Scale-up and coverage of Avahan: a large-scale HIV-prevention programme among female sex workers and men who have sex with men in four Indian states

Abstract

Objective: Documenting 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.

Methods: Implementing 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.

Results: In 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.

Conclusion: Avahan'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.

Figure 1

(A) Percentage of maximum number of NGOs contracted drop-in centres (DICs) and static STI clinical services established over time. (B) Total number of active outreach workers, female sex worker (FSW) peer educators and high-risk men who have sex with men peer educators. (C) Ratio of active peer educators to total target denominator intended to be covered for FSWs and high-risk men who have sex with men (HR-MSM). (D) Ratio of estimated condom distribution (free and socially marketed) per FSW and HR-MSM per month by state-level lead implementing partners using total target denominator intended to be covered throughout.

Figure 2

(A) Number of high-risk group members (HRGs) ever contacted through outreach and ever visited the clinic for STI services by female sex workers (FSW) and high-risk men who have sex with men (HR-MSM). (B) Percentage of HRGs based on 2008 denominator intended to be covered ever contacted through outreach and ever visited the clinic for STI services by female sex workers (FSW) and HR-MSM. (C) Percentage of total number of HRGs (based on 2008 denominator intended to be covered) contacted monthly through outreach services. (D) Percentage of total number of HRGs (based on 2008 denominator intended to be covered) visiting the clinic for STI services monthly.