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Scaling up prevention with MARPs

Scaling up prevention with MARPs. Padma Chandrasekaran The Bill & Melinda Gates Foundation February 20, 2009 Chennai , India. Today’s discussion – . India’s HIV epidemic and MARPs prevention response to date BMGF’s experience with the Avahan program in scaling up HIV prevention for MARPs.

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Scaling up prevention with MARPs

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  1. Scaling up prevention with MARPs Padma Chandrasekaran The Bill & Melinda Gates Foundation February 20, 2009 Chennai, India

  2. Today’s discussion – • India’s HIV epidemic and MARPs prevention response to date • BMGF’s experience with the Avahan program in scaling up HIV prevention for MARPs

  3. Four southern and two north eastern states have relatively higher burden of HIV ANC HIV PREVALENCE 2006 148 No data available 368 HIV prevalence at ANC sites <1.0 83 HIV prevalence at ANC sites >=1.0 Source: NACO’s Sentinel Surveillance data: ANC sites (2003 and 2006), National Family Health Survey 3

  4. Local Partners High risk network (distal) High risk network (local) Bridge Population Local Partners High risk network (distal) Bridge Population The Transmission Dynamics of different types of HIV Epidemics Truncated epidemic – very slow, small trickle down • Sexual patterns not sufficient to sustain an epidemic • HIV infection dependent on individuals infected elsewhere (migrants, truckers) • Source stage high risk group prevention focus Local concentrated epidemic - slow, sizeable trickle down • Transmission driven by distal and local high-risk networks • Size of epidemic dictated by size of high-risk populations • Prevention strategies should focus on interrupting transmission within distal and local high-risk networks Generalized epidemic – lateral spread • Sexual networks and behaviors conducive to widespread transmission beyond high-risk sub-populations • Sexually active population level focus needed for prevention Most Asian countries and India specifically do NOT have generalised epidemics Source: Moses et al HIV / AIDS in South Asia, World Bank (2006)

  5. India has a classic concentrated epidemic in the key southern and north east states MARPs in India Female Sex Workers (FSW) High Risk Men who have Sex with Men (HR-MSM) Intravenous Drug Users (IDUs) HIV among Antenatal Clinic (ANC) attendees is used as a proxy to track general population HIV prevalence Source: NACO’s Sentinel Surveillance data 2006

  6. Selected MARPs size estimates (southern states) 330,000 odd Between 0.6% and 1.4% of urban adult women practice sex work in these states This is consistent with other Asian countries such as Indonesia A rough rule of thumb for curtailing transmission from core to bridge groups is to ensure saturated (>=80%) coverage of groups with high transmission potential

  7. Scale up of MARPS coverage in India over time… NACP2 had a stated focus on Targeted Interventions (TIs) for high risk group prevention but the focus was diluted in actual interventions on the ground with only 31% of 965 so called TIs focusing on the real MARPS in India (FSW, HR-MSM, IDU) The BMGF funded Avahan program began in 2003-4 with the aim of saturating prevention coverage, in concert with the Government of India, of these groups in 4 southern and 2 north eastern states NACP3 has an appropriate focus and sufficient budget, backed by the will and ability to saturate coverage in these states and elsewhere in the country

  8. Today’s discussion – • India’s HIV epidemic and MARPs prevention response to date • BMGF’s experience with the Avahan program in scaling up HIV prevention for MARPs

  9. Introduction to Avahan…. • Foundation’s entry rationale (c2003) • Prevention for concentrated epidemics via HRG focus well known • Global calls for bridging prevention gap • Globally few examples of HRG prevention at scale • Evidence of large growing concentrated Indian sub-epidemics • National program had low prevention coverage of high risk groups • Avahan’s ten year charter • Impact the HIV epidemic and response over long term in India by: • Build / operate (implement) HIV prevention program at scale for high risk groups • Transferring programs to Government and other implementers in India • Actively fostering and disseminating learnings • Timelines • Avahan I (implement) launched in December 2003 ($ 258 million) • Avahan II (transition to natural country owners) launching now…..

  10. BMGF tried to take a thoughtful, comprehensive approach to designing AvahanI as a MARPS focused prevention program • MARPS Prevention Package • Outreach, BCC • Commodities (condoms, lubricants, needles) • Clinical services for STIs + counselling • Case managed approach to referral - TB, HIV testing, ART • Local advocacy – police sensitisation, crisis response, community advisory committees

  11. Avahan’sscale of operations 6 states, 83 districts Combined State Population ~ 300 million High risk groups covered FSW – 213,000 MSM / TG – 76,000 IDU – 25,000 Men at risk – 5 million High risk groups Men at risk

  12. Delivered through a Virtual Organisation of lead partners, grassroots NGOs / CBOs, peer educators… State-level Strategy 9 LEAD PARTNERS District-level Planning 134 GRASSROOTS INDIAN NGOs / CBOs Hotspot-level Implementation 7,500 PEER EDUCATORS AND OUTREACH WORKERS Individual-level Tracking ~280,000 FEMALE SEX WORKERS HIGH-RISK MEN WHO HAVE SEX WITH MEN INJECTING DRUG USERS MEMBERS OF CORE GROUPS ~5,000,000 MEN AT RISK RECEIVING SERVICES Cross cutting support Capacity building, Advocacy, Monitoring and Evaluation, Knowledge Building Source: Avahan routine monitoring data, December 2007

  13. Building Scale…. Zeroing in on geographies, critical districts, sub districts in partnership with governmentExample of Belgaum district, Karnataka state

  14. HIV prevalence at ANC sites <1.0 HIV prévalence at ANC sites 1.0-1.5 HIV prévalence at ANC sites 1.5 – 2.0 HIV prévalence at ANC sites 2.0-2.5 HIV prévalence at ANC sites 2.5-3.0 HIV prévalence at ANC sites >=3 Building Scale…. Zeroing in on geographies, critical districts, sub districts in partnership with governmentExample of Belgaum district, Karnataka state KARNATAKA STATE PROFILE • Population 55 million • 27 districts, 175 sub-districts, 270 towns, 29,406 villages • ANC median prevalence 1% • FSW population >70,000; more than 80% street based • MSM population 25,000 • Estimated client population 3.5 million Source: NACO’s Sentinel Surveillance data: ANC sites (2006)

  15. Building Scale…Accurate denominators in a districtBelgaum district, Karnataka To Mumbai, Maharashtra (325 miles) To Sangli, Maharashtra (186 miles) Accurate denominators on sub-geographies Mapping, size estimation, needs assessment for FSWs, HR- MSM, and IDU in urban, peri-urban and where warranted, rural areas Next steps: Start programming in top 6 to 8 towns To Kolhapur, Maharashtra (64 miles) FSWs in Belgaum district, Karnataka Estimated FSW population in district = 2000 Estimated FSW worker population in first 6 towns receiving Avahan interventions = 1400 (70% of denominator) Sex worker mapping (~2000 FSWs, equal number of MSMs) Police harassment / local goon violence Sex worker and client mobility To Goa (99 miles)

  16. Building scale … the 80:20 service rule (or bang for buck!) FSW / MSM programs Male at risk programs Select semi-urban, villages (10 or more sex workers) Sub-district (taluka) headquarters • Satellite clinic /health camps or referral clinics • STI program clinics with referral diagnostic facilities • STI program clinic with at least syphilis testing on-site Other district headquarters • Behavior change communication (interpersonal communication/mid- media/mass media) • STI “franchise” clinics(clinics at truck stops) • Socially marketed condoms/condom normalization/mass media Large cities (8-10 across Avahan); red light areas; and ~100 townsin highly affecteddistricts Free condoms Less intense STI infrastructure Franchised clinics

  17. Building scale…. Getting community buy in from the start Example of peer educators street mapping to determine their “beats”, service placement

  18. Building scale….. Knowing the customer, helping her (them) advocate against stigma & discrimination at local, state and national levels

  19. Building Scale …. Establishing a footprintBelgaum district, Karnataka Services and commodities for female and male sex workers • Peer-led outreach (48 peers and outreach workers) • Program-owned community centers and clinics (8) • Referral doctors (10) • Free condom distribution (~39,000 per month) Services and commodities for clients of sex workers • Condoms socially marketed to high-risk men (~76,000 per month) • Franchised STI treatment clinics for high risk men (18 in top 4 towns) • Outreach workers for IPC with high-risk men (57 in top 4 towns) Community mobilization and creation of an enabling environment • Capacity building of local community-based organization to provide: • Crisis response cell • Police sensitization training • Community advisory committees Sex worker mapping (~2000 FSWs, equal number of MSMs) Police harassment / local goon violence Sex worker and client mobility Program owned community centers and clinics Referral clinics PSI male client programs CBO advocacy efforts, community advisory committees

  20. Resulting in simultaneous, not sequential scale up across states Jun-04 Dec-04 Jun-05 Dec-05 Jun-06 Dec-06 Jun-07 Dec-07 Dec 03 604 605 598 578 531 465 408 376 Towns covered 7500 7200 7100 6200 5000 4000 2300 240 Peer educators 280 250 171 135 104 79 49 States (6) 22 Districts (83) Core groups covered (figure in thousands) Intervention sites 15 13 10 7 6 5 2 1 Condoms distributed and sold per month(figure in millions) Source: Avahan routine monitoring data

  21. Intense Field Engagement Living Common Minimum Program Monitoring Data Formal Reviews Managing scale… Management Systems

  22. Managing scale…. Frontline data capture and use (tailored for non-literate, pictorial use) Data is a perishable good! Source: Pathfinder International, Pune, India

  23. Community members Clinic Data Outreach Data Individual visits to clinics (recorded by clinic staff) Individual interactions (recorded pictorially by peer educators) Data used to plan outreach and service promotion at peer level Individual data plus other operational data Aggregated at NGO level and used to monitor progress locally Aggregated at lead partner level Managing scale… consolidation of data from frontline Avahan partners’ MIS systems Are key to their management of scale up Are complex as any financial / banking transaction s Are mined for rich information at aggregate and drill down levels

  24. Monitoring Data Size Estimates Quality Monitoring Core & Bridge Surveys (n=23,000) Gen Pop Surveys (n=25,000) Cost Data EVALUATING AT SCALE… QUESTIONS, METHODS, DATA SOURCES 3 questions Scale / coverage? Outcomes / Impact? Cost Effectiveness? Government’s ANC Data By district

  25. Results… increasing condom use across all districts In the context of other survey data on FSW in India… … overtime among FSW in Avahandistricts Percent Percent … as reported by male clients of FSW too Percent Source: NACO BSS 2001; NACO BSS 2006; Avahan IBBA 2006 Avahan’s Karnataka program data

  26. Reduced STI levels Compared to historical biological data... Percent Percent ….and within Avahan districts Percent Source: APAC FSW Survey, 2003; IBBA Round 1, 2006; FHI/DFID FSW Survey, 2001, IBBA Round 1, 2006; Avahan IBBA Round 1 and 2, Karnataka

  27. Encouraging early signs of general population impact…. Age segregated antenatal clinic prevalence shows declines in intervention intensive districts Source: Moses, S, et al. AIDS, 2009, 23 (suppl). In press.

  28. A selection of recent peer reviewed articles and other publications about the Indian HIV epidemic and the Avahan program……page 1 INDIAN HIV EPIDEMIC & RESPONSE http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(06)70551-5/fulltext http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61756-5/fulltext http://content.healthaffairs.org/cgi/content/abstract/27/4/1091 http://sti.bmj.com/cgi/content/abstract/83/suppl_1/i30 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68435-3/fulltext http://www.aidsonline.com/pt/re/aids/abstract.00002030-200812005-00012.htm;jsessionid=JdQV2JjlV1dD64R4QB1VVmSNttp2b2HGpBRL7BxTJQLrFCYXv65P!1910807570!181195628!8091!-1 http://www.aidsonline.com/pt/re/aids/abstract.00002030-200812005-00010.htm;jsessionid=JdQh7TGZCS72qbTl8xB6qcgCzGWtGn2hgSLhLXTmS1nJyPg5wyL7!-1429555639!181195629!8091!-1 http://www.aidsonline.com/pt/re/aids/abstract.00002030-200901140-00011.htm;jsessionid=JdQTXgRDdt1hgXZ1vvvbj8B67Tnz43Jpn8Vgn4hc1K9jYPGK8LnH!1910807570!181195628!8091!-1 http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00007.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00006.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00004.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00003.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00011.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00010.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00005.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://www.hcs.harvard.edu/~hhpr/publications/current/Stones_and_Pallikadavath.pdf

  29. A selection of recent peer reviewed articles and other publications about the Indian HIV epidemic and the Avahan program……page 2 Peer reviewed publications about the Avahan Program and its Evaluation http://sti.bmj.com/cgi/content/abstract/84/Suppl_2/ii19?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Avahan&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00001.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00014.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00009.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://aidsonline.com/pt/re/aids/abstract.00002030-200812005-00008.htm;jsessionid=Jd6DXn10TxY5sh3HQYGDH4McG84QMqJxDGQQ1vD2jDhj1Tv6vTy2!1910807570!181195628!8091!-1?index=1&database=ppvovft&results=1&count=50&searchid=2&nav=search http://sti.bmj.com/cgi/content/abstract/82/5/381?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Avahan&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT http://sti.bmj.com/cgi/content/abstract/82/5/372?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Avahan&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT http://sti.bmj.com/cgi/content/abstract/83/7/582?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Avahan&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT Monographs about Avahan http://www.gatesfoundation.org/avahan/Documents/Avahan_HIVPrevention.pdf http://www.gatesfoundation.org/avahan/Documents/Avahan_UseItOrLooseIt.pdf http://www.gatesfoundation.org/avahan/Documents/Avahan_OffTheBeatenTrack.pdf http://www.gatesfoundation.org/avahan/Documents/Avahan_PowerToTackleViolence.pdf http://www.gatesfoundation.org/avahan/Documents/Avahan_PeerOutreach.pdf

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