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People living with HIV and AIDS have a wide range of critical needs that go beyond the treatment of HIV; these include nutrition, psycho-social support, and the prevention and treatment of opportunistic infections. Providing care and support to people with HIV is fundamental to the success of HIV programming and achieving the goal of universal access for people living with HIV.

HIV care and support services include a continuum of critical interventions to improve health and extend life. Broadly, care and support interventions address the overall needs of people living with HIV, their families, caregivers and communities, and are designed to address the health, emotional, nutritional, social, spiritual and financial needs of people living with HIV. This includes HIV testing and counseling, treatment, palliative care, support and prevention.

The National AIDS Control Program III (NACP- III) was launched in July 2007 to halt and reverse the HIV epidemic in India. One of the strategies to contain the infection has been to consolidate efforts in prevention, care, support and treatment of HIV/AIDS. Activities have been undertaken to improve the availability, accessibility and affordability of ART treatment for the poor; strengthen family and community care and psycho-social support to individuals affected by HIV, particularly marginalized women and children; improve compliance to prescribed ART regimens; and address stigma and discrimination associated with the epidemic.

Effective interventions require the active engagement of communities in providing home- and community-based care for people living with HIV. By strengthening local responses, NACP–III aims to ensure high levels of drug adherence and compliance to prescribed ART regimens. Under NACP-III community care centers have been set up in partnership with HIV-positive people in some districts to provide treatment, care and support to people living with HIV/AIDS. People with HIV can access an array of critical services form these centers, including counseling on ARV drug adherence, nutrition and HIV prevention; treatment of opportunistic infections; referral and outreach services for follow-up; and social support services. These centers also refer people with HIV/AIDS to treatment and intervention services such as integrated testing and counseling (ICTC) centers, DOTS and prevention from parent to child transmission (PPTCT) counseling centers. Additionally, family members are counseled on HIV-positive people’s nutritional needs, the importance of treatment adherence and their need for psychological support.

Source: National AIDS Control Organisation.
Community participation is critical to the success of any development initiative and globally, community mobilization is considered essential to HIV/AIDS programming. In addition to risk-reduction services, it is important to design interventions to address the factors contributing to the vulnerability of high-risk groups. The aim of community mobilization programs is to build community ownership of the program, and to strengthen the individual and collective agency of high-risk communities to address factors exacerbating their vulnerability so that they can adopt and sustain safe behaviors.

breaking-thru-barriers Community mobilization is essential to establish interventions on the ground (through mapping and peer led outreach) and to drive the demand for HIV prevention services to ensure program sustainability. Through this process, community members themselves shape and lead the implementation of the program and advocacy efforts, resulting in concrete interventions to make community members safer—as in violence response programs—or in structures such as community-based organizations that act on a range of issues affecting the community. Long-distance truckers, for example, often help decide how to use truck stops as one-stop shops for HIV prevention services. Some sex workers have united to develop shared savings schemes, and others have established a 24-hour response network to address violence and harassment. Similar programs have been shaped to support peer involvement among injecting drug users.

As the program expands, it creates a platform for increasing numbers of community members to interact with each other. They start coming together and expressing greater interest in directly engaging with critical issues such as HIV-related stigma, violence perpetrated by those in authority such as police or clients, and denial or non-availability of essential entitlements such as ration cards.

Community-based organizations: Community mobilization results in the formation of self-help groups, community groups or organizations, some of which have legal registration and charge annual membership fees. These organizations are an effective strategy to ensure effective and sustainable outcomes for prevention interventions, and can foster changes in practices, policies and laws; address societal perceptions that lead to stigma and discrimination; and advocate with government authorities and other stakeholders to secure an enabling environment for high-risk groups to adopt safe practices.

Community members are given formal training in areas such as media management, advocacy and legal literacy so they can effectively manage the activities of local organizations. With program support, community members start shaping local advocacy activities and leading activities such as violence response systems and negotiations with local power structures.

Community based organizations aim to foster community empowerment and leadership by:
Avahan_PowerToTackleViolence Creating critical awareness: Disseminating information on relevant policies among high-risk groups and engaging community members in a critical analysis of relevant issues.
Accessing entitlements: Helping high-risk groups access government schemes and social entitlements such as ration cards, pension schemes and housing.
Provision of services: Identifying high-risk groups’ essential needs, for example, medical, psychosocial or financial, and helping to meet their needs either directly or by linking them with organizations with services in the area.

Empowerment process: Although empowerment is an ongoing lengthy process, community-based organizations focus on encouraging high-risk groups to speak against discrimination and assert their rights.
Challenging structures to address injustice: Community-based organizations aim to develop participatory strategies to challenge societal structures that discriminate and marginalize high-risk groups.
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In many countries, HIV is primarily spread through unprotected sexual intercourse; in such settings the adoption of safer sexual practices is critical for reversing the epidemic. Indeed, in several countries such as Thailand and Cambodia, condoms have played a key role in HIV prevention efforts.
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In India, where HIV is largely transmitted through unsafe sex, consistent condom use is an effective method to prevent the spread of HIV and other sexually transmitted infections (STIs) among sexually active populations.

Condom programs seek to reduce the sexual transmission of HIV by increasing the number of protected sexual acts, resulting in a reduction in the incidence of STIs. However, programs have shown that while it is important to create demand by educating at-risk populations to use condoms to prevent the transmission of HIV and other infections, it is equally critical to ensure that condoms are easily available and promoted in ways that address barriers to their use.

Condom programming operates at several levels to address barriers to condom use and access. Programs, for example, seek to increase awareness and motivate individuals to change behaviors, improve supply and distribution systems, and address community norms and inequitable gender relations. Programs target multiple players and groups including individuals, couples, social networks, community institutions, the private sector and mass media.

Key principles of condom programming are the adoption of strategies to ensure the effective procurement, promotion and delivery of quality condoms, and the implementation of activities to link condom supply and demand. To ensure sustained behavior change, condom programs seek to design appropriate promotional campaigns and distribution infrastructures to reach various target groups in the most cost-effective way.

Condom programming is an important prevention strategy under the Government of India’s National AIDS Control Program (NACP) III. The program seeks to increase consistent condom use among high-risk groups through specific strategies. Additionally, it aims to integrate these activities with prevention services like STI care, counselling and prevention of parent-to-child transmission.
The program addresses both supply and demand side issues. It aims to increase the number of condoms distributed by social marketing programs, the number of condoms commercially sold and the number of free condoms distributed through STI clinics to reach those most at risk of acquiring or transmitting HIV. For example, given the lack of widely available condom stocking retail outlets, other than conventional government-supported family planning outlets and traditional outlets like chemist shops, several non-traditional outlets at paan shops, lodges and strategically located hotspots (venues for soliciting sex) are marketing condoms under the program.

Additionally, states are required to reduce the wastage of ‘free supply’ condoms and establish appropriate storage facilities to ensure the quality of condoms being socially marketed.

In view of the poor increase in condom use, National AIDS Control Organization (NACO), in partnership with a not-for-profit organisation, has designed a national level social marketing plan by which states are required to implement an IT-enabled condom tracking system and manage a condom promotion communications campaign.

To build a demand for condoms, various communication channels, such as mid-media and mass media are being used to promote condom use and address barriers to condom use.
Several innovative approaches have been adopted under NACP III to increase condom use. In several states condom vending machines provide access to quality condoms in a non-personalized context at all times. Female condoms are also being promoted; a pre-programming assessment of the female condom in terms of acceptability, willingness to pay and impact on dual protection has shown encouraging results and is being scaled up in a few states. Thicker, better lubricated condoms will be socially marketed in targeted intervention sites to meet the special needs of high-risk groups.

Source: National AIDS Control Organisation

Violence and discrimination among high-risk communities in India are barriers to the adoption of safe sex practices and the delivery of HIV prevention services. Violence against sex workers, men who have sex with men and transgenders is widespread, and to an extent is condoned by society. The low socio-economic status of sex workers is compounded by the precarious legal status of sex work in India. Without a support system, high-risk groups are more likely to experience violence, making them vulnerable to HIV.

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A prompt and effective community-led response to incidents of violence harassment, abuse, and discrimination directed against members of high-risk groups can lessen the immediate physical danger in which high-risk individuals find themselves, and also reduce vulnerability to high-risk behavior that may be exacerbated by violence.

Crisis response systems advocate with the authorities and other stakeholders to secure an enabling environment, that is, a more supportive legal framework and less hostile social environment. Today, the key role of community led crisis management in HIV prevention interventions is recognized and has been added to the operational guidelines for targeted interventions of the Government of India's National AIDS Control Program III.

While the components of crisis response systems may vary according to the high-risk group involved, the types of crises experienced and the level of NGO support required, most systems share common features. Trained members: The core of the crisis response system is a team of trained high-risk individuals available 24x7 who can rapidly respond to a reported crisis. Roles include receiving calls and sending teams to respond to the crisis; explaining sex workers’ rights and the law to community members and perpetrators of violence, including the police; providing counseling support to victims of violence; referring victims to social services and support; and documenting incidents of violence.

Avahan_PowerToTackleViolence Legal support system: Lawyers are required to respond to crises. They also train high-risk groups to be legal advocates and sensitize various stakeholders, including the police, on the law and rights of high-risk groups. Response protocol: A rapid response is necessary to ensure a community member's safety when threatened with or experiencing physical violence; rapid medical follow-up if necessary, and in cases of arrest or detention by the police, to ensure the victim is not harassed or unlawfully detained at the police station. Some cases require not just an immediate response but strategy, coordination and additional resources. For example, if a female sex worker is forced to fight a charge of lewd conduct in court, she may require advice or financial support to hire a lawyer.

Mobile phone network: A phone-based communication system is integral to crisis response. Members of the crisis response team can be provided mobile phones to respond to calls. In some states crisis response phone hotlines have been established to serve all the program districts. This system also facilitates centralization of data monitoring. Information on the availability of the crisis response system is provided by word of mouth, business cards and fliers, and during community meetings and events at drop-in centers.

Monitoring and documentation: Recording all crisis incidents and responses allows crisis response teams and communities to analyze events, track the overall impact of the system and refine prevention and response efforts. At the local level, accurate records may be required for legal cases to be filed or for complaints to be lodged. At the state and national level, these data can guide decision-making and improve crisis response efforts, and more broadly, can be used to publicize the issue of violence against high-risk groups at the state, national and international level.

Crisis response systems work with other structural interventions, such as advocacy with the police, legal empowerment workshops and media sensitization to address the circumstances that make high-risk individuals vulnerable to HIV.

Violence, whether actual, threatened, or feared, compromises the effectiveness of HIV programs when peer outreach workers are prevented from doing outreach. Ensuring support from law enforcement officials at the state and district levels, for peers to work without harassment has been effective in getting senior police officials to sign peers' ID cards and issue letters supporting their HIV prevention work.

Ongoing efforts are required to collaborate with the local police and sensitize them to HIV related issues as they often harbor misconceptions about high-risk communities, leading to discrimination. Sensitization is an ongoing process; local officers are frequently transferred and collaboration and sensitization efforts need to begin again with new incumbents.

While lawyers are keen to work for a crisis response system, they may harbor prejudices against high-risk groups. Trainings for lawyers address misconceptions about HIV and negative attitudes toward high-risk groups. The media can influence attitudes to HIV, HIV-positive individuals and high-risk groups. However, programs would need to sensitize media persons at the local, state and national levels to HIV-related issues and advocate for sensitive coverage. High-risk individuals would also need to be trained to design and implement effective advocacy strategies for the media.

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Data is a perishable good. Timely and relevant use of data to guide decision-making, though challenging, is critical, particularly for large and complex programs. Programs need to invest resources not just to gather and report data, but also to create and stimulate a culture that emphasizes appropriate data analysis and use at all levels.
Avahan was started in 2003 with the aim of helping slow the transmission of HIV in India by raising prevention coverage to scale in populations most at risk (high-risk groups*) and bridge populations by achieving saturation levels (over 80 percent) across large geographic areas. Avahan works in six highprevalence states—Andhra Pradesh, Tamil Nadu, Maharashtra, Karnataka, Manipur, and Nagaland—which in 2003 accounted for 83 percent of India's estimated HIV infections.

Avahan has three primary goals:
1. Build an HIV prevention model at scale in India
2. Catalyze others to take over and replicate the model
3. Foster and disseminate learnings within India and worldwide

Working within a ten-year timeframe, the initiative has built a large-scale HIV prevention intervention program in the first five-year "build and operate" phase. Avahan operates in six high prevalence states and across major national highways of India. Avahan, as part of the second five-year "transfer and replicate" phase and in keeping with its second goal, is now beginning to hand over the program to "natural owners" like the Government of India and the communities served by the program.

Gathering and using data is critical for all of Avahan's goals—to continuously refine the program and its many moving parts, to inform other HIV prevention efforts including the national prevention program and its direction, and to capture results and best practices.

Data sources relevant to the generated through Avahan program can be grouped into two categories: (1) data generated by the implementation programs; and (2) data relevant to implementation and evaluation collected by evaluation or knowledge building partners funded by Avahan.

Data streams generated by implementation programs include:
Avahan_UseItOrLooseIt Formal mapping and size estimation related to most-atrisk (high-risk) populations; needs assessment studies; and community led mapping of the high-risk populations.

Behavioral data from surveys of high-risk populations and men at risk. Routine program monitoring indicators on service provision, service uptake, and community activities. Several of these indicators are reported monthly since late 2004. These indicators aggregate data captured from communities' interactions with peer educators and utilization of program-owned and -supported STI clinics. They also provide information on other operational and infrastructure aspects reported by the NGOs. Qualitative measures of STI clinical services and community mobilization.
Data streams generated primarily for evaluation or knowledge building purposes include:
Two rounds of a cross-sectional behavioral and biological survey (called the Integrated Behavioral and Biological Assessment—IBBA). This assessment covered: (1) about 27,000 female sex workers, high-risk men who have sex with men, injecting drug users, and male clients of female sex workers, in 29 districts; and (2) 2,000 long-distance truckers along four national highway route corridors.3 These surveys capture an array of data elements—sociodemographic, HIV risk behavior including condom use, and presence of several STIs and HIV infection.

Surveys of general population in five districts to capture sociodemographic behavior, condom use, and prevalence of several STIs and HIV.

Data from other knowledge building grants in areas such as migration and mobility, validation of STI treatment algorithms, and community mobilization and structural interventions.

Over time, Avahan has consciously emphasized analysis and use of data by all stakeholders in the program. Data analysis is used to guide program decisions and activities in areas such as resource allocation, implementation scale-up, course corrections and shifts in implementation, program redesign, impact evaluation, and advocacy.

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Peer led outreach is an approach to providing large-scale HIV prevention services to populations most at risk of infection (high-risk groups). These groups are often difficult to reach due to their poor socioeconomic status, low level of education, and social marginalization. However, trained high-risk individuals can reach their peers effectively using mapping and micro-planning tools to plan and track service delivery at the individual level. These tools position high-risk individuals as leaders and managers of service provision.

Peer outreach workers can be critical resource for providing effective HIV prevention programs at scale, as they can identify and understand the factors that put community members at risk for HIV and STIs, and have the access and influence that make behavior change possible.
By connecting with hard-to-reach groups on the ground, peer outreach workers can improve uptake of clinical and social support services and are thus a critical resource for providing effective HIV prevention programs at scale. Peers are able to identify and understand the factors that put community members at risk for HIV and STIs, and they have the access and influence that make behavior change possible. Developing the capacity of high-risk individuals to serve as peers creates a number of benefits for an HIV prevention program:

Breadth of outreach: It enables outreach to diverse communities of high-risk individuals in varied geographic areas.

Access: It strengthens outreach to communities that are unlikely to seek services on their own, due to poor self-esteem, stigma, or marginalization. In addition, as peers take on aspects of outreach that were previously the responsibility of NGO staff, they become the face of the program to the community that is served.

Management: It makes the best use of peers' credibility and insider knowledge and their understanding of risk. This is most effective when combined with training and tools that enable peers to collect and analyze data, and then use the information to manage their own work.

Sustainability: It helps to enhance leadership among high-risk individuals, strengthens community ownership of programs, and fosters problem-solving within high-risk communities. Peers may begin by doing outreach within their community and progress to supervise other peers, become full-time staff members of the NGO that is coordinating the intervention, or lead other community actions beyond the program.

Empowerment: It gives high-risk individuals the skills and impetus to participate in more general advocacy on issues of importance to their communities, such as access to health and educational services, and freedom from discrimination and violence.

Components of Peer led outreach:-
Mapping takes place in two stages: hotspot mapping and social network mapping. Peer and NGO staff outreach workers, supported by a facilitator, first map the hotspots where they will work. A hotspot map is a simple pictorial representation of an area where there is a concentration of high-risk behavior. It includes streets, buildings, major features such as railways, bus, and train stations, cinemas, police stations, and locations where condoms are available. The peer also identifies the location and number of high-risk individuals within the hotspot. In the second stage, peers create maps of their social networks within their beat. These non-topographical maps list the names of their friends and acquaintances in the high-risk communities, and use symbols or colors to mark their typologies and baseline risk characteristics (e.g., number of clients per month), and the connections between them. Examined together, hotspot and social network maps provide a visual representation of the total high-risk population across several locations. They enable outreach supervisors and peers to assign outreach groups to peers at the sites where they know the most people, ensuring that each high-risk individual is covered through outreach and there is no overlap in coverage. Peers revise hotspot and social network maps on a regular basis (usually every six months) to track changes, such as new high-risk individuals who should be assigned to a peer for initial outreach, others who have left the area, and peers' own expanding social networks. More frequent revisions may be needed when there is high mobility among high-risk individuals.

Performing outreach at regular time intervals to an average number of high-risk individuals, spending few hours each day for outreach activities. Conduct face-to-face discussions with the peer’s outreach group, primarily on ‘one-to-one’ basis but sometimes also in small groups and provide information and services.

Micro-planning enables peers to record individualized data about the people with whom they do outreach, so that they can analyze their work and plan their future outreach. The peers use daily, weekly, and monthly tracking tools, which can be developed with their participation at the district or regional level, and field tested at the local level. In some instances each local NGO may develop its own tracking tools to take into account local preferences and needs, but the data points gathered must correlate with any data standards established by the program at the regional or state level.

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The treatment and prevention of sexually transmitted infections (STIs) among high-risk groups has been demonstrated to be an effective component of an overall strategy for preventing the spread of HIV. In addition, counseling about condom use can occur in the context of clinical services, and individuals are more likely to heed prevention messages if such services are provided. For these reasons, the scale-up of treatment and prevention of STIs within high-risk groups has been an important part of Avahan's intervention strategy.
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In a country as large as India, scale-up is a significant challenge, especially for a program that seeks to reach a large and diverse number of high-risk individuals including female sex workers, high-risk men who have sex with men, transgenders, injecting drug users, and male clients of sex workers, all of whom are dispersed across widely varied geographic areas and cultures. Avahan: The India AIDS Initiative addressed this challenge by designing, organizing, and executing its program to operate at scale.

Avahan's approach for STI service delivery was based on the overall project design for scale-up: Designing for scaleOrganizing for scaleExecuting and managing for scale Designing for scale
Before starting STI service delivery, Avahan partners conducted detailed mapping and size estimations of the highrisk populations across the districts they were to cover. These exercises helped establish an initial denominator and locations against which Avahan planned scale-up of services. Based on this mapping and size estimation exercise within each district, Avahan identified key locations that contained large concentrations of high-risk group members where services should be established first in order to cover the largest number of individuals. This was done without compromising the need for simultaneous scale-up for different populations across different districts. For example, Avahan saturated coverage of sex workers in major urban areas with the largest populations before expanding coverage to less dense, peri-urban areas. Depending on the density of the high-risk populations and proximity to service delivery sites, clinic services were provided through project-owned static clinics, outreach clinics (including mobile vans, satellite clinics, and health camps), preferred providers (private clinics that are screened and contracted to provide services to high-risk individuals), and government clinics strengthened through equipment provision and staff training. In addition, Avahan provided STI support in 14 districts where the government was already providing services. The two male client programs focused on intervention locations with the highest concentrations of men at risk, either in large "hotspots" (places where sex is solicited) or large truckstops on the national highways. With these estimates in hand, Avahan partners next set about designing a number of elements that would promote consistent and high-quality roll-out of the STI services. Several of these elements were technical while others concerned program management and monitoring services to improve delivery and gauge the success of the intervention.

The most important elements related to STI services are: Creating a common minimum program that clearly defined: STI "Essential Services Package" that all clinics should provide; A manual of operating standards called the Clinic Operational Guidelines and Standards for all clinics; Key project milestones that provided measurable targets and timelines for the program to guide implementation.Providing capacity building support to NGOs responsible for operating and managing STI clinics since many were undertaking this type of work for the first time.Creating a common management framework that defined relationships and management support guidelines (such as intensity of engagement and relationship with lead implementing partners, STI capacity building partners, and other stakeholders), and formal review process guidelines.

Developing and using data collection tools, such as routine program data and qualitative and quantitative assessments to monitor and improve services. These data are used to inform all decision making.This includes metrics for program-wide analysis of Avahan, predictive and warning capabilities for a district,and the ability to look at individual NGO- and clinic-level data.

Organizing for scale
Avahan designed its organizational structure to enable rapid and simultaneous scale-up across geographic areas, facilitate standardization of key elements, and share best practices across all programs, including STI services.

Executing and managing for scale
With a design and organizational structure in place, Avahan focused on rolling out and managing the STI intervention. Key activities included: Near simultaneous creation of the service delivery footprintCustomizing services to high-risk population needsMaintaining execution focusManaging all levels of the intervention.
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