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

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Presentation on theme: "11 Scaling up prevention with MARPs Padma Chandrasekaran The Bill & Melinda Gates Foundation February 20, 2009 Chennai, India."— Presentation transcript:

1 11 Scaling up prevention with MARPs Padma Chandrasekaran The Bill & Melinda Gates Foundation February 20, 2009 Chennai, India

2 22 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 33 Source: NACO’s Sentinel Surveillance data: ANC sites (2003 and 2006), National Family Health Survey 3 Four southern and two north eastern states have relatively higher burden of HIV No data available HIV prevalence at ANC sites <1.0 148 368 HIV prevalence at ANC sites >=1.0 83 ANC HIV PREVALENCE 2006

4 44 The Transmission Dynamics of different types of HIV Epidemics High risk network (distal) Bridge Population Local Partners 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 Source: Moses et al HIV / AIDS in South Asia, World Bank (2006) High risk network (distal) Bridge Population Local Partners High risk network (local) 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

5 55 India has a classic concentrated epidemic in the key southern and north east states Source: NACO’s Sentinel Surveillance data 2006 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

6 66 Selected MARPs size estimates (southern states) 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 330,000 odd 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 77 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 88 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 99 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 10 BMGF tried to take a thoughtful, comprehensive approach to designing Avahan I 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 11 Avahan’s scale of operations High risk groups Men at risk 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

12 12 Delivered through a Virtual Organisation of lead partners, grassroots NGOs / CBOs, peer educators… 9 LEAD PARTNERS 134 GRASSROOTS INDIAN NGOs / CBOs 7,500 PEER EDUCATORS AND OUTREACH WORKERS ~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 State-level Strategy District-level Planning Hotspot-level Implementation Individual-level Tracking Cross cutting support Capacity building, Advocacy, Monitoring and Evaluation, Knowledge Building Source: Avahan routine monitoring data, December 2007

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

14 14 Building Scale…. Zeroing in on geographies, critical districts, sub districts in partnership with government Example of Belgaum district, Karnataka state 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 Source: NACO’s Sentinel Surveillance data: ANC sites (2006) 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

15 15 Building Scale…Accurate denominators in a district Belgaum district, Karnataka 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) To Goa (99 miles) To Kolhapur, Maharashtra (64 miles) To Mumbai, Maharashtra (325 miles) To Sangli, Maharashtra (186 miles) Sex worker mapping (~2000 FSWs, equal number of MSMs) Sex worker and client mobility Police harassment / local goon violence 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

16 16 Building scale … the 80:20 service rule (or bang for buck!) Large cities (8-10 across Avahan); red light areas; and ~100 towns in highly affected districts Select semi-urban, villages (10 or more sex workers) Sub-district (taluka) headquarters FSW / MSM programs Male at risk programs Socially marketed condoms/condom normalization/mass media Other district 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 Free condoms Less intense STI infrastructure Behavior change communication (interpersonal communication/ mid- media/mass media) STI “franchise” clinics (clinics at truck stops) Franchised clinics

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

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

19 19 PSI male client programs Sex worker mapping (~2000 FSWs, equal number of MSMs) Sex worker and client mobility Police harassment / local goon violence Program owned community centers and clinics Referral clinics CBO advocacy efforts, community advisory committees Building Scale …. Establishing a footprint Belgaum 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

20 20 Resulting in simultaneous, not sequential scale up across states Source: Avahan routine monitoring data Towns covered 376 408 465 531 578 598 604605 Peer educators Core groups covered (figure in thousands) Condoms distributed and sold per month (figure in millions) 240 22 1 2300 49 2 4000 79 5 5000 104 6 6200 135 7 7200 171 10 7100 250 13 7500 280 15 Dec 03 Jun-04Dec-04Jun-05Dec-05Jun-06Dec-06Jun-07Dec-07 Districts (83) States (6) Intervention sites

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

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

23 23 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 Community members Individual interactions (recorded pictorially by peer educators) Individual visits to clinics (recorded by clinic staff) Aggregated at lead partner level Clinic DataOutreach Data Data used to plan outreach and service promotion at peer level Aggregated at NGO level and used to monitor progress locally Individual data plus other operational data

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

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

26 26 Reduced STI levels 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 Compared to historical biological data... ….and within Avahan districts Percent

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

28 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 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=an d&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&sear chid=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&sear chid=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&sear chid=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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