XVII International AIDS Conference Mexico City Sex workers use business skills to reach their peers for HIV prevention resulting in high coverage over four states in India Experience from Avahan – India AIDS Initiative XVII International AIDS Conference Mexico City Peer outreach workers have significantly accelerated the pace and intensity of coverage in Avahan. I am going to walk you through how that happened, share the microplanning tools they use which have allowed them to become data users and analysts – case manager for prevention, and share data with you to show you how peers have enhanced condom distribution, clinic attendance and our understanding of the needs of high risk individuals. (insert the data) Abstract Session TUAC01 - Prevention Programs with Female Sex Workers

Avahan Scaled Up Rapidly Dec 03 Year 1 Year 2 Year 3 Year 4 489 30 Towns covered 7,458 240 Peer outreach workers 278,000 53,000 Talk about Scale: Coverage of areas with 300 million people, to pop of 280K (200K FSW, 60K MSM/T, 20K IDU) and 5 million men at risk; This accounts for 83% of infections in India. Grant portfolio of 260 million between 2005-8; Seven lead implementing partners and they have 134 grass roots NGOs. At the front line are Avahan’s peers, 7,458 manage services meeting 278,000 individuals in a month. Data Use: messaging? Each peer is responsible for managing the service demand for 35 to 50 of her colleagues. She responds to strengthen condom demand, clinic attendance, STI treatment and confront vulnerability. Denominator covered (FSW, MSM, IDU) Avahan states (6) 14.7 m Avahan districts (83) Avahan intervention sites (489) 0.8 mil Condoms distributed and sold per month (in millions) Source: Avahan’s routine monitoring data

Sex workers are leading prevention efforts Working with Peers at scale Like other HIV prevention programs Avahan works with peers for HIV prevention. In India, small-scale models using peer led outreach as part of structural intervention approaches have achieved three- to fivefold reductions in prevalent STIs among sex workers. However, there have been few models for large-scale outreach led by peers. Given the scale of the epidemic in India, the challenge for Avahan was to develop rapidly scaled, peer led HIV prevention interventions that would saturate coverage of high-risk groups in the 83 districts with over 600 sites. The program had to maintain a high quality of coverage even as programs were growing rapidly in scale and intensity. The particular vulnerabilities faced by high-risk individuals are often complex, and the program must find effective ways to support them in changing their behavior. Achieving scale by building peers capacity in three steps Avahan’s story is one of building peers capacity to lead outreach lead outreach progressively and our data shows how that has contributed to more effective outreach. The phases were start up when we recruited the majority of peers and trained them (at this time they took on a basic service package), enhanced roll out of services (microplanning was introduced to facilitate more peer data analysis and action to address risk and vulnerability directly – without added layer of management) and refining the scope of services (when we started more initatives that peers could like colleagues to so that vulnerability and risk reduction were more viable). I am going to tell you about these steps now and then share some data on the outcomes. (enhanced roll-out, Avahan’s lead implementing partners began shifting their focus from scaling up to intensifying services. The partners consulted peers and NGOs to devise ways of increasing demand and outreach. It was clear that the peers’ depth of knowledge about the sex work environment and risk factors was not always being used in their outreach. The need to address these underlying factors—such as violence, fear of the police, and dependence upon abusive partners—was recognized, and Avahan decided to make fuller use of peers’ knowledge and skills to do so. The components of peer outreach expanded, peer selection, oversight and training were all enhanced. It was at this time that the methodology of micro-planning was introduced so that peers could analyze and plan their work with greater depth and autonomy. Micro-planning tools allow peers to increase the quality of their outreach while simultaneously increasing its breadth, i.e., the number of high-risk individuals with whom they are in regular contact. Peers use these low-literacy management tools to collect data, analyze risk and directly plan outreach based on the individual needs and vulnerabilities of the high-risk group members they are serving. Micro-planning tools were designed to reflect important tenets of participatory development. )

Phases of the program Start-up Established the peer outreach network Denominators defined, standards introduced, tools for planning outreach Training in 70 districts Enhanced roll-out of services Improved outreach and service delivery outputs • Micro-planning introduced, Redefined the role of the peer Field visits to assess the quality of peer interaction Refining scope (current) Building peer leadership Expanding from risk reduction focus to address underlying vulnerability. Networking among peers Avahan initiated the start-up phase of its HIV prevention intervention in mid-2004 having inherited 240 peer outreach workers and coverage of 22,000 high risk individuals from HIV prevention work already undertaken by the NGOs it contracted. The initial focus was on building the infrastructure for scale, contracting local NGOs, setting up clinics, recruiting peer outreach workers, and introducing services to high-risk groups. At this early stage there was a drive to recruit peers from local areas all across Avahan’s broad coverage area, transforming the ratio of peers to staff so that peers would greatly outnumber staff, shift outreach responsibility down to peers and so the program would be represented by the individuals it serves. At this time the essential elements of the package were somewhat limited to the following: Weekly one-to-one meeting with each of the 25-50 high-risk group members in her/his assigned area. Refer and/or accompany high-risk group member to clinic for regular quarterly check-up and STI services Need-based distribution of condoms (free or socially marketed) and demonstrate their correct use As the we enhanced the roll out of services we were began studying innovations from the ground, problems in outreach, and fostering solutions with our partners to scale up what was working best. Microplanning across Avahan’s 600 towns of operation and with it a significant focus on enhancing peers role in outreach. We introduced new methods to address self-esteem, enhance leadership and foster peers analytical skills in their work. We have entered a new stage of further refinement to the scope of our work. We’ve

Start up (2004-05): Move peers into forefront Refined scope Enhanced Roll out Start up I want to talk about the beginning or start up of the program so I am showing you data from one of our lead implementing partners – a kind of case study. This case study demonstrates that initially staff outreach workers were delivering services to high risk individuals. Peers were brought in to manage outreach but there was initial reluctance from staff to hand over responsibility. When their program began in December 2004 with outreach to 4,300 high-risk individuals, there were no peer outreach workers, and the partner used staff outreach workers for outreach. Avahan set common minimum standards for outreach one of which was that there must be a ratio of 1 to 25 and up to 1 to 50 peers to community members depending on typology. Peer outreach workers deliver a standardized service package to ensure a minimum quality and comparability of reporting data across the program. When the program shifted to enable peers to manage outreach there was a vast jump in coverage.

Roll out (2005-06): micro-planning In the second stage, enhanced roll out we began devolving responsibility to peers. The field came up with techniques to allow peers to analyze the data from outreach that they were collecting. This outreach calendar is the form one peer uses to manage her workload and monitor monthly service uptake and risk and vulnerability factors for each individual she covers. With this information she will know who is high priority and what the specific needs are of each person she meets. The beige columns are the four weeks in the month; The blue are the vulnerability and risk factors, and now I’ll show you a closer view. Source: Pathfinder International, Mukta Project

Micro-planning: Peers analyze and act directly Here you can see how she fills in the information. She uses a symbol to identify the individual. Talk through all of these. This represents one contact. Tools like this ensure that education is not a constraint and further empowers individuals who might have thought they couldn’t have such a leading role. This gives the person directly in contact with high risk individuals, the female sex worker, the means to understand who is a priority for outreach. By managing all the information on risk and vulnerability; services delivered; and tracking this over a month Stickers cover up the risk and vulnerability factors that do not apply Symbols are used in the place of names Stickers with symbols show the services provided for each week of the month: one to one contact / counseling, condoms, STI consultation A purple ”priority” sticker reminds the peer to follow up Source: Pathfinder International, Mukta Project

Refined Scope (2007-08): Making vulnerability & risk reduction viable In mid-2006, Avahan undertook a number of efforts to refine the scope of outreach. At a central level Avahan consulted partners through program reviews to understand what needed to be added or taken away in terms of monitoring, approaches and emphasis. Avahan program staff worked with NGO’s in the field to diagnosis gaps in coverage and address them. In partnership with the community the program laid out steps to enhance the role of high risk individuals in the program, in large part through the work of peers. Peers began receiving additional training using participatory methods such as role play and group discussions to understand issues such as power and self-confidence and how these relate to condom negotiation skills. The program scaled up efforts to tackle vulnerability that had been proving effective on a more local basis. Crisis response systems were introduced to tackle and prevent violence against high-risk group members.Peers were issued with identity cards to show that they were associated with HIV prevention, and where advocacy efforts were successful police directors signed the identity cards to endorse their work. The program focused on building: Peer capacity to become opinion leaders and act as agents of norm change in the community Peer outreach expanded from a risk reduction focus to address underlying vulnerability. High-risk individuals were to be linked not just to services but to crisis response systems, local advocacy efforts and community groups. Peers from different geographies network to learn from one another across districts and states. Peers are increasingly community leaders who set norms for health-seeking behavior and role models as responsible program partners—they practice safe sex, go to the clinic, and take initiative to tackle community priorities.

Increased coverage and condom distribution Progress Increased coverage and condom distribution Refined scope 10 m condoms Enhanced Roll out Start up The short point of this graph is, the number of condoms distributed by each peer increased overtime. By the end of Dec 07 our data says that each peer was giving 30 condoms a month to each individual she was serving. This corresponds to 10 million condoms across the program. At the same time peers began to contact more individuals in a month. These are unique contacts so in the early days a peer could reach 20 people in a month and by Dec 07 peers were reaching 37. The initial jump in condom distribution in June 06 and subsequent slight decline demonstrates that distribution stabilized. As a team Avahan spends a substantial amount of time in the field and from our observations we believe that this initial surge in June 06 was not necessarily consistent with use. We think that from that point when we began doing reviews and intesifying the training peers were getting, the distribution began to increasingly match actual use. During this period peers started looking at the number of sex acts each of their colleagues were undertaking a week, how many condoms clients usually brought and were distributing condoms based on actual need. Note that condoms are also socially marketed by the program. The number of condoms distributed by each peer increased by 50% as their roles in the program were enhanced Source: Avahan program monitoring data

Three-fold increase in clinic attendance Progress Three-fold increase in clinic attendance Refined scope 280,000 individuals covered Enhanced Roll out Start up Here is another example of increased coverage. As the peers reached more and more individuals represented by the cream coloured bar, the proportion of high risk group individuals coming into the clinics has steadily gone up every month. It moved from 7 to 20 percent. Our aim is to have 33% of the population coming in a month or 99% a quarter. This graph also shows that each peer can contact more individuals today compared to two years ago. (point to cream bar) The peer to KP ratio in the program (red). While increased clinic attendance is not a direct measure for quality we think that measuring service uptake can be a proxy for quality outreach. Our field observations are that peers now understand how to assess risk and vulnerability and then conduct outreach accordingly. They are much more confident and capable today than they were two years ago. We believe this makes not only outreach stronger but makes for a more sustainable community led effort. As peers made more individual contacts with community members, clinic attendance improved significantly Source: Avahan program monitoring data

Lessons Scale and intensity improves with peers at forefront Peers should assess risk and vulnerability Use tools that allow peers to manage their portfolio Measure progress to determine evolving needs Quality can be maintained in rapid scale up (THIS SECTION NEEDS SOME FINE TUNING TO BE DONE TONIGHT) Mid-way through its ten-year effort, Avahan has assimilated a number of lessons from its experience implementing peer led outreach, particularly with female sex workers, high-risk men who have sex with men, and transgenders in the four southern Indian states of Andhra Pradesh, Karnataka, Maharastra and Tamil Nadu. These lessons are informed by both program monitoring data and qualitative learning from the field. Scale and intensity of outreach improves with a high proportion of frontline workers. The majority of Avahan human resources are peer outreach workers. The high proportion of workers from the community, representing local areas across the program, enhances the reach and makes it more sensitive and responsive to local contexts. Devolving data use and program management from NGO staff to the peers themselves has enabled Avahan to operate on a large scale without losing quality. Investing in building peers’ skills is critical to the program. Given the crucial role of the peer, one-time classroom-based trainings are insufficient to develop peers skills. There must be a constant effort on the part of staff outreach workers to develop each peer’s case management skills. This includes numerous formal and informal training sessions using the tools of micro-planning and social network mapping, as well as techniques for group communication and individual counseling Application of intensive participatory tools such as micro-planning can be rapidly scaled up with quality. Because micro-planning tools are designed for peers with low levels of literacy or formal education, they can be easily understood and put to use. The participatory nature of mapping and micro-planning reinforces the peers’ learning and skills, and gives an immediate sense of ownership of data. These tools also provide a rapid grasp of the complex network of risk and vulnerability factors affecting each high-risk individual, which is essential for quality outreach. Avahan has found that the process of weekly review of micro-planning tools among peers and their supervisors reinforces peers’ learning and their outreach management skills, and enables them to support each other as the intervention is scaled up. It is possible to enhance the leadership of peer outreach workers on a large scale over a period of time by devolving roles and responsibilities from implementing partners to peers. Strong leadership is emerging in varying degrees from peers across Avahan, informed by multiple factors. Avahan’s experience reflects that enhancing peers’ skills and offering mentoring support is critical so that they can influence the direction and management of the program. The systematic development of peers’ roles in program decision-making and management over a period of time is only possible if the devolution of the implementing partners’ role is designed into the intervention. This ensures that peers will progressively oversee outreach to the greatest extent of their interest and capacities.

Thank you

Extra slides

HIGH RISK GROUP STI PREVALENCE ALSO HIGH… STI prevalence among FSWs in Avahan districts (Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu) STI prevalence among MSM and transgenders in Avahan districts (Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu) Median=13.6% Median=13.8% Source: Avahan IBBA data (2005-2007)

HIGH RISK GROUP HIV PREVALENCE CONTINUES TO BE HIGH… Median district level FSW prevalence 14%, 10 of 26 districts have > 20% Median district level MSM HIV prevalence 15%, 4 of 10 districts surveyed have > 20% Median=14% Median=15% Source: Avahan IBBA data, 2006

INDIA: TOP 30 DISTRICTS WITH HIGH ANC PREVALENCE HIV prevalence at ANC sites ( %) Districts ANC prevalence trend up Source: NACO’s Sentinel Surveillance data: ante-natal clinic (ANC) sites (2007)

SOME GOOD NEWS, BUT NOT GOOD ENOUGH…. RATE OF HIV DECLINE Source: NACO’s Sentinel Surveillance data: ANC sites (2003)

THE BEST NEWS IS FROM TAMIL NADU Median ANC Prevalence in Tamil Nadu - Six Sites with Continuous Data From 1998