11

1

Community Mobilization can reduce HIV/STI risk among female sex workers:

Emerging evidence from AvahanWhere the Tide will Turn: How is Community Level Participation Most Effective in Turning the Tide?

AIDS 2012 (SUSA72)

Tisha Wheeler, Anne Sebert Kuhlmann, Tara Beattie, Narender Kande, Christine Galavotti, Gina Dallabetta, Parinita Bhattacharjee, Sudha Chandrashekar, H L Mohan, M Suresh, Dhanunjaya Rao, Shajy Isac, Lori Heise, BM Ramesh, Stephen Moses, and Charlotte Watts

22

2

Mounting Focus on Structural Interventions and Community Mobilization

…major efficiency gains through community mobilization…

On Ground Scope of Avahan Program

Programcoverage

• 6 states, 83 districts,• 600+ towns

• Combined State Population• ~ 300 million

• High risk groups covered• FSW – 221,000• MSM & TG – 81,000• IDU – 18,000• Men at risk – ~5 million

Prevention Package

• Outreach, Behavior Change Communication

• Commodities (condoms, lubricants, needles)

• Clinical services for STIs + counseling

• Case managed approach to referral - TB, HIV testing, ART

• Community mobilization

• Structural Interventions: Local advocacy, police sensitization, crisis response, community advisory committees

10 Years (2003 – 2013)

44

4

Coverage and Condoms: New Peer Approaches Made a Difference

The Difference• Peer Empowerment • Real time data use• Evolving program design• Leadership beyond services

2005-01

2005-07

2006-01

2006-07

2007-01

2007-07

2008-01

2008-07

2009-01

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

200

400

600

800

1,000

1,200

1,400

Peer educators' share of high-risk individuals contacted through outreachAverage number of condoms distributed per peer educator

Perc

enta

ge o

f con

tact

s by

pee

r edu

cato

rs

Num

ber o

f con

dom

s

Source: Wheeler T, et. Al, J Epi Comm Health 2012

55

5

Collective identity Collective efficacy Collective agency0%

20%

40%

60%

80%

100%

71%

26% 30%

80%

36% 42%

Among inconsistent condom users Among consistent condom users

Condom Users Have Collective Power

Collective identity – sense of unity with FSWs they don’t knowCollective efficacy – agreed that all or most FSWs would help to solve a community problemCollective agency – participate in a public event where could be ID’ed as an FSW or spoke to police in last six months

Source: Blankenship K et al, AIDS 2008Behavioral Survey, 2007, East Godavari district, Andhra Pradesh, N=813

AOR=1.61, p<0.05

AOR=1.64, p<0.05

AOR=1.72, p<0.001

0%

1%

2%

3%

4%

5%

6%

5%

3%

Infected with Gonorrhea

Experienced Violence No Violence Reported

0%

20%

40%

60%

80%

100%

55%

76%

Consistent Condom Use

Experienced Violence No Violence Reported

Violence means Less Condom Use, Access and Higher STIs

AOR 1.9 95% CI p<0.02

Source: Beattie T, et al. BMC Public Health 2010

AOR 0.4, 95% CI p<0.001

Integrated Biological and Behavioral Survey, Karnataka, India, N=3852 FSW

0%

20%

40%

60%

80%

100%

85% 90%

HIV program access

HIV program access

AOR .7 95% CI p<0.04

Addressing violence is central for HIV prevention among

FSW

77

7

High-Titre Syphillis

Syphillis Trichomoniasis Chlamydia Gonorrhoea0%

10%

20%

30%

40%

50%

14%

25%

33%

11%5%

3%

12%14%

5%2%

20042006

Changes after Community Mobilization Strengthened in Mysore, Karnataka

CCU occasional client CCU repeat client0%

20%

40%

60%

80%

100%

65% 53%

90%

66% 20042006

Increases in Consistent Condom Use

Reza-Paul S, et al, AIDS 2008Integrated Biological and Behavioral Survey, Mysore-Karnataka, India

Survey 2004 N=525, Survey 2006 N=529 FSW

AOR=4.3, 95%CI, p<0.001

p<0.001p<0.001

p<0.001

p<0.001p<0.03

Significant Reductions in STI’s

88

8

Testing Community Mobilization Theory of Change in Avahan

OD• Readiness &

capacity of community

groups, networks• Mature

processes

HRG Intervention

activities

Structural Intervention (SI) activities

Organizational Development (OD) activities

HRG• Reliable

denominators• Increased coverage

& service uptake• Quality

SI• Access to

entitlements• Crisis response

• Advocacy capacity &

practice (media, legal etc)

Social norm &

behavior change

Enabling Environment

Strong community groups and

organizations

Reduced risk &

vulnerability

Sustained community structures

Sustained HIV

Response through

communities

Participation

Participation

ParticipationEnhanced program

outputs Improved outcomes ImpactCommunity-level changes

Stage 3-

Ownership

Reinforces

Stage 1-Identification

w/others

Stage 2-

Collectivization

Source: Galavotti et. al, J Epi Comm Health 2012

Collective identity Collective agency Individual efficacy0

20

40

60

80

100

Know ART available government hospital

Visited STI clinic past 6 months

Ever taken HIV test0

20

40

60

80

100

HIV-1 infection High-titre syphilis Gonorrhoea & or chlamydia (R2)

0

2

4

6

8

10

12

14

16

18

20

Last occasional client Last repeat client Last sex regular partner

0

20

40

60

80

100

Emerging Results: High Exposure to Community Mobilization Drives Results

Increased Collective and Individual Power

Increased Knowledge and

Uptake of Services

Increased CCU Reduced Gonorrhea and Chlamydia

Prevalence

Data Source: Biological and behavioral survey, 2011 with random samples of FSWs in 4 districts in Karnataka, India (Bellary, Bangalore, Shimoga, Belgaum) N=1934 FSW

Beattie et al, THPE275

Low Medium High

** **

**

**

*

*

***

**** ** **

** ***

*

*

*

*AOR p<0.05 **AOR p<0.001

Conclusion

Authors:  Tisha Wheeler1, Anne Sebert Kuhlmann2, Tara Beattie3, Narender Kande4, Christine Galavotti5, Gina Dallabetta4, Parinita Bhattacharjee6, Sudha Chandrashekar3, H L Mohan6, M Suresh6, Dhanunjaya Rao6, Shajy Isac6, Lori Heise3, BM Ramesh6, Stephen Moses6, Charlotte Watts3

1 Futures Group, Washington D.C. USA2 Manila Consulting Group, Inc., McLean, VA, USA3 London School of Hygiene and Tropical Medicine4 Bill & Melinda Gates Foundation, India/Washington DC, USA5 CARE, Atlanta, GA, USA6 Karnataka Health Promotion Trust; University of Manitoba, India

www.gatesfoundation.org/avahan

• Start with peer led outreach• Address violence (and other SI)• Mobilize communities• Measure to capture progress