERIES strengthens a targeted intervention approach and When structural interventions and makes it more accountable. NACO and SACS have community mobilization are added learned from and with Avahan and give the program credit for demonstrating what can be done with to a mix of prevention services, the good data, monitoring, management, advocacy, and synergy achieved with combination intense involvement with affected communities. HIV prevention is evident. Combining a mix of interventions: When structural interventions and communityWorking with volunteers: Peer educators join mobilization are added to a mix of preventionAvahan as volunteers. However, Avahan provides services, the synergy achieved with combinationa monthly stipend equivalent of between $10 and HIV prevention is evident. The approach adopted$20 each. The stipend is an important supplement by Avahan demonstrates the effectiveness of afor women and men who live very marginally; many large-scale combination HIV prevention approachare in debt. However, when they describe their in concentrated epidemics. The Avahan experiencemotivation for becoming peer educators, they talk shows that combination HIV prevention is notnot about the extra income but about the sense of simply an ideal or theoretical construct, but a viableaccomplishment and self-fulfillment they feel. programmatic approach.Removing structural obstacles to HIVprevention: To counter local-level harassmentby police of female sex workers and MSM, Avahan Challengeslaunched sensitivity training, peer advocacy, andrapid responses to individual cases of harassment or There is wide acknowledgment by the Indianviolence. As relations between the police and MARPs National AIDS Control Organization, SACS, Avahan’simprove, it becomes easier for targeted populations state partners, and most participants that theto practice safer sex and to seek care. As confidence program has generally worked well. However, therehas grown within CBGs, other structural impediments are several areas where program weaknesses havehave been addressed: peer community members been encountered, and these provide lessons forhave now acquired ration cards, access to public other large, focused HIV prevention facilities, and, for some, health insurance—allservices long denied to marginalized groups. Sustainability: The Avahan program has several more years to run. In 2009, Avahan began to handAuthentic community ownership: The active over district-level program activities to SACS; suchinvolvement of target audiences has been critical transfers will be completed in 2014. The financialin building community involvement and ownership sustainability of the Avahan approach is assured bythroughout Avahan. Not all community groups the government’s very substantial budget for HIVorganized under the Avahan umbrella will survive, and AIDS work and its commitment to community-but many will, and they will become more powerful in driven programming. Yet not all are convinced thatrepresenting their constituents in the process. the Government of India’s resources can maintain the Avahan program at current operating costs. InStakeholder learning from and with addition, Avahan’s partners are concerned that theAvahan: Avahan adds value to the government’s support given for CBGs will wane as the governmentHIV prevention program as it broadens and takes over programs. Partners also fear potential The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics 13
  14. 14. AIDSTAR-One | CASE STUDY SERIESfunding disruptions, especially to local NGOs and seeking a greater role in running their own affairs. ButCBOs and to those that employ sex workers as it also means that the strong coordination featurespeer educators, given the government’s more of the Avahan program will begin to loosen tocumbersome bureaucratic structures for transferring accommodate diverse local interests and methods.funds. These concerns are fueled in part by along-held suspicion of authority by CBO members, Replication: Avahan’s combination HIV preventionalthough many have gained confidence about approach appears to be very replicable in countriespressing for their rights. Also, CBO members are with concentrated HIV epidemics and likely replicablenew at organizational management; it remains to be where there are mixed epidemics. Replication willseen if the capacity-building element of Avahan will require a good, but not necessarily perfect, set ofbe sufficient to build the skills and experience CBO epidemiological and behavioral data, good planning,leaders need to manage the organizations. and a sound management structure at all levels. Any replication of the Avahan model should reflectSome of Avahan’s implementing state partners and local realities and organizational experiences. TheNGOs are likely to have their roles taken over by financial and human resources needed to build suchSACS. It is possible that technical assistance and a program are, in most cases, within the reach ofmonitoring of local programs may not receive the HIV and AIDS budgets in many countries—if donors,same intensity of attention as has occurred under governments, and implementing agencies can agreeAvahan. That said, the acknowledged learning to work on a common program.that has occurred within SACS—with support fromAvahan, USAID, and other sources—provides a solid Even countries that lack an adequate budget orbase for sustaining many of the technical aspects for consensus on focusing resources on the mainreaching MARPs, which is a NACO priority. Finally, drivers of the epidemic can learn from the Avahanwith four years to manage the transition from Avahan model and replicate some of its elements. Threeprogram to government program, opportunities exist of those elements stand out. First, use availableto identify and correct problems and strengthen key data to identify the main drivers, most-at-risk,areas for continued community mobilization. or underserved groups in the epidemic and put adequate resources toward reaching them. Second,Coordination at scale: Avahan is a large- focus on building and sustaining community buy-inscale coordinated program, with common program and an active role in program development. Third,elements used in all locations where it works. Its address the structural barriers that make it difficultindividual components and diverse state realities for individuals to practice risk reduction.are held together by those common elementsand by standards of service delivery and a strong Monitoring qualitative and emotivemanagement structure. While program managers aspects of the program: Although Avahan hashave handled coordination well, the ability to systems to regularly collect and use large amountshandle differences is an ongoing challenge. CBG of data, it has been slow to develop methods forinvolvement is being integrated into the program’s monitoring the effects of advocacy efforts at allprocesses very slowly. Avahan management is levels, measuring levels of violence against MSMexploring ways to strengthen CBGs by converting and female sex workers (other than police violence),some groups into registered CBOs, and then quantifying expanded access to non-programestablishing systems to monitor community group services (such as food ration cards) for high-riskactivities. The program has done well to support— people, and capturing information about communityrather than feel threatened by—communities who are mobilization. The program’s initial emphasis on14 AIDSTAR-One | March 2011
  15. 15. AIDSTAR-One | CASE STUDY SERIESquantitative indicators was not adequately followed implementation are motivated when they are involvedup by developing mechanisms to capture “soft” deeply and regularly in the Thus, while anecdotal reports and accountsexist on impacts of the program on these indicators, Identify and work on structural obstaclesmore solid data to back up those accounts are only and opportunities at all levels: Structuralbeginning to emerge. factors may be very local, such as police harassment, or national, such as policies thatMeasuring costs: The Avahan program is criminalize sex work, or in between, such as cliniccollecting and analyzing data on the cost of various rules and processes that discourage MARPs fromprogram components. A challenge will be to accessing services.determine the cost-effectiveness of the differentprogram components without losing sight of thecoherence and mutually reinforcing nature of each. RESOURCES Avahan has produced several publications thatAnother challenge will be for NACO to revise its cost describe aspects of the program. These can beestimates for interventions to adequately sustain found on the program’s website: www.gatesfoundationNGO and CBO activities. .org/avahan/Pages/overview.aspx. Avahan’s state partners also maintain websites thatRecommendations for provide information on their involvement. • For Tamil Nadu, see • For Andhra Pradesh, see andhrapradesh.htmThe experience of Avahan highlights the need forgood evidence for programming; adequate resources For more information on the APAC project, please visitto meet identified needs, including strong project; and the importance of addressing the In addition, the following publications were useful insocial and cultural context that may contribute to or preparing this case study:hinder a project’s success. Avahan. 2008. Managing HIV Prevention from the GroundIdentify and understand the main drivers Up: Peer Led Outreach at Scale in India. New Delhi:of the epidemic: An effective combination HIV Avahan.prevention program relies on good (but not necessarilyperfect) data and an understanding of what the data tell Cornish, Flora, and Catherine Campbell. 2009. Theabout the core drivers of the epidemic. Social Conditions for Successful Peer Education: A Comparison of Two HIV Prevention Programs RunPut enough people on the ground to fully by Sex Workers in India and South Africa. Americancover the target populations: A ratio of 1:50 Journal of Community Psychology 44(1-2):123–35.of peer educators to target groups is sufficient to Jana, S., et al. 2004. The Sonagachi Project: aaffect behaviors and foster community ownership. sustainable community intervention program. AIDS Education and Prevention 16:405–14.Develop a management structure thatuses the skills and resources of all staff Kenya National AIDS Control Council. 2009. Kenyaand volunteers at all levels: Staff and HIV Prevention Response and Modes of Transmissionvolunteers who contribute to program planning and Analysis: Final Report. Nairobi: NACO. The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics 15
  16. 16. AIDSTAR-One | CASE STUDY SERIESKim, Caron R., and Caroline Free. 2008. Recent Pradesh, P. Shailaja and the staff of the Swagati ProjectEvaluations of the Peer-Led Approach in Adolescent within the Hindustan Latex Family Planning PromotionSexual Health Education: A Systematic Review. Trust provided information and access to project sites.International Family Planning Perspectives 34(2):89–96. Thanks also to V. Sampath Kumar and Kerry PelzmanAvailable at with USAID/India, Timothy Mah and Shyami DeSilvahtml (accessed September 2010) with USAID/Washington, and the Prevention Technical Working Group for their review and insight.UNAIDS. 1999. Peer Education and HIV/AIDS: Concepts,Uses and Challenges. Geneva: UNAIDS. RECOMMENDED CITATION Rau, Bill. 2011. The Avahan-India AIDS Initiative: PromisingACKNOWLEDGMENTS Approaches to Combination HIV Prevention ProgrammingA special thanks to the staff of the Bill & Melinda Gates in Concentrated Epidemics. Case Study Series. Arlington,Foundation who assisted with information and logistics VA: USAID’s AIDS Support and Technical Assistancein the preparation of this case study. At the Foundation, Resources, AIDSTAR-One, Task Order 1.Gina Dallabetta and Matangi Jayaram were especiallyhelpful. In Tamil Nadu, the staff of the Tamilnadu Please visit forAIDS Initiative of Voluntary Health Services, including additional AIDSTAR-One case studies and otherProject Director R. Lakshmibai, generously shared the HIV- and AIDS-related resources.organization’s experiences within Avahan. In Andhra AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approaches around the world. These engaging case studies are designed for HIV program planners and implementers, documenting the steps from idea to intervention and from research to practice. Please sign up at to receive notification of HIV-related resources, including additional case studies focused on emerging issues in HIV prevention, treatment, testing and counseling, care and support, gender integration and more.16 AIDSTAR-One | March 2011