ObjectiveDocumenting the implementation of a public health programme as per its design is critical to interpretation of results from survey-led outcome and impact evaluation activities, the authors describe the scale-up and coverage of large-scale HIV-prevention services provided to female sex workers (FSWs) and high-risk men who have sex with men (HR-MSM) during the first 5 years of the Avahan programme in India.MethodsImplementing NGO partner-generated denominator estimates from 70 districts were used to estimate the programme's intended coverage. Routine programme-monitoring data until December 2008 were used to describe the service and commodity availability, service utilisation to generate internal estimates of coverage. Coverage was validated in few districts using data from a cross-sectional survey.ResultsIn December 2008, the estimated denominators for intended services were about 217 000 FSWs and 80 000 HR-MSM. By January 2007, 79% of eventual total clinics and 75% drop-in centres were established, and 83% of eventual peer educators were active. By month 48, sufficient condoms to cover all estimated FSW commercial sex acts were distributed free. By month 60, 75% of the estimated denominator intended to be covered was met monthly. 86% of FSWs and 67% of HR-MSM ever contacted had used sexually transmitted infections services at least once. Cross-sectional survey generated coverage results suggest that programme-monitoring data provide a proxy to coverage of services.ConclusionAvahan's monitoring data show that Avahan achieved infrastructure scale by year 3 and high contact coverage through peers and with commodities by year 5 of implementation as per the design.

Background This paper examines the association between degree of confidence in collective efficacy and self-efficacy for condom use and empowerment among heterogeneous female sex workers (FSWs) in two metropolitan Indian cities with high HIV prevalence. Methods The study utilises data from the Behavioural Tracking Survey, a cross-sectional behavioural study with 2106 FSWs recruited from 411 intervention sites in Mumbai and Thane. The key independent measures used determine the degree of confidence in collective efficacy (belief in the power to achieve goals and address problems together) and outcome measures included: self-efficacy for condom use with occasional clients and condom use with regular partners, self-confidence in handling a crisis situation and public speaking ability. Univariate and multivariate statistical methods were used to examine the study objectives.Results Of the analytical sample of 2106 FSWs, 532 (25.3%) reported high degree of collective efficacy for achieving certain goals and 1534 (72.8%) reported collective efficacy for addressing specific problems. FSWs reporting a higher collective efficacy as compared with those reporting lower collective efficacy were as follows: more likely to negotiate condom use with occasional clients (60.3% vs 19.7%; adjusted OR (AOR) ¼6.3, 95% CI 4.8 to 8.4) as well as regular partners (62.8% vs 20.2%; AOR ¼6.4, 95% CI 4.9 to 8.4); confident in facing troublesome stakeholders (73.5% vs 38.8%; AOR ¼4.3, 95% CI 3.3 to 5.6), confident in supporting fellow FSWs in a crisis (76.1% vs 49.6%; AOR ¼2.9, 95% CI 2.2 to 3.7), received help from other FSWs when a client or partner was violent (73.9% vs 46.3%; AOR ¼3.5, 95% CI 2.7 to 4.5) and had stood up to the police or madams/brokers to help fellow FSWs in the past 1 year (5.8% vs 3.3%; AOR ¼2.7, 95% CI 1.5 to 4.9). Conclusion The results suggest that the strategy of collectivisation in HIV prevention programme has much broader benefits than merely the promotion of safer sex practices. Future HIV prevention interventions in India and elsewhere may include collectivisation as the core strategy within HIV prevention programmes.

BackgroundAvahan, the India AIDS Initiative, implemented a large HIV prevention programme across six high HIV prevalence states amongst high risk groups consisting of female sex workers, high risk men who have sex with men, transgenders and injecting drug users in India. Utilization of the clinical services, health seeking behaviour and trends in syndromic diagnosis of sexually transmitted infections amongst these populations were measured using the individual tracking data.MethodsThe Avahan clinical monitoring system included individual tracking data pertaining to clinical services amongst high risk groups. All clinic visits were recorded in the routine clinical monitoring system using unique identification numbers at the NGO-level. Visits by individual clinic attendees were tracked from January 2005 to December 2009. An analysis examining the limited variables over time, stratified by risk group, was performed.ResultsA total of 431,434 individuals including 331,533 female sex workers, 10,280 injecting drug users, 82,293 men who have sex with men, and 7,328 transgenders visited the clinics with a total of 2,700,192 visits. Individuals made an average of 6.2 visits to the clinics during the study period. The number of visits per person increased annually from 1.2 in 2005 to 8.3 in 2009. The proportion of attendees visiting clinics more than four times a year increased from 4% in 2005 to 26% in 2009 (p<0.001). The proportion of STI syndromes diagnosed amongst female sex workers decreased from 39% in 2005 to 11% in 2009 (p<0.001) while the proportion of STI syndromes diagnosed amongst high risk men who have sex with men decreased from 12% to 3 % (p<0.001). The proportion of attendees seeking regular STI check-ups increased from 12% to 48% (p<0.001). The proportion of high risk groups accessing clinics within two days of onset of STI-related symptoms and acceptability of speculum and proctoscope examination increased significantly during the programme implementation period.ConclusionsThe programme demonstrated that acceptable and accessible services with marginalised and often difficult–to-reach populations can be brought to a very large scale using standardized approaches. Utilization of these services can dramatically improve health seeking behaviour and reduce STI prevalence.

BackgroundIt is important for targeted interventions to consider vulnerabilities of female sex workers (FSWs) such as poverty, work-related mobility, and literacy, for effective human immunodeficiency virus (HIV) prevention. This paper describes and examines the association of the Aastha HIV/sexually transmitted infection (STI) prevention project in Mumbai and Thane, India, on the relationship between vulnerability and behavioral outcomes.Materials and methodsData were drawn from the Behavioural Tracking Survey, a cross-sectional behavioral study conducted in 2010 with 2,431 FSWs recruited in Mumbai and Thane. The key independent measures used were program exposure and “vulnerability index”, a composite index of literacy, factors of dependence (alternative livelihood options, current debt, and children), and aspects of sex work (mobility and duration in sex work). Dependent measures included service uptake, self-confidence, self-identity, and individual agency. Logistic regression analysis was used to examine the study objectives.ResultsOf the analytical sample of 2,431 FSWs, 1,295 (53.3%) were categorized as highly vulnerable. Highly vulnerable FSWs who were associated with the Aastha program for more than a year were more likely to have accessed crisis-response services in the past 6 months (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.4–3.6; P<0.001), to have visited a clinic to get a checkup for STI symptoms (AOR 2.4, 95% CI 1.2–4.8; P<0.015), not to be ashamed to disclose identity as an FSW to health workers (AOR 2.1, 95% CI 1.2–3.5; P<0.008), and to be confident in supporting a fellow FSW in crisis (AOR 1.7, 95% CI 1.0–2.8, P<0.033) compared to those less vulnerable with similar exposure to the Aastha program.ConclusionIt is critical for HIV/STI interventions to consider vulnerabilities of FSWs at project inception and address them with focused strategies, including a segmented service-delivery model and community involvement, in order to strengthen the structural response to HIV prevention.

BackgroundThe objectives of this paper are: (1) to study the feasibility and relative benefits of integrating the prevention of parent-to-child transmission (PPTCT) component of the National AIDS Control Program with the maternal and child health component of the National Rural Health Mission (NRHM) by offering HIV screening at the primary healthcare level; and (2) to estimate the incremental cost-effectiveness ratio to understand whether the costs are commensurate with the benefits.MethodsThe intervention included advocacy with political, administrative/health heads, and capacity building of health staff in Satara district, Maharashtra, India. The intervention also conducted biannual outreach activities at primary health centers (PHCs)/sub-centers (SCs); initiated facility-based integrated counseling and testing centers (FICTCs) at all round-the-clock PHCs; made the existing FICTCs functional and trained PHC nurses in HIV screening. All “functional” FICTCs were equipped to screen for HIV and trained staff provided counseling and conducted HIV testing as per the national protocol. Data were collected pre- and post- integration on the number of pregnant women screened for HIV, the number of functional FICTCs and intervention costs. Trend analyses on various outcome measures were conducted. Further, the incremental cost-effectiveness ratio per pregnant woman screened was calculated.ResultsAn additional 27% of HIV-infected women were detected during the intervention period as the annual HIV screening increased from pre- to post-intervention (55% to 79%, p < 0.001) among antenatal care (ANC) attendees under the NRHM. A greater increase in HIV screening was observed in PHCs/SCs. The proportions of functional FICTCs increased from 47% to 97% (p < 0.001). Additionally, 93% of HIV-infected pregnant women were linked to anti-retroviral therapy centers; 92% of mother-baby pairs received Nevirapine; and 89% of exposed babies were enrolled for early infant diagnosis. The incremental cost-effectiveness ratio was estimated at INR 44 (less than 1 US$) per pregnant woman tested.ConclusionsIntegrating HIV screening with the broader Rural Health Mission is a promising opportunity to scale up the PPTCT program. However, advocacy, sensitization, capacity building and the judicious utilization of available resources are key to widening the reach of the PPTCT program in India and elsewhere.