1. COMMUNITY MOBILIZATION IN AVAHAN
Mexico IAS Conference – NACO Satellite Session
August 3, 2008
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2. AVAHAN – A VERY LARGE SCALE HIV PREVENTION PROGRAM
Dec 03
Jun-04
Dec-04
Jun-05
Dec-05
Jun-06
Dec-06
Jun-07
Dec-07
578
598
604
605
531
465
376
408
Towns covered
7200
7100
7500
6200
5000
4000
2300
240
Peer educators
280
250
171
135
104 79 49 22
High risk groups covered (figure in thousands) 15 13
States (6) 10
Districts (83) 7
Intervention sites 5 6 2 1
Condoms distributed and sold per month (figure in millions)
Source: Avahan routine monitoring data

3. SETTING CONTEXT – OUR COMMUNITIES ARE MARGINALIZED AND FACE HIGH RISK
Female sex workers
Men who have sex with men
Injecting drug users

4. SETTING CONTEXT – OUR DEFINITION OF COMMUNITY MOBILIZATION FOR HIV PREVENTION
Community mobilization is the coming together of persons from a community to utilize their intimate knowledge of vulnerability to overcome the barriers they face and realize reduced HIV risk and greater self reliance through their collective action.
Community Mobilization is the creation of an active and informed consumer of health services –aware of her rights, and driving improvements across the supply chain, in demanding better service
Persons from a marginalized community come together
Knowledge of vulnerability factors used to overcome barriers
Collective action leads to reduced HIV risk and greater self reliance

5. OUR VISION ENVISAGES INCREASING COMMUNITY INFLUENCE AND OWNERSHIP OVER PROGRAM…
led
Action BY the Community
Community Driven
Community tackles own priorities
Networked from sites, districts, state
Broader vulnerability reduction
Action WITH the Community
Peer Driven
Safe spaces are hubs for community activities
Peers understand risk profile of every sex worker she serves
Action FOR the Community
NGO Driven
Peers do outreach
Peers trained in communications techniques
Externally
led

6. THESE COMMUNITIES ARE THE FOUNDATION OF THE AVAHAN SERVICE DELIVERY ORGANIZATION

7. Service delivery channels Subject matter experts
OUR DESIGN ENVISAGES COMMUNITIES IN MANY CRITICAL ROLES IN PROGRAM DESIGN AND DELIVERY
Service delivery channels
Microplan-based peer outreach
Crisis response
Consumers
Service uptake and feedback
Norm setting around risks
Accountability from service providers
Subject matter experts
Mapping and size estimation
Vulnerability reduction
Governance
Program monitoring
District and local advocacy

8. MICROPLANNING - UNLOCKING THE POTENTIAL OF COMMUNITIES
Micro-planning uses specially designed tools that allow peers —including those who have low literacy—to record and analyze data on the specific personal and social factors that make each individual vulnerable to high-risk behavior, and to track their outreach at daily, weekly, and monthly intervals.
Adopted to improve outreach targeting and efficiency by unlocking community knowledge

9. MICRO-PLANNING FORMATS – DAILY TRACKING

10. MICRO-PLANNING FORMATS – MONTHLY TRACKING

11. MICRO-PLANNING RESULTS
40 percent increase in contacts per peer
Source: Avahan program monitoring data

12. CORRELATION BETWEEN VIOLENCE AND HARASSMENT AND HIV RISK
Source: Karnataka Health Promotion Trust (KHPT), Bangalore, Integrated Biological and Behavioral Assessments among FSWs and MSM-T in selected districts of Karnataka, 2006

13. CRISIS HOTLINE CARD

14. VIOLENCE AGAINST FEMALE SEX WORKERS IN 11 DISTRICTS OF TAMIL NADU
Level of police and client violence experienced by female sex workers have decreased over three years but reports of partner violence are going up; this may be attributed to backlash violence or increased reporting.
Note: Out of 1,023 total cases, cases for 2008 are only recorded through May
Source: TAI program monitoring data

15. VIOLENCE AGAINST HIGH-RISK MEN WHO HAVE SEX WITH MEN
Family violence is a problem for high-risk men who have sex with men, as well as violence from police and partners. All appear to be going down as their are being addressed by crisis response systems.
Note: Out of 261 total cases, cases for 2008 are only recorded through May
Source: TAI program monitoring data

16. TYPICAL GOVERNANCE STRUCTURES ON THE GROUND
State Federations
District Community Based Organization
Representation by peers capped at 40% and community members 60%
Elected offices; deals with HIV service deliver and advocacy at high level
Committees for Clinics, DIC, Outreach, Advocacy, Crisis Management
Block Group (at the sub-district level)
10-20 members total with 2 representatives
Brings organized approach to advocacy and service influence down and priorities up
from site level groups. Depending on the # blocks, the numbers will change
District CBO also mention - Distinctions are made to ensure community leaders for advocacy work separately and financial resources for advocacy work are mobilized separately from programme related activities to ensure autonomy
Hot-spot/Site Level Groups
5-10 Site level groups, usually informal, with members
Determines needs; acquires training and brings in support to address

18. in sex workers and clients
…LEADING TO RISK AND VULNERABILITY REDUCTION FOR SUSTAINABLE PREVENTION
Activities
Outputs
Intermediate outcomes
Long-term outcomes
Impact
Vulnerability Reduction
24 hour violence response
Savings / insurance schemes
Strong service engagement
Community projects tackle local KP problems
Linkages with entitlement schemes
Functional community based organizations
Networked community groups
Enabling Environment
Coalitions built in wider community
Police endorse peer outreach
Media outreach to reduce stigma
Sex workers empowered, stigma reduced
Strengthen
Collective Agency
Crisis Response
Advocacy Planning
Community Savings
Community Groups (CG)
CG Network
Safe spaces
Community members represented in district and state-level structures
Strong community structures are sustained
Social Impact
beyond HIV
Sex workers have increased financial independence
Community voice
Influences supportive policy decisions
Reduced HIV
incidence
in sex workers and clients
Violence reduced
Condom use with clients becomes normative
Police harassment
reduced
Background: Avahan works from the theory that service driven solutions alone cannot tackle HIV vulnerability and community mobilization is essential to bridge the gap between the needs on the ground and what the programme can deliver on its own. “In addition to individual risk, HIV transmission dynamics are also a function of vulnerability, which stems from social, economic, or legal circumstances that increase susceptibility to infection, deter individuals from seeking essential pre­vention services, or enhance the likelihood of engaging in unsafe behaviour.” (Global HIV Prevention Working Group, 2007)
Avahan’s field experience to date and global best practices reveal that communities should be at the center of the program to reduce risk and vulnerability to HIV
Communities are one of the two natural owners during the transition phase. Empowered key population members, strong networks and community capacity are critical not only to consolidate the work to date but also to sustain the results of the Avahan program
National AIDS Control program III is ambitious and places communities at the center and in fact plans to hand over the program to communities in many places
Avahan is well positioned to influence and inform the national program’s community approaches given the invaluable experience and lessons from the past few years of implementation in multiple contexts
Priorities for the next phase of the program are informed by progress and evidence to date, implementation and capacity gaps and the community aspirations and the national program directions
It is critical for Avahan to document and fully establish the science of community mobilization as it can inform large scale HIV programs around the world
Reduced HIV
incidence in
larger community
Better condom negotiation and efficacy
Strengthen
Individual Agency
Peer led DIC
Violence Reporting
Program Committee
BCC / IPC
New HIV and STI infections prevented
Quality HIV Services
Health clinics established and accessible
On going peer outreach and behavior change communication
Commodities provided
Counseling for risk, care & treatment
Condoms normalized
Improved health-seeking behavior

19. TENETS OF MICROPLANNING
Give peers an in-depth understanding of the risk and vulnerability factors for each high-risk individual they serve, and helps them to track these over time
Allow peers to manage and plan their own work
Enable peers and their supervisors to track each high-risk group member's progress over a period and to prioritize and monitor outreach
Improve the quality and scale of outreach by individual peers
Improve program service delivery levels
Provide ways for peers to participate in program planning, determining priorities and devising improvements

20. MEASURABLE CHANGES DUE TO COMMUNITY MOBILIZATION
Early impact of community mobilization from a district survey in coastal Andhra Pradesh
Program-wide behavioral surveys initiated in 2008 to assess key measures of community mobilization including violence, stigma and collective action
Source: Yale Parivartan RDS Survey round one and two (Rajahmundry)