This assessment of the Avahan initiative, using multiple data sources, provides information on the role of Avahan initiative in HIV prevention efforts among the HR-MSM/TG population in AP. Avahan's intervention for HR-MSM/TG was able to reach the intended target of monthly contact of 80% of the estimated HR-MSM/TG by 2008. HR-MSM/TG were more likely to be exposed to various components of the Avahan programme by Round 2 of the IBBA. They also reported a higher consistent condom use with various male and TG partners in Round 2 of the IBBA compared with Round 1. HR-MSM/TG who were exposed to various components of the Avahan programme were more likely to report consistent use condoms with their male partners compared with those who were not exposed. The estimated HIV prevalence remained high in both the rounds of IBBA; there was no significant difference in the HIV prevalence and other STI prevalence between the two rounds of survey.
An important achievement of this Avahan intervention was the rapid scale-up of the prevention programmes for HR-MSM/TG in AP; the proportion of HR-MSM/TG reporting ‘ever contacted’ by the intervention was >100% in the second year of the programme. This probably also indicates the high degree of the mobility in the population: the denominator was the quarterly size estimates of HR-MSM/TG population, whereas the numerator included all unique HR-MSM/TG who were ever contacted in the districts where Avahan had an intervention (and they may include HR-MSM/TG who were temporarily resided in the district). The increase in coverage as observed in the programmatic data is also supported by the findings from the IBBA. HR-MSM/TG reporting exposure to various components of the Avahan programme increased significantly in the Round 2 of IBBA compared with Round 1. These estimates are higher than the average estimate of 33% programme reach in the MSM population in low and middle income countries.16
Along with scaling up the coverage, the programme was also able to improve the ratio of HR-MSM/TG to peer educators, improve the monthly contact by peers (80% or more) and increase the condom use to cover the estimated commercial sex acts. It will be important to monitor the coverage as the programme is transitioned during Phase 2 of Avahan.
Such improvements in programme coverage and services have also been reported in FSW interventions.12
These studies found that not only did the clinic attendees increase across all the Avahan STI clinics but also there was a significant improvement in the quality of services received at these clinics. Since the quality assessment of these clinics was combined (included all the high-risk groups), this improvement in the scores also reflects improved quality of services in the MSM clinics.19
Even though the programme fared well in these areas, low monthly STI clinic attendance of these groups remained an area of concern. Avahan had set a target of 20% monthly clinic attendance; however, the programme could achieve about 16%. Thus, there is an urgent need to continue these initiatives in the HR-MSM/TG population with an increased emphasis for regular STI check-ups and follow-ups, especially since there was no significant decline in HIV and STIs in this study.
It has been noticed that behavioural interventions are useful tools for HIV prevention in the HR-MSM/TG population globally.21
We found that improvements in the outreach and service delivery were associated with the improvements in the reported condom use by the HR-MSM/TG population—which had ranged from 47% to 94% in earlier reports23
Interestingly, even in the first round of IBBA, HR-MSM/TG exposed to the Avahan initiative were significantly more likely to use condoms. Thus, potentially increased outreach and availability of condoms did translate into increased condom use. Notwithstanding these encouraging findings, an issue of ongoing concern and challenge was low consistent condom use with regular female partners. Similar findings of low condom use with women have also been reported from other areas of India.23
Thus, the intervention programmes need to stress the importance of condom use with men, women, as well as male-to-female TGs/hijras
Another important area of concern was the high prevalence of HIV and syphilis in both the rounds of IBBA. Incidentally, such a high prevalence of HIV in the MSM population in AP has also been reported by the sentinel surveillance. They have found that the HIV prevalence among MSM in AP has shown an increasing trend from 2005 onwards.26
However, this was not the case in these three IBBA districts, where the analysis has shown that the HIV prevalence remained stable between the two rounds of IBBA. These findings are in contrast with the FSW population in AP. Indeed, Rachakulla et al20
found that there were significant reductions in the overall prevalence of HIV and syphilis in the FSWs in AP. In addition, Ng et al27
have demonstrated that a high intensity of Avahan programme was significantly associated with lower HIV prevalence in AP. Even though we did not observe a decline in the HIV prevalence, we did observe a significant decline in ‘Active syphilis’ (ie, high-titre syphilis) and Neisseria gonorrhoeae
. It is important to state over here that there was a slight delay in the roll out of the MSM intervention programme in AP. Hence, to see a significant change in the HIV prevalence, we may require more time than the time gap between the two rounds of the survey presented in the paper. Additionally, an incidence measure would probably be a better measure of the decline of HIV in this population. As stated earlier, even though the prevalence of HIV has declined in FSWs in India, the same trend has not been observed in the MSM/TG groups.1
Thus, efforts to contain HIV and STI transmission in the MSM/TG population need to be continued, and perhaps even newer approaches and additional prevention modalities are needed for the MSM population.
This assessment had several limitations. As stated earlier, the programme CMIS captured data on HR-MSM/TG who were covered by Avahan in its implementation areas, whereas the sampling design of IBBA included the entire district. However, results from different data sources facilitated data triangulation. In addition, the Avahan implementation and evaluation design was not a classical ‘intervention-control two group’ design; thus, this assessment did not allow for any control groups. This was due to ethical concerns of withholding known HIV prevention services, the state goal of rapid scale up and the political issue of using government districts as controls.5
Hence, given these constrains, a design that was appropriate for the current assessment and feasible for a large scale-public health programmes was adopted.8
In such a scenario, where multiple interventions are aiming to reach vulnerable populations to rapidly scale up coverage, such evaluation designs using different sources of evidence have been recommended as an alternative to randomised controlled trials.28–32
Though we did collect urethral and serological sample for STIs, we could not collect rectal specimens due to logistic difficulties; thus, we may have missed some rectal STIs in both the rounds. Additionally, some of the results in Round 2 may be attributed to the changes in the population composition (as seen by a decrease in the proportion of bisexuals in Round 2 of the IBBA). One potential reason for this change could be due to migration and mobility of MSM in the region. However, we adjusted for identity in our multivariate models. Finally, it is quite likely that some of the responses—particularly condom use—may be influenced by social desirability bias and we may have overestimated these outcomes specifically in Round 2 as the programme had scaled up rapidly during that period. However, we compared two rounds of data; thus, presumably, the bias was similar in both these settings. Furthermore, we did find that HR-MSM/TG reported low levels of condom use with regular female partners. Even though some of the IBBA districts were solo Avahan districts, we cannot rule out the role of some small/independent interventions in the increase of condom use. Nonetheless, it is important to note that safe sex behaviours such as consistent condom use increased in the same geographical areas over a period of time.
In spite of these limitations, this assessment has several strengths; this is one of the few assessments of a large-scale HIV intervention on HR-MSM/TG in India. The analysis was based on the Avahan evaluation design and presented evidence along the programme's logical model: examined coverage, outputs and intermediate outcomes followed by associations with the programme exposure. This was done using programme monitoring data and independent survey data for validation of trends, and provided evidence for programme effectiveness based on the congruency of trends.8
In conclusion, Avahan implemented a programme for HR-MSM/TG in AP which scaled up rapidly to achieve coverage in the context of a highly mobile target population, ensured adequate condom supply and delivered high-intensity peer and STI clinical services resulting in positive behavioural outcomes including increased condom use. Some of the important achievements of the Avahan intervention include high consistent condom use with different types of male partners and relative stabilisation of the HIV and STI prevalence in the community. Challenges, however, remain about low consistent condom use with regular female partners and relatively high prevalence of HIV among HR-MSM/TG in AP. Thus, there is a need to maintain the intensity of these programmes to ensure high STI clinic attendance and long-term reduction of HIV and STIs in this population in India.