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.
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).