The Avahan Decade

Avahan India AIDS initiatiive focused its efforts on key populations

So much has been written about Avahan – by implementers, academics, and journalists – that to write more might be unnecessary. Many have reflected on the complexity of the programme and its ambition. What would it take to have an impact on the HIV epidemic in India’s highest burden states at a scale usually expected only of government? The learnings of Avahan are ample and thusly well documented. India’s fascination with Avahan’s donor surely was a story unto itself and told many times.

Yet, for me, the central contribution of Avahan is simple, and remarkably, it still remains radical today. Leveraging the prestige and resources of the Bill & Melinda Gates Foundation, Avahan focused its efforts on key populations, groups whose social marginalization previously all but ensured that their needs would not be adequately prioritized in spite of their disproportionate vulnerability to HIV.

Before Avahan arrived, India had already recognized that sex workers were an important driver of the country’s epidemic. The data told this story, and the government had a plan. Other key population groups like men who have sex with men and people who inject drugs were similarly targeted. Yet, capacity in the government to meet these challenges was limited. Apprehension about HIV was just part of the problem. How does a government effectively protect the health of groups that are criminalized and pushed to the margins of society?

What Avahan did – putting key populations first – should have been game-changing for the global AIDS response. How little the global AIDS response has actually changed now a decade later is testament to how difficult it is to break through the stigma and discrimination that define this disease. For all our talk in public health about evidence-based responses, what is done about AIDS still passes through a moral and political filter. Though we know we can find HIV concentrated in sex worker, MSM and drug using populations worldwide, we still don’t invest resources to match the relative scale of the epidemic in these groups.

Avahan showed it can be done. The Gates Foundation deserves great praise for its vision and resolve. The Government of India’s National AIDS Control Organisation (now, Department of AIDS Control) and the State AIDS Control Societies were essential collaborators, giving the programme the space it needed to show impact. Avahan’s implementing partners took the programme to the community level in six states across the country, with Alliance India working in Andhra Pradesh. Together, over the Avahan decade, we had the journey of a lifetime, empowering vulnerable communities and changing the trajectory of India’s epidemic.

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The author of this post, James Robertson, is Executive Director of India HIV/AIDAlliance. This post is based on his foreword to the Alliance India publication Empowering Key Populations for Sustainable HIV Prevention: Avahan in Andhra Pradesh 2003-2014.

Avahan India AIDS Initiative (2003-2014) was a focused prevention initiative funded by the Bill & Melinda Gates Foundation that worked in six states of India to reduce HIV transmission and lower the prevalence of sexually transmitted infections in vulnerable high-risk populations – female sex workers (FSWs), men who have sex with men (MSM), transgenders, people who inject drugs (PWID) – through prevention education and services, such as condom promotion, STI management, behaviour change communication, community mobilization, and advocacy. Alliance India was a state lead partner for Avahan in Andhra Pradesh (AP).

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Keeping Violence at Bay in Andhra Pradesh: International Day to End Violence against Sex Workers 2013

Violence, stigma and discrimination decrease the capacity of sex workers to access health care and other social services. (Photo by Peter Caton for India HIV/AIDS Alliance)

Violence, stigma and discrimination decrease the capacity of sex workers to access health care and other social services. (Photo by Peter Caton for India HIV/AIDS Alliance)

“I filed an application for a ration card in the mandal (block) administrative office. The clerk made me come to office 15 times, and every time he slept with me,” rues Meena  (name changed), a sex worker from Andhra Pradesh. “Wherever we go – offices, schools, hospitals or banks – we are sexually exploited and discriminated against.”

Sex workers across the world are easy targets for violence and discrimination at work, at home and in society at large. Data show that violence faced by sex workers ranges from slapping to sexual assault, physical and psychological torture, and sometimes even murder. HIV programmes across the world are grappling with this reality of sex workers facing high levels of stigma, discrimination, gender-based violence and other human rights violations, which prevent them from accessing HIV information, health care and needed social services.

To tackle the problem, India HIV/AIDS Alliance has worked through our Avahan programme to develop community-led strategies for prevention and mitigation of violence among female sex workers and other sexual minorities. Working in a total of six states, the Avahan India AIDS Initiative is funded by the Bill & Melinda Gates Foundation. In Andhra Pradesh, our programme covered over 40,000 sex workers in 14 districts. Programme strategies on violence include: community mobilisation and empowerment, crisis response systems and teams; and sensitisation of police and other law enforcement agencies, media personnel and service professionals. The crisis response teams respond within 24 hours to any violence reported by liaising with legal services in the event of unlawful arrests, sexual assault, violence and other rights violations against sex workers.

Since 2006, our team has successfully sensitized around 7,000 police officials at state, district and block level. Over 700 community members have received training on law and human rights and have been recognized by the District Legal Cell Authority as para-legal volunteers (PLVs). PLVs from sex-worker communities provide support to those in need. In addition, community collectivization and legal education has empowered sex workers to recognize and address cases of violence against them.

Routine monitoring on violence and crisis response including data collected from Targeted Interventions for HIV prevention and from special Behavioural Tracking Surveys (BTS) among 2,000 female sex workers in five districts in Andhra Pradesh between 2009 and 2012 showed an improved response to violence in sex worker communities. The number of cases of violence against sex workers has declined by 68 percent, from 900 cases in 2009 to 288 cases in 2011. The BTS data indicate that there has also been a reduction in violence by police (from 29% in 2009 to 19% in 2011-12). The perception of fair treatment by police has increased from 14% (2009) to 29% (2011-12), and around 70 percent of sex workers now experience what they consider to be fair treatment at public institutions.

“Earlier we shuddered at the sight of police. Not anymore. We now know our rights and what to do in a crisis,” says Meena with confidence.

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The author of this post, Dr. Parimi Prabhakar, is Director of Alliance India’s Regional Office in Hyderabad.

The Avahan India AIDS Initiative (2003-2014) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, notably female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

Five Priorities: Alliance India at ICAAP (November 20, 2013, Bangkok, Thailand)

India HIV/AIDS Alliance puts particular emphasis on five priority populations: men who have sex with men: transgenders & hijras; sex workers; people who inject drugs; and people living with HIV. Today at the 11th International Congress on AIDS in Asia and the Pacific (ICAAP 11) in Bangkok, Thailand, we have five sessions that showcase some of our work with key populations. If you are attending, please join us.

Skills Building Workshops:

Me and My Partner’ – A Community-Based Skill Building Training on Positive Prevention for Key Populations

Nov. 20, 1:15-4:15pm, Hall P

Workshop1Equal Access/Equal Rights: Empowering Transgender Communities through Advocacy, Mobilization, and Capacity Building under the Pehchan Program

Nov. 20, 4:15-7:15 pm, Hall K

Workshop2Oral Presentations:

  • Reaching the Hard-to-Reach: Engagement & Facilitation as Research Strategies with Sexual Minorities: Nov. 20, 3:45-5:15pm, Hall H
  • Building Capacity of MSM & TG CBOs to Partner with Government HIV Prevention Interventions in India: Nov. 20, 3:45-5:15pm, Hall H

Press Conference:

  • Engagement & Facilitation as Research Strategies with Sexual Minorities: Nov. 20, 2-3pm, Press Conference Room

Please download our roadmap of sessions at ICAAP that include Alliance India team members or discussions of our work. It includes a full list of our 31 posters describing our responses to a range of key priorities in India’s epidemic. Please also visit our Community Booth (#C3) to learn more about our work.

“11 for ICAAP 11”: A Selection of Alliance India Posters at ICAAP (November 17-22, 2013, Bangkok, Thailand)

Alliance India is presenting a total of 31 posters at the 11th International Congress on AIDS in Asia and the Pacific (ICAAP 11) in Bangkok, Thailand, 17-22 November 2013. To mark the 11th ICAAP, below are a selection of 11 of our posters displayed in Bangkok that detail our work supporting community-based programming for people living with HIV (PLHIV), men who have sex with men (MSM), transgenders, hijras, sex workers and people who inject drugs (PWID), all key priorities to addressing India’s complex epidemic.

Paving the Pathway: PLHIV community consultations enhance national care and support programme in India

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Factors Influencing SRH Service Uptake by PLHIV: Findings from the Koshish baseline study in India  

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An Emergent Crisis: Addressing the Hepatitis C Epidemic in People Who Inject Drugs (PWID) in India

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By the Community, For the Community: Involving PWID in Assessment of Drug-using Patterns Assessments

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Identifying Access Barriers for Transgenders Seeking Gender Transition Services in India

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Community-led Advocacy to Address SRH Needs of PLHIV: Experience from the Koshish programme in India

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Service without a Smile: Pehchan study of the friendliness of HIV services to sexual minorities in India

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Positive Rights and Sexual Health: A review of SRH laws and policies for PLHIV in India

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Tracking Organisational Development of Sexual Minority CBOs in India Using Pehchan’s ‘CBO CyclePoster_Page_10

Power in Our Hands: Increasing involvement by sexual minorities in HIV programme oversight in India 

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Promoting Entrepreneurship among Sex Workers to Reduce HIV Vulnerability in Andhra Pradesh

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Alliance India at ICAAP 11 (November 17-22, 2013, Bangkok, Thailand)

Blog2India HIV/AIDS Alliance is excited to be part of ICAAP 11. You are warmly invited to attend our sessions and learn more about our work in India to improve the AIDS response for communities most affected by the epidemic, including MSM, transgenders and hijras; female sex workers; people who inject drugs, and PLHV from all demographics.

Alliance India staff, board members and representatives from our partner organisations will participate in a range of sessions including pre-conference meetings, skills building workshops, oral presentations, poster exhibits and press conferences.

Please download our roadmap of sessions at ICAAP that include Alliance India team members or discussions of our work. It includes a full list of our 31 posters describing our responses to a range of key priorities in India’s epidemic. Please also visit our Community Booth (#C3) to learn more about our work.

The conference takes place at the Queen Sirikit National Convention Centre (QSNCC) from November 17-22 in Bangkok, Thailand.

APCOM Pre-Conference on MSM and Transgender Issues in Asia and the Pacific

– FOREPLAY: The Final Push Toward the Three Zeroes: Nov. 17, 8.30am–5.30pm, QSNCC

Community Forum

 – Nov. 18, 8.30am–5.00pm, QSNCC

Community Booth & Marketplace

 – Alliance India Community Booth (#C3): Nov. 19: 4-7pm; Nov. 20-21: 9 am-9pm; Nov. 22: 9am-3pm. Zone CG

Oral Presentations

– Reaching the Hard-to-Reach: Engagement & Facilitation as Research Strategies with Sexual Minorities: Nov. 20, 3:45-5:15pm, Hall H

– Building Capacity of MSM & TG CBOs to Partner with Government HIV Prevention Interventions in India: Nov. 20, 3:45-5:15pm, Hall H

Poster Discussion

 – Cervical Cancer Awareness in Women Living with HIV: Findings from the Koshish Baseline in India: Nov. 22, 12:45-1:45pm, Plaza

Skills Building Workshops

– Me and My Partner’ – A Community-Based Skill Building Training on Positive Prevention for Key Populations: Nov. 20, 1:15-4:15pm, Hall P

– Equal Access/Equal Rights: Empowering transgender communities through advocacy, mobilization, and capacity building under the Pehchan program: Nov. 20, 4:15-7:15 pm, Hall K

– Strengthening Community Systems for MSM, Transgender and Hijra Populations in India: The Pehchan Training Curriculum in Action: Nov. 21, 4:15-7:15pm, Hall O

– Beyond My Infection: A workshop to build capacities of PLHIV and Key Populations as advocates on Sexual and Reproductive Health and Rights (SRHR): Nov. 22, 10am-1pm, Hall O

 Press Conferences

 – Engagement & Facilitation as Research Strategies with Sexual Minorities: Nov. 20, 2-3pm, Press Conference Room

– Building capacity of MSM & TG CBOs to partner with Government HIV prevention interventions in India: Nov. 22, 2-3pm, Press Conference Room

We’ll update Facebook, Twitter and our blog every day with details of our activities, including documents to view online or download. We look forward to connecting with you at ICAAP in Bangkok!

If you have any questions, please contact us at info@allianceindia.org. For more information, please visit:

Facebook: https://www.facebook.com/indiahivaidsalliance

Twitter: https://twitter.com/AllianceinIndia

Blog: https://indiahivaidsalliance.wordpress.com/

Website: http://www.allianceindia.org/

Strengthening STI Services for Key Populations: Alliance India’s Mythri Mainstreaming Model

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Providing STI/HIV services in rural areas with fewer and scattered key populations (female sex workers, men who have sex with men, transgenders) is a challenge for HIV prevention programmes in India. In such scenarios, project-supported static clinics are not a sustainable option because of the limited availability of skilled health professionals and operational costs involved. Realising this need for sustainable approaches for providing STI services to key populations, India HIV/AIDS Alliance in collaboration with Andhra Pradesh State AIDS Control Society (APSACS) conceptualized the Mythri Mainstreaming Model in March 2007 as part of programming it supported under the Bill & Melinda Gates Foundation-funded Avahan India AIDS Initiative.

Alliance India initiated the model through a public-private partnership (PPP).The model used infrastructure and personnel of existing government healthcare facilities. Capacity building of staff, provision of STI drugs, and syphilis screening kits were provided by Alliance India to enable the provision of an essential package of STI services. STI services were provided after regular outpatient hours to female sex workers, men who have sex with men, and transgender communities. To address stigma and discrimination in accessing government facilities, doctors and staff were trained on issues faced by these clients.

The Mythri Mainstreaming Model achieved notable success. It resulted in improved utilisation of public healthcare facilities. Within the first year of initiating these clinics, more than 60% of targeted key populations had accessed these STI services. It successfully brought these groups to mainstream healthcare services. The Mythri model serves as a ‘one-stop’ centre for HIV/STI as well as other health care needs of key populations. Considerably greater understanding on health issues of key populations developed among medical staff, and these groups reported less stigma and discrimination while accessing services. Additionally, government healthcare facilities enjoyed improved infrastructure and staff capacities.

A study done by Alliance India to identify the most effective healthcare model for the delivery of STI services found that of the three models studied—project-owned clinics, private clinics, public private partnership (Mythri) clinics—the Mythri model was the most cost-effective. The model was also found to be the most effective in leveraging the strengths of the public and private sector and was the most sustainable of the three.

Due to lower operational costs and with better performance indicators, the Mythri Mainstreaming Model offers characteristics that make it preferable to other models of HIV/STI service delivery for scattered key population groups in rural areas. Similar models should be promoted in other resource-poor settings to improve HIV prevention and overall healthcare for vulnerable populations, such as female sex workers, men who have sex with men and transgenders.

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The author this post, Dr. M. Ravikanth, was Documentation & Communication Specialist with India HIV/AIDS Alliance in Andhra Pradesh.

The Avahan India AIDS Initiative (2003-2013) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, specifically female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

Community Collectivisation to Sustain HIV Prevention: Findings from Avahan in Andhra Pradesh

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Community collectivisation empowers key populations such as female sex workers, men who sex with men and transgenders to voice their concerns and more confidently exercise their right to access healthcare and social welfare schemes. Photo by Peter Caton for India HIV/AIDS Alliance

Community collectivisation can help develop a stronger sense of purpose and interconnectedness among key populations (KPs) such as female sex workers, men who sex with men and transgenders. Sometimes known as ‘community mobilisation’, community collectivisation enables these groups to utilise their experience of vulnerability to overcome barriers they face and realize reduced HIV vulnerabilty and greater self-reliance. Collective action by KPs also empowers them to voice their concerns and more confidently exercise their right to access healthcare and social welfare schemes.

With support from the Bill & Melinda Gates-funded Avahan programme, a recent study led by Niranjan Saggurti of Population Council in collaboration with India HIV/AIDS Alliance was designed to demonstrate if community collectivisation is associated with consistent condom use and STI treatment seeking behaviours among female sex workers (n= 3,557) and high-risk men who have sex with men/transgenders (n=2,399) in Andhra Pradesh. Recently published in the journal AIDS Care, the study generated significant positive findings.

Entitled ‘Community collectivization and its association with consistent condom use and STI treatment seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India’, the study showed that high levels  of collective action and participation in public events by both populations led to higher levels of consistent condom use, increased STI treatment seeking from government facilities, and improved ability to negotiate condom use.

The findings confirm the value of sustained community system strengthening to empower communities to meaningfully engage in national HIV prevention efforts and show the key role played by community collectivisation as an essential strategy to encourage consistent condom use and health seeking behaviours among KPs.

Read the complete study here.

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The author of this post, Dr. Parimi Prabhakar, is Director of Alliance India’s Regional Office in Hyderabad.

The Avahan India AIDS Initiative (2003-2014) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, notably female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.