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Local Solutions to a National Problem

Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India

Local Solutions to a National Problem Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India

Contributors
The TI Implementing Partners who participated in all the three regional workshops:

Asha Kirana Ashodaya Samithi Bhoruka Charitable Trust Chaitanya AIDS Womens Sangha Citizens Alliance for Rural Development and Training Corridors Group for Urban and Rural Development Hind Kusht Nivaran Sangha Institute for Youth and Development Indo Dutch Management Society Jagruthi Mahila Sangha Karnataka Goods Transporters Association Karnatak Parisishta Jati Parisistha Pangadagala Janaseva Sangha Mahila Kranti Milana MYRADA Population services International Prawarda Rakshane Zilla Mahila Okkuta
Year of Publication Copies Printed Copyright Design & Layout : : : 2013 300 Artwist Design Lab : KHPT & KSAPS

Sadhana AIDS Thadegattuva Mahila Sangha Sahabagini Samara Samraksha Sangama Shakti AIDS Thadegattuva Mahila Sangha Sharana Tatva Prasara Rural Development Seva Samasthe Shri Durgashakti AIDS Thadegattuva Mahila Sangha Society for Peoples Action and Development Soukhya Samudaya Samasthe Spandana Mahila Okkuta Spoorthi HIV/AIDS information centre Suraksha Swami Vivekananda Youth Movement Swathi Mahila Sangha Sweekar Ujwala Rural Development Service Society Vimukthi AIDA Tadegattuva Mahila Sangha Vijay Mahila Sangha

Publisher Karnataka Health Promotion Trust IT/BT park, 4th & 5th floor, #1-4, Rajajinagar Industrial Area Behind KSSIDC Administrative office, Rajajinagar, Bangalore- 560004 Phone: 91-80-40400200, Fax: 91-80-40400300 www.khpt.org Compiled by: Best Practices Foundation
This document is published with the support from AVAHANs India AIDS initiative funded by Bill & Melinda Gates Foundation. The views expresses herein do not necessarily reflect those of either the AVAHAN project or of Bill & Melinda Gates Foundation

Acknowledgement
We hope that this compendium will showcase some of the best practices from the Targeted Interventions in Karnataka. We would like to thank the following people and organisations:

Research Team
Priya Pillai: Principal Investigator was responsible for designing the conceptual framework and leading the research team. She was the primary editor of the document and authored four case studies. Tara Tobin: Researcher responsible for primary data collection, analysis and author of four case studies Sudha Menon, Marly Augustine and James Brockington were responsible for primary data collection, data analysis and authoring of one case study each Maya Mascarenhas was responsible for content editing

Core-committee
Mr. Vijay Hugar (JD TI) of KSAPS, Mr. John (Team Leader TSU) of TSU KSAPS, Mr. Joseph (Team Leader TI) of TSU KSAPS, Ms. Maya Mascarenhas of MYRADA, Mr. Rex Reginald of Payana, Ms. Parinita Bhattacharjee (Director Programs) of KHPT, Ms. Gursimran Grewal of KHPT, Ms. Lakshmi Sripada (Manger Transition) of KHPT for their strategic level decisions, directions, monitoring the implementation and co-ordination with stakeholders.

Workshop panellists
Ms. Maya Mascarenhas of MYRADA, Mr. Rex Reginald of Payana, Ms. Sanghamitra Iyengar of Samraksha for helping indentifying good practices from the regional workshops. Dr. Stephen Moses, Project Director, Sankalp,KHPT; Mr.Senthil Murugan, Director-KHPT; Ms. Elizabeth Michael, Mr.Rajnish Ranjan for their technical and handson support.

Abbreviations
AIDS ART BCC CBO CSO DAPCU DD DHO DIC FSW HIV HRG HRM ICTC IDU IEC IPC KHPT KSAPS MSM MSM-T N/S - - - - - - - - - - - - - - - - - - - - - - Acquired Immunodeficiency Syndrome Anti-Retroviral Therapy Behaviour Change Communication Community Based Organisation Civil Society Organisation District AIDS Prevention and Control Unit Double Decker District Health Office Drop-in Centre Female Sex Worker Human Immunodeficiency Virus High-Risk Group High Risk Migrant Integrated Counselling and Testing Centres Injecting Drug User Information, Education and Communication Inter-personal Communication Karnataka Health Promotion Trust Karnataka State AIDS Prevention Society Men having Sex with Men Men having Sex with Men-Transgender Needle and Syringe NACO NACP NGO NSEP NSP ORW PE PL SACS SC/ST SHG SSG STI TG TI TSU VP VPL - - - - - - - - - - - - - - - - - National AIDS Control Organisation National AIDS Control Programme Non-government Organisation Needle Syringe Exchange Programme Needle Syringe Programme Outreach Worker Peer Educator Peer Leader State AIDS Control Society Scheduled Caste/Scheduled Tribe Self-Help Group Soukhya Service Group Sexually Transmitted Infection Targeted Intervention Technical Support Unit Volunteer Peer Voluntary Peer Leader

- Transgender

Table of Contents
Chapter
i 1. 2. 3. 4. 5. 6. 7. 8. 9. The Journey Introduction: Targeted Interventions for HIV/AIDS Prevention in Karnataka. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 07 Read the Writing on the Wall: BIRDS Tumkurs Use of Phone Numbers Written on Public Toilets. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 10 Enhanced Service Utilisation through Soukhya Groups: the Soukhya Samudhaya Samasthe Experience in Chitradurga . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 19 Social Protection for FSWs: Soukhya Service Groups Create an Enabling Environment in Chikballapur . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 26 Making Strides in Improving Lives of FSWs: Stepping Stones for Mahila Sangha Staff in Davangere . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 34 Building Solidarity among FSWs: Innovative Cultural Mobilisation by Rakshane Zilla Mahila Okkoota in Gadag . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 40 Reaching Rural MSM for HIV Prevention in Bijapur: Navaspoorthi CBOs Volunteer Peer Strategy . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 47 Changing Outreach Strategy and Innovations in Service Provision: BCTs Experience in Yeshwantpur . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 54 Preventing HIV on Dry Land: Peer Leaders Help HKNS Reach Migrant Fishermen in Mangalore . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 61

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10. Filling Internal Communication Gaps: Low-Cost Mobile Phone Strategy Used by Prawarda, Bidar . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 69 11. Improving Public Health Outcomes: PSIs Waste Disposal Management Creates a Safer Environment in Urban Bangalore . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 75 12. Conclusions . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 82

The Journey
As part of the post transition plan, 2011-12, it was agreed that the Karnataka State AIDS Prevention Society (KSAPS) and Karnataka Health Promotion Trust (KHPT) will jointly organize a State Level Best Practice Dissemination Workshop at Bangalore. During the workshop a compendium of the Best Practices for service delivery from the various Targeted Intervention programs in Karnataka would also be released. The main objectives of the workshop were:

To identify the Innovative/ Good Practices developed under TI programs in Karnataka

To facilitate mutual learning between TI implementing organizations

To document the Innovative/ Good Practices and share with wider audiences

As a first stage of preparation, a concept note for the workshop along with a tentative plan with the names of Core Team Members and Panellists was shared with KSAPS. Based on KSAPS feedback the plan for workshop, names of core team members and dates for the workshop were finalized. Post finalization, all the partners were invited by KSAPS to be a part of the workshop A core team was formed to take strategic level decisions, give directions, and monitor the implementation and co-ordination with stakeholders. It was decided that the Core team will comprise of members from KSAPS, TSU & KHPT. A pool of panellists, comprising of experienced HIV/AIDS professionals with a good understanding of the HIV/AIDS program in Karnataka and also a balance between community & non community, was identified to select the good/innovative practices from the regional workshops. A one day orientation of the panellists was conducted on their roles & responsibilities.

The panel comprised of : Ms. Maya Mascarenhas Mr. Reginald Watts Ms. Sanghamitra Mr. Karunakaran Barlaya

Three regional workshops were conducted to identify the Innovations/ Good Practices which could be shared at the state workshop in Bangalore and documented in the compendium. During the workshops, various TI implementing partners (NGOs/CBOs) made presentations on their work and innovative strategies developed. As an outcome of the workshops the panellists selected 12 best practices for Oral Presentation and an additional 20 were selected for poster presentation at the workshop. Best Practices Foundation was contracted by KHPT to help put together and compile the selected best practices under the oral presentation category. All the selected presentations were documented in detail and were later reviewed by Ms. Maya Mascarenhas, who was a member of the panel for all the three regional workshops. A state level workshop was planned to be organized in which the identified Innovations/ Best Practices would be presented along with the release of the Best Practices Compendium. At the National level, NACO was hosting a workshop on the NACP III best practices and therefore had communicated to KSAPS to withdraw the state level workshop. As the compilation for the compendium on Best practices in Karnataka was underway, the core committee decided to go ahead with printing and sharing of the document at the national and district level. This document is an outcome of the combined efforts of all partners involved in Targeted intervention programs in the state of Karnataka.

Chapter 1

Targeted Interventions for HIV/AIDS Prevention in Karnataka

The spread of the Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) epidemic in India has been largely an outcome of unprotected sexual intercourse or sharing of injecting equipment between infected and uninfected individuals1. The Indian epidemic has followed a focused pattern with new infections occurring primarily among high risk groups - female sex workers (FSWs), men who have sex with men and transgenders (MSM-Ts) and injecting drug users (IDUs). The infection then spreads through bridge populations - clients of sex workers and sexual partners of drug users to the general population2. The HIV prevention initiatives of National AIDS Control Programme (NACP) Phase I, Phase II, and Phase III, launched in 1992, 1999 and 2007 respectively, has transformed the landscape of interventions. The move from NACP I to NACP II shifted from generating awareness to establishing targeted interventions (TIs) with high risk groups. NACP III focused on scaling up TIs through community mobilization and building ownership via the formation of community based organizations (CBOs) for core high risk groups (HRGs). The highest priority is given to implementing targeted interventions with HRGs including FSWs, MSM-Ts and IDUs, since they collectively have a disproportionately higher incidence of HIV infection3. It must be noted that IDUs are often people who also buy or sell sex which further increases their vulnerability to infection4. In addition, the programme also focuses on so-called bridge populations, especially migrant workers and long-distance truckers. High mobility, combined with long periods of separation from regular sexual partners/spouses means, these groups commonly engage in unprotected sex with commercial sex workers, with a proportionally higher risk of contracting HIV. Once infected, bridge populations then act as a primary mode of HIV transmission into the general population. Under NACP-III, targeted interventions (TIs) have been implemented by civil society organisations (CSOs) in partnership with State AIDS Control Societies. Activities include outreach programmes focusing on behavioural change, risk reduction through distribution of condoms and other materials, treatment of sexually transmitted infections (STIs), linkages to other health services and advocacy. A specific objective introduced
1 2 3 4

NACO (2007) Targeted Interventions Under NACP-III: Operational Guidelines. Volume 1: Core High Risk Groups, p. 7 Website of AVERT, http://www.avert.org/hiv-india.htm Website of NACO, http://www.nacoonline.org/National_AIDS_Control_Program/Prevention_Strategies/ World Health Organisation (2011) Global HIV/AIDS response: epidemic update and health sector progress towards universal access: progress report 2011, p.34

Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India

in NACP-III was to decentralise HIV prevention efforts to local levels, with increased attention to building the capacities of community-based organisations (CBOs) to take control of programme implementation. Four components of targeted interventions which have demonstrated success globally are highlighted in this document of best practices, and they include: behaviour change communication, service delivery (STI treatment and condom promotion), creation of an enabling environment and community mobilization.

Behaviour Change Communication (BCC): The first component in BCC includes outreach differentiated by risk (targeting different HRGs)
and typology (types of populations within each HRG). The second includes inter-personal behaviour change with communication going beyond increasing awareness about HIV prevention and service utilization to encouraging problem solving thus creating locally appropriate solutions to overcome barriers to HIV/STI risk reduction.

Service Delivery: Delivery of services includes condom distribution, provision of clinical services, and referrals for HIV and syphilis testing.
Distribution of condoms and lubricants are done to reduce risk through safe-sex practices while distribution of needles and syringes reduces risks for IDUs. Clinical services include diagnosis of STIs, linkages to health services such as voluntary counselling, and referrals to public health facilities for free treatment of HIV/STIs.

Creation of an Enabling Environment: This includes advocacy with key stakeholders and power structures, crisis management systems
to deal with stigma-related discrimination and harassment and finally, through using a rights based approach promoting legal literacy and accessing social entitlements.

Community Mobilisation: Community mobilisation in the context of an HIV/AIDS programme aims for collective action to influence safe sex
behaviour and to address structural barriers. It involves collectivizing HRGs (FSWs, high risk MSM, and IDUs) and building their capacity to assume ownership of the TIs. Overall these elements rest on certain pre-conditions including:

Outreach through Peer Educators (PE) is an integral part of all HIV prevention and treatment initiatives. The capacity building of PEs
becomes an essential part of their ability to actually identify and reach HRGs, who are otherwise invisible populations. With higher probability of identification, greater familiarity because of similar identities and non-judgmental behaviour these peer educators have higher success rates in reaching and linking HRGs to services.

Community participation for core HRGs, which include FSWs, MSM-Ts and IDUs, is a second tenet upon which success of these
interventions rests. This participation varies across NGOs starting with them delivering TIs at the doorstep of these communities, gradually building their trust and ownership through peer educators. It can also result in the creation of CBOs which manage the intervention themselves over time leading to greater ownership, improved efficacy and better sustainability.

Sustainability of Targeted Interventions is a recognized challenge. While community ownership is a primary factor, sustainability
also depends significantly on the capacity of CBOs to sustain themselves. The systematic withdrawal of NGOs has resulted in CBOs taking over their functions and sustaining the interventions even after the NGOs withdraw.
8 Local Solutions to a National Problem

The ten case studies in this compendium represent unique creative strategies to improve outreach and increase service delivery in the prevention of the spread of HIV/AIDS. Five of the case studies are examples of outreach interventions that have improved contacts with the HRGs and migrant groups. Innovations include BIRDS' (Tumkur) accessing HRGs by peer educators using phone numbers obtained from public toilets, Rakshane Mahila Zilla Okkootas (Gadag) use of cultural events to attract these groups, Navaspoorthi's (Bijapur) use of volunteer peers to create site level meetings in hotspots where MSMs socialize and sometimes engage in sexual activity. Bhoruka Charitable Trust (BCT, Yeshwantpur) and Hindu Kusht Nivaran Sangh (HKNS, Mangalore) through the creation of peer support groups that conduct site specific outreach to provide HIV/ AIDS prevention services for migrant construction labourers and fishermen respectively. The innovative service delivery models include Prawadas (Bidar) use of low cost telecommunication services for TI employees, which improved communication between staff, District Aids Prevention and Control Unit and other key stakeholders facilitating faster provision of services to the construction labourers. BCT provides STI clinic, health camp facilities and counselling services at the labour colonies thereby facilitating increased uptake of these services by the migrant groups. Population Services International (PSI, Bangalore Urban) has created a needle syringe exchange programme which distributes new needles and syringes and collects and disposes off used needles and syringes in a safe manner. All three initiatives promote access to services through dissemination off information, distribution of condoms and medicines along with clinical services. Shri Durgashakthi AIDS Thadegattuva Mahila Sangha in Davanagere has used a proven capacity-building method called Stepping Stones to increase the awareness of HIV AIDS prevention and gender based discrimination among FSWs leading to behavioural change and an improved sense of their own identity. Female Sex Worker CBOs (Soukhya Samudaya Samasthe) in Chikballapur and Chitradurga districts represent the power of mobilized groups facilitating access to social entitlements and improved solidarity among the community. Access to social entitlements such as housing, pensions, ration cards and voter ID cards among FSWs has resulted in a noticeable decrease in sex work, reduced vulnerability and increased bargaining power with clients. Increased solidarity among groups has improved their crisis management skills, use of health services, their questioning and ultimately reducing risky sexual behaviour. Each practice is an example of localized, community focused solutions developed to address the outreach and service delivery imperatives of HIV/AIDS prevention interventions with increased effectiveness.

Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India

Chapter 2 Read the Writing on the Wall

BIRDS Tumkurs Use of Phone Numbers Written on Public Toilets


By calling numbers from public toilet, I get my community to the project. We are working in every way to reach the community. Using this strategy, we reach previously unreached community members. That makes me very happy Murthy, Peer Educator of BIRDS Tumkur

The relative invisibility of men who have sex with men (MSM) in India creates difficulty for HIV prevention strategies. Strong societal pressures force MSM and transgenders (MSM-T) to hide their non-traditional sexual behaviour, which makes identifying members of the community a major challenge5. As late as 2004, information on HIV/AIDS and STI prevalence among Indian MSM was limited. This bias in official figures led prevention efforts to be primarily focused on reducing transmission through heterosexual contact6. While the National AIDS Control Programme III categorizes MSM-T as a core high risk group (HRG) for targeted intervention (TI), the sensitive nature of working with this community continues to make outreach difficult. This case study documents the innovative strategy used by the Belgaum Integrated Rural Development Society (BIRDS) for better outreach among MSM-T community in Tumkur district. Situated in South Karnataka, Tumkur district7 is divided into ten talukas. According to the 2001 Census of India the district has a total population of 25.8 lakhs and a sex ratio of 967 females per 1000 males. The overall literacy rate is 67% with 77% males and 57% females being literate. HIV prevalence among the general population is low at 0.32% (PPTCT, 2009), with an estimated 3 MSM-T per 1000 adult population in the urban areas of the district. The majority of MSM-T (39% of the total) was found to be in Tumkur taluka. In January 2010, BIRDS began implementation of the Karnataka State AIDS Prevention Societys (KSAPS) TI for MSM-T. KSAPS mapping estimates produced an outreach target of 845 community members in Tumkur. In an effort to gain the trust of the MSM-T community and establish their presence as HIV prevention service providers, BIRDS initiated a needs assessment with the community to determine the accuracy of the 845 projection. From this assessment, BIRDS staff found that in fact between 2,000 and 3,000 MSM-Ts were active in Tumkur, well over the 845 target. BIRDS staff knew that they would need innovative approaches to reach this largely hidden population.
5 6 7

Go, Vivian, et al. High HIV Prevalence and Risk Behaviours in Men Who Have Sex With Men in Chennai, India Epidemiology and Social Science Vol. 35, No. 3: March 1 2004. Ibid District profile information from, HIV Situation and Response in Tumkur District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010

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Local Solutions to a National Problem

To capitalise on local knowledge regarding MSM-T activity and improve their outreach strategies, BIRDS leaders approached the community. In an April 2010 brainstorming meeting, one MSM stated that a common way for MSM community members to meet is by leaving their phone number on the walls of various public toilets around Tumkur town. The community advised that by calling these numbers, BIRDS might expand their outreach to new groups of MSM-T. Community members directed Programme staff to the most popular public toilet hotspots, including bus stands and railway stations. Programme Manager Santosh explains, The walls were full of phone numbers. There was no empty space in the toilets. They were covered with writing saying If you want sex, contact me. After seeing the quantity of men soliciting sex with men, BIRDS staff decided to operationalise collecting and calling phone numbers written on public toilets to reach the hidden MSM-T population in Tumkur.

2.1. Outreach through Public Toilets


All BIRDS TI staff are involved in the public toilet outreach innovation, including the Programme Manager, Outreach Workers (ORWs), and Peer Educators. While encounters may vary (see Box 1), the process of converting a phone number written on a public toilet into a active recipient of BIRDS services follows a particular pattern, detailed below. Collecting Telephone Numbers Giving a Missed Call Establishing Friendships over the Phone Meeting New Contacts in Person Inviting MSM to the DIC

Collecting telephone numbers The Programme Manager and ORWs currently go to six public toilets every three to four months. These toilets are located in well-frequented MSM hotspots which include public parks, bus or railway stations, and the public library in Tumkur town. Because the volume of phone numbers and writing covers a vast area on the walls, staff take photographs and video footage instead of recording the copious information on site. This saves time, as photo and video recording requires no longer than ten to fifteen minutes for collection. Once they are back at the drop-in centre (DIC), staff input unique phone numbers (not repeat contacts) into the computer and let other BIRDS staff know that there are fresh contacts. Information is entered on all unique numbers, including those advertising sex with women, as some MSM-Ts write their numbers next to illustrations of women or accompanied by female names. Generally, four or five out of 10 phone numbers are that of an MSM.
Contact information is scripted in a variety of ways on public toilets. Some numbers are written beneath a name, either male or female, while other MSM-Ts prefer to leave only their number. Many are
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 11

Box No 1: Phone Numbers Written on a Public Toilet Wall

accompanied by drawings of a penis, anus, mouth, or vagina (advertising favoured sexual activities), while others are written at the end of long paragraphs of sexually-explicit text. MSM do not necessarily stick to one strategy when writing their phone numbers, as one community member explained that he sometimes left his number with a womans name and sometimes without. For these reasons, BIRDS staff do not limit themselves to only calling those phone numbers explicitly advertising sex with men.

Giving a Missed Call Among many MSM, a widespread approach used to spark interest in potential partners is giving missed calls where the caller will dial a phone number, let the phone ring once or twice, and then hang up so that the receiver knows to return the call. This missed call strategy is used at night, when MSM conversation and activity normally occur. The Programme Manager and ORWs dial new numbers and leave missed calls after work usually around 9:30 p.m. This helps the staff to approach new contacts in a natural and customary manner and ensure the comfort of the MSM they are calling. Giving missed calls is not used only for the initial connection, but usually throughout the entire cycle of establishing a friendship over the phone. Establishing friendships over the phone ORWs and PEs do not immediately reveal their affiliation with BIRDS HIV prevention project to new contacts. Rather, they concentrate on building a friendship and developing trust. Conversations remain on neutral topics primarily, though some might advance to more sexual or flirty banter depending on the expectations and desires of the employee. BIRDS staff pay special attention to contacts reactions to conversation and adjust their efforts accordingly. Employees try to relate to the community members and make them feel comfortable, so trust is built between them. Usually, after a period of one to four weeks, an ORW or Peer will ask the contact to meet them at a local hotspot or other public place. Because BIRDS staff are aware that confidentiality and privacy are so valued among the MSM-T community, they are patient with new contacts and continue to follow up with those who are reluctant to meet. Meeting new contacts in person After some trust has developed between BIRDS staff and new contacts, either one or the other will suggest a meeting. The nature of the interaction may be sexual, depending on the preferences of the BIRDS employee and agreement between both parties (for example, outside of work, some peers regularly call phone numbers found in public toilets in order to expand their personal social networks or meet potential sexual partners). First time meetings usually take place in neutral public settings, like a tea-house or cinema theatre. Topics of conversation vary, but again, most BIRDS staff do not introduce the Programme or their work straight away, allowing multiple face-to-face meetings to occur before doing so. The in-person encounter serves to reinforce and legitimize the friendship established over the phone. Staff try to relate to their new friends and strengthen trust to increase the likelihood of registering the contact at the DIC. Inviting new MSM to the DIC Usually following a few or more meetings in person, BIRDS staff invite the contact to the DIC. They may not have yet disclosed their employment with BIRDS and the TI, though discussions on condom use, feelings and emotions about sexual orientation, or favoured sex practices usually
12 Local Solutions to a National Problem

occurs by this point. When a new community member decides to come to the DIC, BIRDS staff will show them around the office and introduce the Programme. The MSM-T will then be shown a video about sexual orientation and is introduced to the Programme Manager, Counsellor, and any other staff member present. BIRDS services will be explained in the first meeting, though this is sometimes postponed, as contacts can feel overwhelmed. They are told that the DIC is a space for people like them and that they are welcome to return if they want to. Counsellors and ORWs will offer to take new contacts to an Integrated Counselling and Testing Centre (ICTC) to be tested for HIV or other STIs. The ultimate goal of this introduction at the DIC is contact registration and repeated use of BIRDS services. On an average, it takes 20 days to one month to convert a call into a repeated user of BIRDS services. Interaction between BIRDS Staff and MSM via Public Toilet Strategy Samir, age 20, wrote his number with a girls name, Aarti. Programme Manager Santosh missed called him and Samir called back after 2 days. Santosh: You have written your number in a girls name, why? Samir: I like contacting people this way because I get to meet people. I enjoy it very much. Samirs mother came in, so he said he would talk later. After 5 or 6 days, Santosh called him back. Santosh: Will you come to have tea with me? Samir: How will I come to drink because I dont know who you are? Santosh: Come to KSRTC bus stop, I will be waiting. Samir met Santosh at the bus stop on time. They went to get tea, but didnt discuss anything explicit because people were around. After, they found a private place to sit and talk. Santosh asked about his sexual preferences. Samir felt embarrassed to talk, but was interested in Santosh. Samir: Are you interested in having sex with me? Santosh: Well, have you used condoms? Samir: I havent used condoms. Santosh Why are you endangering your life for 5 minutes of pleasure? Samir left, but said he would meet Santosh next time. Once home, Samir called Santosh because what he learned about condoms was worrying him. He asked Santosh for some more information about condoms. Then, after three more phone calls, Santosh suggested that they meet again at the same place. They went to have tea and then Santosh spoke to him again about condoms and BIRDS. Santosh: You have to use condom or else you will get a lot of diseases

Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India

13

Samir: You told me so much about condom use, I will definitely use condoms next time I have sex Santosh: Next time we meet, can you come with me to my office? I will come and pick you up from the bus stop where we met last time. Samir was shocked when he came to the office, and a bit scared seeing posters on the walls of hijras and boxes of condoms. He was expecting a normal working office, but this office looked different, which worried him. Santosh: Dont be scared, I will show you a condom, show you whats in those boxes and how to use it. [A condom] is what you have to use when you have sex. This was the first time ever that Samir had seen a condom. Samir: Is this the only thing you use during sex? Santosh No, you should also use this gel with a condom. Dont use saliva Samir: Its good you showed me, I will use next time I have sex Santosh How many men do you have sex with? Samir: I have had sex with one person since three years Santosh suggested that Samir get a blood test to make sure that he was healthy, and he told Samir, you cannot tell by looks if someone has an STI or HIV. Samir: How will he take blood? What will he do with it? Santosh: The doctor will check to see if any diseases have come to you, only little blood will be taken. Samir: I will do it next time, Im too scared. Samir took two gels and one condom. He was very worried about all these things. He called Santosh the next day and told him that he was ready for a blood test. Santosh took him to the government hospital for a blood test. When the report came back normal, Samir was happy and thanked Santosh. Santosh told him to keep visting the BIRDS office and since then he has been coming regularly to the office to get condoms and gels. He has also been to a condom demonstration. Since he keeps coming to the DIC, he meets a lot of community members.
Source: Interview with MSM-T BIRDS members, 12 Nov 2011

14

Local Solutions to a National Problem

2.2. Strategies to Successfully Register New Contacts


Within the process of converting phone numbers into registered contacts, BIRDS staff use the following strategies to hone their communication skills and ensure uptake of services.

Using attractive voices of potential partners Pantis, Kothis, and Double Deckers (DDs) are the key populations targeted by this innovation, defined in Box 2. MSM Identity distinctions extend beyond the roles assumed during sexual activity and into their flirtation and friendship-building behaviours. Because this innovation relies initially on voice-only interaction, contacted MSM lack visual signals to aid them in identifying the sexual preference of the person calling. ORWs and Peers have found that they are more successful in converting calls into registered members when they try, as quickly as possible, to take on the vocal tone, language, and identity of the contacts preferred partner. For example, a kothi-identified Peer Educator will endeavour to speak and act like a panthi on the phone if they believe they are talking to another kothi in order to sustain the attention of the listener.
Box 2: MSM Terminology While the identifying labels used by the majority of MSM appear to provide clear-cut distinctions in sexual practices, these are not necessarily a true indicator for all types of MSM, even though there is a clear link between a kothi identity and a sexual preference and practice of receptive anal sex. The term double-decker (sometimes also the word bisexual is used) defines a mutuality of sexual practice, i.e. both receptive and penetrative, while some panthi-identified, and even heterosexually identified men, also practice receptive anal sex.
Source: Increasing the coverage of sexual health services for MSM in Andhra Pradesh, Karnataka, Tamil Nadu and Uttar Pradesh, India a pilot project The Naz Foundation: April 2007.

Speaking with Northern Karnataka accents as a way to ensure confidentiality BIRDS employs a small number of employees who speak Kannada with Northern Karnataka accents. Santosh, Programme Manager of BIRDS, explains, We make sure to use strong accents from the North when we speak to contacts on the phone. This helps them believe that we arent someone they know already who is trying to discover their sexuality. They will trust us more then. Confidentiality is crucial when working with the MSM community, and using outsider accents helps assure the MSM on the other side of the phone that they arent talking to a family member or neighbour who could expose them as an MSM.

Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India

15

Sharing successful communication strategies at monthly meetings Some ORWs and PEs are more skilled than others at converting calls into new registered contacts of BIRDS. Programme Manager Santosh notes, Peer Educators are using this strategy better than I am! They speak like they are really concerned. Theyre in the habit and they know how to speak to each other. Since some BIRDS staff members are non-MSM, PEs also give advice on relating to the community and using the right language and terminology with them. One ORW detailed, At our monthly review meetings, we have a separate time to discuss the toilet strategy. Some of the senior Peer Educators tell everyone what things are working. We do role playing [of phone conversations] during these meetings, so we can better understand what the community members are feeling. We learn to listen to what they are saying on the phone. If they want you to talk in a particular way, then you talk in that way. If they like movies, it wont be a good strategy to talk about politics.
In Meetings like this, Peers & ORWs Share Successful Strategies for Converting Calls into Contacts

Building rapport with janitors of public toilets


To ensure sustainability of this strategy, BIRDS employees need to collect telephone numbers frequently. In Tumkur town, janitors whitewash the public toilet walls often, but numbers reappear within some days. BIRDS benefits from the whitewashing through regular interaction with toilet custodians who inform them of recently painted toilets. BIRDS staff have been so effective at maintaining friendly relationships with the janitors of some public toilets that they are notified a few days prior to the whitewashing so that staff can make final recordings before the numbers are covered.

2.3. Impacts of the Public Toilet Strategy


BIRDS staff are tremendously in favour of using the public toilet innovation. But beyond their personal enjoyment of the strategy, its use has had strong impacts in helping to reach outreach targets set for the TI in Tumkur.

Outreach targets Met


In Tumkur, 1,008 MSM-T are currently registered with BIRDS, well exceeding the target of 845. Of these, 421 registered community members were contacted using the public toilet innovation. These figures denote that 41.7% of registered MSM-Ts are a product of this strategy and were registered between the months of April 2010 to October 2011 (the latest available data). Furthermore, the 421
16 Local Solutions to a National Problem

registered MSM-T come from a pool of just 503 contacted via public toilets. Thus, the success rate for converting contacts into registered members is 83.6%. Out of 421 registered, 378 maintain regular contact with the BIRDS TI staff. This data is demonstrated in graph below. Public Toilet (PT) Outreach Numbers

Total MSM-T Contacted via PT Registered after PT Regular Contact after PT 0 200
Expanded social networks for MSM
As a result of this innovation, PEs and community members have been able to develop their social network of MSM-T in Tumkur. The calling strategy exposes PEs to a larger number of both friends with similar life circumstances and potential sexual partners (for either paid or unpaid sex). They develop lasting friendships and maintain regular contact with the community members they meet through this strategy well after registration with BIRDS. Furthermore, for new contacts who come to the DIC without any previous associations with MSM-Ts, they are exposed to regularity of their sexual behaviours and the sense of camaraderie that accompanies real connections to the struggles and triumphs of other community members.

400

600

800

1000

1200
Source: BIRDS Tumkur MSM-T TI, CMIS Reports

Improved understanding of the lifestyles and challenges of MSM for non-MSM staff
Many staff at BIRDS (save for Peer Educators) are non-MSM. This strategys frequent interaction with the broad scope of Tumkurs MSM community allows these staff members to familiarize themselves with the daily lives, struggles, desires, and needs of the population they work to assist. Closer contact to the target population endows non-MSM staff with greater empathy in working with MSM-Ts and gives them in-depth knowledge about the true sexual practices and behaviours of registered BIRDS community members, which may not be so openly shared in other institutional environments.
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 17

2.4. Challenges and Opportunities


It is clear that BIRDS TI staff have had success with their public toilet innovation for outreach in Tumkur. However, a few challenges have become apparent since its initial implementation. First, outreaching to Double Deckers is more difficult using this strategy, given the fluid nature of their sexual preferences. PEs and ORWs find it difficult to quickly identify which vocal identities to assume to continue to hold DDs interest. As this population engages in both receptive and penetrative anal sex, they are at high risk for HIV infection and transmission if practicing unprotected sex. Innovations beyond the public toilet outreach strategy might be required to reach this population. At present, calls are made using the staffs personal mobile phones and calling is paid for out-of-pocket, save for the Programme Manager and some ORWs who use the BIRDS office landlines for making some calls. For PEs (also MSM community members), this expense isnt considered a burden, as calling these numbers is not outside their normal socializing behaviour. They are happy to spend their money and free time talking to new contacts and enjoy giving information about BIRDS after a few meetings. However, calling for non-MSM staff is motivated solely by their work with BIRDS, so the cost is extra for them. Investigation into low-cost telecommunication schemes might ease the financial investments ORWs are required to make to continue this strategy. Also, because this strategy relies on sustained communication with contacts who believe that BIRDS staff members are interested sexual partners, there exist a small number of contacts who are unresponsive to discussing topics other than sex, and persist in calling staff members to initiate sexual contact. This sometimes puts pressure on PEs to interact with community members who they would not talk to under normal circumstances and is a nuisance to both MSM and non-MSM staff. This challenge might also be mitigated by the use of low-cost telecommunication, so that non-MSM staff can inexpensively keep a separate mobile phone strictly for work calls. In light of these challenges, TI staff are still confident that the public toilet strategy is the main force behind BIRDS high level of regular contacts. This is due in large part to the fact that the innovation works in synergy with the normal social behaviours of MSM-Ts and the outreach goals of the TI. BIRDS PEs believe that the lessons learnt from utilizing this innovation are applicable to the many MSM TIs in Karnataka and can work to reach the often hidden MSM-T population.

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Local Solutions to a National Problem

Chapter 3 Enhanced Service Utilisation Through Soukhya Groups

The Soukhya Samudhaya Samasthe Experience in Chitradurga


You tell me that you like me and come to me for sex. What guarantee do I have that I will not get infected? - Female Sex Worker in a Focus Group Discussion on 24th November, 2011

The National AIDS Control Programme Phase III (NACP III, 2007-2012) notes the significance of community led response for HIV prevention to achieve scale and coverage, improve quality of services and ensure programmatic sustainability8. Enlisting grassroots support to form Community Based Organisations (CBOs) is perceived to be an effective strategy to increase effective and sustainable outcomes for prevention interventions, bring about changes in practices, policies and laws, as well as reduce stigma and discrimination9. It is expected to lead to a change in individual attitudes and beliefs, build capabilities, and develop critical consciousness empowering the women in sex work while simultaneously creating an enabling environment to access their rights10 . This case study documents the experience of the female sex workers (FSWs) CBO, Soukhya Samudaya Samasthe, in Chitradurga district towards promoting the health seeking behaviour of its participants. Chitradurga district11 lies in the eastern part of Karnataka state. With a total population of 15.2 lakhs, and six talukas, it is the seventh largest in terms of land area. The district had a sex ratio of 955 females per 1,000 males in 2001. The overall literacy rate is 64% with 75% of males and 54% of females being literate. The HIV prevalence among the low risk general population is only 0.24% (PPTCT, 2009). The HIV positivity rate among Integrated Counselling and Testing Centre (ICTC) walk-in females in 2009 was moderate at 4.44%.

8 9

NACP-III guidelines, p.142 and 143 ibid Mohan HL, Machliwala T. Responding to the Situation through Focused HIV Prevention - Equity in Communication: A Communication Strategy for Focused HIV Prevention with Urban Sex Work Interventions. Karnataka Health Promotion Trust; 2007 District profile information from HIV Situation and Response in Chitradurga District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010

10

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Since 2004, Myrada, an NGO, has been implementing focussed HIV/AIDS prevention programmes with high risk groups in the urban areas of Chitradurga amongst four other districts. From the beginning, Myrada recognised that behaviour change required a smaller forum that would allow active community involvement and internal pressures to achieve and sustain behaviour change.12 Thus, the intervention strategy with FSWs involved organising them into small groups, which would act as a platform to discuss issues related to health seeking behaviour HIV risk and vulnerability reduction measures.

3.1. Organising for Access to Health Services


The process began by forming site level groups of female sex workers (FSWs) called Soukhya groups (SG) comprising of 8-15 members. The SGs mission is safe sex, without oppression or harassment and its members have various roles and responsibilities. In addition, the groups undertake internal savings and credit activities. The site level groups are federated at the taluk level into Soukhya Okootas. Every sex worker site is represented in the federation by two members, one from the Soukhya group and the other from the non Soukhya group. The Soukhya Okootas are conceived as a common platform and network that will help protect and advance the interests of the sex workers. The Okootas have constituted sub-committees that address issues of health, crisis management and social entitlements. The Okootas monitor the Soukhya groups, assist them to achieve their mandate, conduct outreach, and support the creation of an enabling environment. The Okootas are further federated at the district level into Soukhya Samudhaya Samasthe (SSS) with two persons from each taluk Okoota nominated as members of the SSS. To be more inclusive, FSWs not in groups can also register as a member if their membership is endorsed by a local Soukhya group. The SSS focus on larger issues such as fund raising, higher level advocacy, organising mass media programmes among others.

Formation and Capacity Building of site level groups


The first step is to form site level groups of FSWs mobilized together based on typology for better solidarity and mutual understanding of issues among members. Immediately after the formation of the group, all Soukhya group (SG) members undergo a ten module13training in Institutional Capacity Building over a period of 16-24 months. The training covers a broad range of subjects, which include group concept and management, leadership, self esteem, social entitlements, crisis management and stigma and discrimination among others. The initial training is completed over a period of one year. One day refresher training is conducted once every three years, to bridge the gaps identified during the annual grading of SHGs. In comparison, non-SG members are trained only on subjects of STI, HIV and condom use through peer educators at the field level.
12 13

Myrada. Community Led Interventions in the Myrada HIV AIDS Sankalp Programme From, The MYRADA Soukhya/Sankalp Experience: HIV AIDS and HIGH RISK GROUP - Strategies for Sustainable Interventions. The 10 module training includes: 1st module introduction to the programme; group concepts; aims and objectives of group; common health problems of women; 2nd module how to conduct meetings; unity and affinity in action; rules and regulations; responsibilities of Soukhya members; gender and HIV; 3rd module leadership; self esteem; communication and conflict resolution; 4th module book keeping, savings and credits; common fund and management; HIV and RCH services; 5th module Soukhya level vision building; 6th module credit linkage; book keeping; social entitlements; other departments; IGP and EDP; 7th module legal issue and HIV crisis management; 8th module HIV AIDS prevention care and support for HIV positive persons; 9th module collective decision making; Okoota concept; stigma and discrimination; 10th module Soukhya group family level approach and community level approach; group grading.

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Local Solutions to a National Problem

Micro-Monitoring of Service Access


Every week, the outreach worker (ORW) attends the SG meeting. The micro plan prepared at the beginning of the month is discussed in the group. The plan has a record of those FSWs who have to access STI and ICTC services. In the group, one or two representatives assume responsibility to ensure service utilization by these FSWs. If the visits are still pending, the representative will take them to the clinic or ICTC. Most of the times, the FSW who has been repeatedly missing the clinic visits is supported and accompanied by another member close to her.

Incentivizing Health Seeking Behaviour


An amount of Rs.250 is given to those groups who have accessed all the project related services every month. The taluka federation committee evaluates the groups on the volume of task given and completed. Those groups who have achieved the target set for the month are given the incentive. Other groups are allowed more time to meet the target and incentives for two months are paid together.
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 21

Incorporating Community Inputs into Planning The proposed plan for the next year is written with inputs from the Soukhya group (SG) members. The training officer attends all the SG meetings and takes feedback on the clinical services. The feedback is then incorporated into the new proposal and discussions are held with donors for a programme design that address those needs. This results in the services being need based and relevant to the community and thus ensuring better outcomes. Staying Informed About Health Topics It is mandatory for the Counsellor or the Project Manager (PM) to discuss a minimum of three health topics in a month at the taluka federation level. The Counsellor or PM consults specialists to collect information and ideate about ways of easily communicating these to illiterate FSWs. Depending on the scope, a number of topics may be discussed in a single meeting or just one issue maybe discussed over many months. For example, the PM spoke to the tuberculosis (TB) officer about symptoms and treatment, and collected the brochure on it. These were then shared with the federation members and within the people living with HIV/ADIS network. As a result, TB referrals increased from 2% to 10% among FSWs and 15% to 85% in the network14. Federation Support to Soukhya Groups Besides monitoring of activities of the lower tiers, the federations act on behalf of their members to ensure access to services. The taluka Okkoota representatives attend the SG meetings to take stock of the progress each group has made with regard to achieving the set targets. The federation then acts to bridge the identified gaps, especially with regard to STI and ICTC testing. For example, in Chitradugra district, the FSWs had to visit the ICTC before 1.30 p.m. to get tested. Many of them found this inconvenient, and as a result ICTC attendance suffered. It was brought to the notice of federation representatives. Successful negotiation with the ICTC authorities resulted in the testing time being extended up to 3.00 p.m. in all eight ICTCs in the district.

3.2. Impacts of Organizing FSWs


Myradas intervention strategy has been to mobilise FSWs into small groups to make them aware of a common need, and empower them to create shared benefits. The Soukhya model has resulted in improved outcomes for HIV/AIDS prevention.

Higher STI and ICTC Clinical Attendance The use of STI and ICTC clinical services has been significantly higher among Soukhya group members as compared to non-members. As shown in the graph, 565 SG members compared to 456 non-members visited the STI clinic at least twice in six months for the given period. Likewise, HIV testing among SG members is much higher as compared to non-members. While 774 SG members visited ICTC for HIV testing, only 486 non-SG members did so for the same period. In short, as compared to non-members, approximately 24% and 60% more SG members have accessed STI and ICTC services respectively. This data is represented in Graph 3.1.

14

Figures from interview with the Project Manager, Chitradurga district on 26th November 2011.

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Local Solutions to a National Problem

Graph 3.1: Clinical Attendance (April 2009 March 2010)

486 HIV Testing 456 Minimum 2 visits to the doctor in last six months Non-SG SG 0 200 400 565 774

600

800
Source: SSS Chitradurga FSW TI, CMIS Reports

Improved Knowledge and Awareness The SG members demonstrated better articulation of their knowledge, thoughts and opinions as compared to non-SG members. In addition to the regular capacity building trainings, the federated structure ensures that there is free and continuous flow of information from taluka and district level to the Soukhya groups. Each of the SGs is represented at the taluka and district federation. There are a total of 78 groups, with 10 to 12 groups in each town. The federation is the best platform to transfer information, as it gets passed on to groups either through the Soukhya group representative or the ORW. Community Ownership of Intervention Efforts Another crucial outcome has been the shift in responsibility of service access by FSWs from peers and ORWs to the Soukhya groups. The Soukhya group model and capacity building of members ensure that peer pressure effectively acts to push health seeking behaviour of its members. As they are mobilised, larger numbers of FSWs can be easily reached with both services and information. This is in comparison to individually meeting scattered non-Soukhya group FSWs. De-Stigmatised Clinical Space As part of quality assurance of service provision, the Health Committee (HC) members from the taluka federation have to visit the referral clinics at least once. A total of 16 HC members visit eight clinics spread across six talukas and eight towns. During these visits, the members observe the attitude, behaviour and approach of the healthcare provider towards the FSWs. In addition, the HC representatives speak to randomly selected FSW members and ask them about their experience at the clinic. Thus, through visits and interactions with FSWs, the HC members are updated about the quality of service provision. Advocacy at the federation level has also resulted in securing a safer space for FSWs to access services from (See Box 3.1).
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 23

Box No 3.1: Safe Space for Service Access The Health Committee at the District Federation level found that the service access by FSWs would increase if it were made available from a non-exclusive location. They placed this need at the monthly DAPCU meeting, and requested the same with the District Health Officer (DHO). Successful advocacy led to a directive from the DHO that resulted in space for DICs being provided within the taluka general hospitals across the district for the FSWs.
Source: Interview with Project Manager, 26 Nov 2011

Need Based Project Design The process of including community feedback in project proposals has resulted in services that are sensitive to their needs. For example, from April 2004 to 2006, as part of clinical services, only STI kits were provided. In 2006, the training officer attended all the SG meetings and took feedback on clinical services before submission of the proposal. The community suggested provision of general medicines along with STI kits as a means to get more FSWs to visit the clinic. This was because FSWs did not necessarily have only STI. This was communicated to the donor and around 32 general medicines were provided from that year till 2009. In 2007, Chitradurga recorded 100 percent clinic visits by SG members. Increased Sense of Community Support In addition to providing HIV/AIDS prevention services to its members, the group also becomes a space where members share their personal problems with each other. The peers become a source of emotional support, helping overcome personal crisis and trauma. Narrating her personal experience, Lakshmi, a FSW had this to say, I first saw boils near my genital areas and thought it was just heat boils. I then went for HIV and STI testing. The report showed that I have STI. I got an injection and my hand swelled up. I thought I was dying and was very depressed. My group, however, said nothing will happen and that I would be fine after three injections. If there was no group I would have been depressed.15
Before group formation, peer used to give condoms. They would come twice or thrice a monthif they are not in our region, it was difficult to get condoms. Now, we come to the DIC every week and get condoms. We are not dependent on peer or an external agent there are 2 representatives per group. They will initiate discussions about health of the members, decide who needs to go for testing and we go together
Source: Focus Group Discussion with Soukhya Group members, on 26th November 2011

Increased Confidence to Deal with Crisis The SG members expressed confidence in dealing with crisis situations and cited the sex worker group and the federation as a support system. Strategies are devised to address crisis with partners, and harassment or abuse from police (Box 3.2), clients and the larger community.
15

Focus Group Discussion with Soukhya Group Members on 26th November 2011

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Local Solutions to a National Problem

Box No 3.2: Support in Times of Crisis Netravati, a young sex worker (18 years old) used to sell sex at Raja Dhaba. If she earned Rs.600, she had to pay Rs.350 as rent for the place. She felt that she could earn more money if she provided sex outside of the dhaba. She started selling sex in the farm area behind the dhaba. One day, the police had forced unpaid sex, arrested and jailed her. Someone from the dhaba informed the ORW. The message was passed to the group, and they along with the ORW, went to the police station and got her released immediately.
Source: Focus Group Discussion with Soukhya Group members, 26 Nov 2011

3.3. Challenges and Opportunities


Organising of the female sex workers into groups and subsequent capacity building has ensured that group members understand the basic qualities of a viable institution, are able to discuss issues related to their profession, are linked to regular health services and condoms, can maintain all books required and operate without the assistance of an external peer educator16. However, a few challenges have emerged over time. The project manager reported that Soukhya groups now face the issue of attrition of female sex workers (FSWs). The presence of other microfinance groups, which provides easy loans without savings or any engagement with activities, has also caused difficulties. The availability of loans prompts many FSWs to join these groups. Once they get the loans, FSWs tend to leave the groups, with many even migrating to another location. As a result, the number of Soukhya groups has reduced from 83 groups in 2010 to 78 in 2011. From 2010 April, the responsibility of project management was shifted to the CBO from Myrada. Since then, the programme has been experiencing gaps in technical support and capacity building initiatives. The CBO lacks funds and expert resource persons to provide regular capacity building. On the technical support front, the CBO does not have the capacity to write proposals or do internal evaluations, as a result of which they miss out on opportunities to win new projects. Despite these challenges, the Soukhya Samudaya Samasthe experience proves that mobilisation of the community when coupled with initiatives that address economic vulnerability of the sex workers and provides them with an enabling environment along with access to services can lead to better health outcomes. The mutually aiding influences of an improved economic condition and a less stigmatized environment, along with ensuring access, availability and a better experience at the clinic has resulted in better health seeking behaviour among the sex workers17.

16 17

Myrada. Community Led Interventions in the Myrada HIV AIDS Sankalp Programme Pillai P. Impact of Two Vulnerability Reduction Strategies Collectivisation and Participation in Savings Activities on Risk Reduction among Female Sex Workers; July 2011

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Chapter 4 Social Protection for FSWs

Soukhya Service Groups Create an Enabling Environment in Chikballapur


We cannot feed them [female sex workers] everyday but what we can do is to show them the way. - Thipamma, a Peer Educator

In 2004, Myrada began implementing a targeted intervention (TI) for HIV/AIDS prevention and management with female sex workers (FSWs) in six towns of Chikballapur district. The district Chikballapur18 lies in the southern part of Karnataka state. Divided into six talukas, Chikballapur is the 22nd largest district in the state in terms of population and the 25th largest in terms of the land area. According to the 2001 census of India, the total population of the district is about 11 lakhs, with a sex ratio of 966 females per 1000 males. The overall literacy rate is 59% with 70% among males and 48% among females being literate. The HIV prevalence among the low risk general population in Chikballapur district was 0.26% (PPTCT, 2009). The HIV positivity rate among ICTC walk-in females in 2009 was also low at 1.98%. As outlined in the National AIDS Control Organisation (NACO) guidelines, targeted interventions (TIs) aimed at FSWs were required to promote six objectives: sexually transmitted infection (STI) services; condom usage; behaviour change through peer communication and outreach; build an enabling environment; build ownership from the community; and link prevention to HIV related care and support services. Myradas established presence in the area and expertise in building local institutions led to its facilitating the creation of a community-driven organisation, Soukhya Samudhaya Samasthe (SSS). Before the intervention began, project staff met with FSWs in the district to discuss its purpose, and gain an understanding of the local context. The discussions highlighted the challenges faced by women engaging in sex work such as higher risk of physical and sexual harassment and abuse, inability to negotiate with clients about condom use or demand due payment, social marginalisation and stigmatisation, and lack of access to basic services and resources. This input from FSWs ensured the TIs activities, were planned in collaboration with the community members.

4.1. From the Bottom Up: SSS Structure and Process


Myradas prior work with building community-driven institutions guided the process of this TI19. The first step involved mobilising groups of 10-20 FSWs into Soukhya Service Groups (SSGs), based on common sites and locations frequented by FSWs, to promote regular, long-term

18

District profile information from HIV Situation and Response in Chikballapur District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010

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Local Solutions to a National Problem

contact.20 The groups meet on a weekly basis with Peer Educators (PEs) and women enlisted from the FSW community for outreach and other programme-related activities. Today, there are 78 SSGs comprising 1,363 community members in Chikballapur district. By 2005, a network of SSGs had emerged and federated at the block-level and six taluka Okkuttas (TOs) or block federations were formed. TOs consist of two representatives from each SSG, the concerned outreach worker (ORW), a counsellor and representatives from various external groups such as doctors and lawyers. As the intervention progressed, the TO members divided to establish four sub-committees for Crisis Management, Drop-In Centre (DIC), Health, and Social Entitlements based on the TIs services and the target populations demands. The TOs meet monthly and its members work to establish linkages with the community and support TI activities at the block level. In 2009, the community-based organisation, SSS, was formed with the aim of reducing the incidence of curable STIs and HIV for FSWs and men who have sex with men (MSM) in select urban locations in the district. SSS follows a similar structure to the TOs and contains the same four sub-committees. Two representatives from each block federation stand for CBO board elections every year; the two elected TO members in addition to the programme manager (PM), counsellor and an ORW constitute SSS membership.

COMMUNITY

1,363 female sex workers

78 Soukhya Service Groups

6 Taluka Okkuttas

Soukhya Samudhaya Samasthe (CBO)

4.2. TI Activities for FSWs


SSSs specific objectives entail increasing FSWs condom usage with clients and other sexual partners, reducing the incidence of STIs, and creating an enabling environment. Towards this end, SSS conducts four programmatic activities for FSWs: outreach, promoting condom usage, providing access to health services, and creating an enabling environment. Outreach activities are primarily conducted by PEs and ORWs with an overall strategy of maximising contact with FSWs, SSG and non-SSG members alike, and disseminating information to the target population, their partners and clients mostly on health related subjects. Weekly meetings are held where PEs provide information on personal hygiene, reproductive health, STIs, HIV/AIDS, condom usage, and group formation. The problems and needs of SSG members are also discussed. For non-SSG members, PEs specifically raise awareness on health issues and safer sexual practices, as well as distribute condoms. However, frequency of contact with this group is less. Condom promotion activities are heavily linked with outreach. SSS procures condoms from the District Health Office (DHO) and then distributes them to FSWs through PEs, based on the
19

MYRADA (2011), HIV/AIDS and High Risk Groups Strategies for Sustainable Intervention: The MYRADA Soukhya/Sankalp Experience, Rural Management System Series Paper 62. Available from: http://www.myrada.org/myrada/node/211 Ibid.

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Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India

DISTRICT

BLOCK

SITE

27

volume of clients. Condoms are also made available either through a designated box on-site or at nearby outlets such as paan shops. SSS provides health services through a referral system, which was established through linkages with both public and private clinics which have doctors trained on STI management. In the district, there are six government and seven private referral clinics. Clinics provide all-around health and HIV-related services including STI diagnosis and treatment, ICTC, TB testing, speculum examinations, health booklets, and counselling. HIV positive community members are registered with the district ART centre for treatment or other local service provider. SSS places strong emphasis on creating an enabling environment for FSWs. Since the initial phase of the TI, the site and block level institutions strategy was to build public and private partnerships in the local community to address stigmatisation, discrimination and the socio-economic needs of High Risk Groups (HRGs). Therefore, SSS has provided sensitisation training for key stakeholders such as health providers, government officials and bodies, local media networks, police officers, lawyers, auto drivers and pimps. In addition, the organisation is involved in crisis management, which entails devising methods and strategies to address site-level crisis such as quarrels with partners, and harassment or abuse from clients and police officers among others. Furthermore, community mobilisation and awareness generation is carried out through large-scale events, particularly by observing World AIDS Day, International Womens Day, Childrens Day, and FSW conventions (for SSG and non-SSG members). These events are held to reduce stigma and discrimination, disseminate information vis--vis HIV/AIDS and STI management, and establish linkages with potential public and private partners.

4.3. Accessing Social Entitlements for FSWs


From the beginning, FSWs had expressed their need for social and economic support in addition to HIV related services; by 2009, the inaction on this subject raised suspicions from community members about the organisations activities and intent. After six to eight months of lobbying, a decision was reached by SSS to place a social protection element on the agenda. SSS board members and district programme staff discussed and finalised the processes to provide access to such services.

Creation of Social Entitlements Committees


As a first step, community members suggested the creation of special bodies at the block level; the Social Entitlements Committee (SEC) was then created and TO members were designated roles
28 Local Solutions to a National Problem

Through SSS, FSWs receive social assistance such as school bags from public and private partners.

and tasks. Today, the social entitlements component of the TI requires the participation of every level, from the community to the CBO and is one of its main strengths. An extensive support system exists within the organisations process to reduce incidences of failed applications; if an ORW is unsuccessful in accessing a particular scheme for the target population, the PM and/or SEC members will intervene to resolve the problem.

Identifying Needs, Schemes and Key Individuals The initial phase of the social entitlement activity involves a needs assessment at the site level where SSG members are asked to list their requirements. Since 2009, they have expressed the desire to access a variety of services and entitlements such as identity cards, pensions, childrens education support, financial assistance and non-HIV related health services. Each SSG members requirements are collated by PEs and then presented to the corresponding TO where it is reviewed by the SEC.
In the first year, SEC members reflected on the process which enables FSWs to access social schemes and services. It was decided that after understanding the communitys needs, concerted efforts would be made to identify available schemes as well as key institutions and personnel working in the specific sectors. Three strategies have contributed towards this activity, all of which involve building rapport with relevant stakeholders. One strategy entails calling on government department officials and private service providers to attend FSW conventions and mass awarenessgenerating events (e.g. International Womens Day celebration) organised by SSS. Their attendance establishes direct contact with key functionaries and the community members, sensitises them to the plight of FSWs and enables SSS to learn about existing resources which align with the needs of the target population. Towards the same end, ORWs visit block department offices with a letter of introduction describing SSS and its activities to enquire about the focal person and available social entitlements. ORWs and PEs were given instruction on how to engage and speak with department officials and NGO staff. In addition, the PM attends regular meetings convened by line departments (e.g. health, social welfare, women and child development), panchayats, CD4 testing laboratories, ART centres, District AIDS Prevention and Control Unit (DAPCU), and banks. Every six months, the PM also requests from each line department a list of available schemes. The efforts made to build linkages and rapport with local authorities and institutions has significantly contributed to the effectiveness of the social entitlements programme as a whole. SSSs methods of identifying available schemes and key personnel have enhanced community members awareness of the process by which to apply for social entitlements. It has created the necessary connections with local authorities to lead to successful bids. Other activities within the framework of creating an enabling environment such as external stakeholder trainings in addition to community-wide events have sensitised local authorities and other service providers to the plight of FSWs in the district and further present opportunities for potential collaboration in support of the community.

Disseminating Information on Schemes Monthly SSS staff meetings convening the PM, ORWs, PEs and counsellor act as a platform to share about available schemes and services that FSWs may access. PEs, in turn, communicate this information to SSG members and other FSWs at sites. ORWs collect required documentation and materials such as photographs for applications as well as completed applications from FSWs; if the community member is unable to fill out any forms, she receives support from SEC members and ORWs. Applications are finalised by the SEC members.
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 29

Schemes/Services Available to SSS FSWs

Economic
Annual grants for OVC/HIV+ children Ration cards Skills trainings Subsidised loans for SC/ST Subsidised loans for SSGs Widow pensions

Education
Computer classes Government scholarships School supplies

Girl-Child Promotion
Bhagya Lakshmi Yojana

Health
ANM & ASHA worker services Birla Sun Life Insurance Post-delivery care for newborns Madilu (post-natal) kits for mother and child Personal IDs Birth certificates Caste ID certificates Senior citizen cards Voters ID cards

Housing Ambedkar Ashraya Yojana Basava Vasathi Yojana Hostels for HRG Hostels for OVCs

Source: Interviews with Programme Manager, Counsellor, and Social Entitlements Committee, 18 Nov 2011

Submission of Applications and Follow-Up ORWs and PEs sort the finalised applications by the granting body and submit them at the respective offices. Prior to the existence of the social entitlements activity, FSWs applying individually faced great difficulties in accessing social schemes, services and resources due to discrimination, lack of awareness of schemes application processes, and absence of support or linkages with relevant institutions. Through the SSS model, however, several ORWs submit FSWs applications at the necessary offices to improve the chances of acceptance. At the time of submission, ORWs do not give any indication that the applicants are FSWs to ward off any undue prejudice. Even if the receiving office is aware of the community which they serve, ORWs push the application forward by mentioning their affiliation with Myrada, which has a long-established presence in Chikballapur district. Community members and PEs also utilise this strategy to add legitimacy to their claims, ease tension and remove stigma.
30 Local Solutions to a National Problem

After submissions, SEC members engage in vigilant follow-up and regularly interface with relevant focal persons and offices to advocate for successful acceptance. This activity is enhanced further by the linkages that are established by SSS; if there are any delays or problems with a specific application, SEC members, ORWs and/or PEs will solicit support from local authorities with whom they have built strong relationships. These authorities provide letters of recommendation for the SSS personnel and further strengthen the FSWs bids for social entitlements. If I cannot finish my work [for social entitlements], I will go directly to the MLA!
Govindamma, Peer Educator

4.4. Impact
The social entitlements component of this TI has been operating for approximately two years and evidence of its success and impact on FSW behaviour already exists. Since 2009, 3,223 FSW applications for social entitlements have been submitted to public and private institutions. As of September 2011, FSWs and their dependents have been successful in accessing 2,824 schemes or services demonstrating an 88% rate of success. SSS FSWs Applications for Social Entitlements Social Entitlements Birth Certificates Caste Certificates Housing HRG Hostels Land Madilu Kits OVC Hostels Ration Card School Supply Kits Senior Citizen Card Voter ID Card Widow Pension TOTAL Submitted Applications 58 117 200 5 45 38 85 1165 180 48 1250 32 3223 Successful Applications 58 117 5 5 10 35 78 1105 180 48 1165 18 2824

Source: Interviews with Social Entitlements Committee, 18 Nov 2011

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Ensuring Social Protections to Enhance the Role of the CBO The addition of a social entitlements component to this TI has shown some impact regarding its effectiveness towards HIV/AIDS prevention and management. Since addressing a more comprehensive package of needs, community mobilisation activities have become easier for TI staff FSWs now hold the CBO and staff members in higher esteem. This can be seen in the full adherence to health targets by the SSG members with 100% condom usage, regular STI treatment and follow-up, bimonthly meetings with PEs and regular medical check-ups. By taking on a priority concern for FSWs, SSS demonstrated respect and a willingness to tackle issues which the members deemed most important. As a result, a sense of mutual understanding has developed with FSWs being more willing to cooperate with the CBO. The additional provision to access social entitlements through SSS is attracting new members with some two to three members having joined since 2009. Shifts in High Risk Behaviour Social protection in Chikballapur has also seen a shift in high risk behaviour. Skills trainings and subsidised loans through the municipality has led to NGOs and financial institutions providing FSWs with alternate avenues for income generation. Since the trainings and commencement of small enterprises or employment, almost all FSWs have utilised their trainings and as a result, decreased their client loads. Furthermore, these women have expressed an interest in building their enterprises and skill sets, which would lower or diminish dependency on sex work alone for income generation. Reducing Vulnerabilities Access to social entitlements, as part of the strategy to create an enabling environment, addresses multiple vulnerabilities particularly with regards to social discrimination and stigma. Awareness-generating activities, sensitisation training and excellent rapport with local authorities are all crucial elements for successful applications for schemes and services, that have resulted in a greater acceptance of FSWs. For example, the DHO held a blood donation camp for the general population and called on SSS to invite other NGOs and FSWs to the event. Out of the 60 participants, 28 were FSWs. Allowing and encouraging this HRG to donate blood indicates a shift in the communitys thinking towards FSWs.
Help for Extremely Vulnerable Women Venkatlaxmi, or Laxmi for short, is a sex worker in Chikballapur town. About 2 years ago, her husband passed away and her mother-in-law forced her to leave the house with her two young children. Without a home or a family, Laxmi moved to Chikballapur in search of work. Unable to find a job, she turned to sex work to support her 6 year old son and baby girl. Sumar, an SSS outreach worker, found Venkatlaxmi crying at the bus stop. After learning of her situation, Laxmi was introduced to SSS and its services. SSS helped her to obtain a voter ID and ration card and to find a free hostel facility for widows and divorcees. Laxmi has been living in Spandana Hostel for the last 18 months and is confident that when the time comes, she will be able to rent a house.
Source: Interview with SSS FSWs, 18 Nov 2011

The social entitlements strategies have had an impact in reducing the social and economic vulnerabilities of the FSWs and raising their status and self-confidence in society. Many of the public schemes made available to FSWs deal with meeting basic services such as education, health and economic subsidies. Successful applications enable women to access these basic provisions to live a more dignified life with lower risks of
32 Local Solutions to a National Problem

poverty and deprivation. The ability to access schemes and services that are usually provided to the general population removes a social barrier and allows for a mainstreaming of FSWs.

4.5. Challenges and Opportunities


This TIs social entitlements component has made remarkable strides in creating an enabling environment for FSWs in Chikballapur and its sustainable systems are a contributing factor to its success. Since its inception, Myrada has infused the community institutions with a sense of self-reliance and autonomy. In the initial stages, SSGs were guided by PEs; today, many of the SSGs no longer require the PEs to lead their meetings and have even assumed specialised roles (e.g. condom distribution, social entitlements). However, a major hurdle for the social entitlements programme is the pervasive presence of illiteracy. Only two out of the eight PEs that met the research team in Chikballapur town were literate. If the community leaders and FSWs they serve are illiterate, they will always require support in accessing social entitlements. In view of this, an adult literacy programme can be carried out for these women to ensure the sustainable growth of this TI. Within the scope of the social entitlements programme, another issue of concern is that the process to access public schemes is long, difficult and restrictive. As a result, the SECs spend a majority of their time following up on submitted applications. Community members need to be enabled to monitor the progress of their own applications. Literacy training would be a first step in this direction. Furthermore, many of the schemes are provided for persons of historically disadvantaged backgrounds (e.g. SC/ST, Muslim). One solution to this problem would be to mobilise resources from the local community. SSS has already partnered with private institutions to provide education support and skills trainings. Considering the success of alternate livelihood support schemes in reducing the frequency of sex work for some FSWs, it is recommended that this type of intervention be strongly pursued and training on building market-oriented enterprises be provided. SSSs community mobilisation strategy and successful activities to build an enabling environment are the major strengths of this TI. By providing FSWs with social protection, SSS provides a package of services that address a more comprehensive set of needs. The process by which the organisation mobilised FSWs into SSGs, which then federated to the block and district levels, and its low-cost methods of service provision such as the health service referral system are a testament to the TIs sustainability. Other organisations working for HIV/AIDS management and prevention with this specific HRG can learn valuable lessons in building a bottom-up institution that is both effective and sustainable. Now we are here but we wont always be. But the Community can access these entitlements always Chandrama, Peer Educator

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Chapter 5 Making Strides in Improving Lives of FSWs

Stepping Stones for Mahila Sangha Staff in Davangere


The lesson [of Stepping Stones] is that there are different kinds of people sex workers, non-sex workers, old, and young and you can share your problems with others and support each other to get through life. Renuka, Shri Durgashakthi AIDS Thadegattuva Mahila Sangha Outreach Worker

The district of Davanagere21 lies in the borders of Deccan plateau and is the 9th most populous district in the state. According to the 2001 Census, the total population is 17.9 lakhs, with a sex ratio of 952 females per 1,000 males. The overall literacy rate is 67% with 76% of the males and 58% of the females being literate. The HIV prevalence among the general population in Davanagere district is low at 0.23% (PPTCT, 2009), however the HIV positivity rate among ICTC walk-in females in 2009 was moderate at 7.80%. According to 2010 estimates, 3,191 female sex workers (FSWs) reside in Davanagere22. For the past eight years, Shri Durgashakthi AIDS Thadegattuva Mahila Sangha (hereafter referred to as Mahila Sangha), a community based organisation (CBO) has been working in five Davanagere district towns to organise FSWs into self-help groups (SHGs) of 9-15 women who meet regularly to discuss issues related to health. Mahila Sanghas CBO formation is done in the hopes that mobilising women into groups will buffer the risks of sex work, which include violence, social stigma, and STI or HIV infection. FSWs in Davangere are at increased risk for HIV, as reflected by the fact that young women have the highest positivity rates in the district23. Because FSW often live under extreme life circumstances, it is crucial that organizations working with this population display sincere empathy in their efforts. Attitudes must show high levels of commitment to servicing this population and employees must regularly reflect and evaluate their own behaviours and biases regarding their interactions with both FSWs and other NGO staff24. For HIV prevention Programmes in India, the National AIDS Control Organization promotes this professional ethos. As outlined in NACP-IIIs Operationalizing Targeted Interventions for FSWs/MSM/TGs: Guidelines for NGOs, capacity-building activities for TI staff are described as:

21 22 23 24

District profile information from HIV Situation and Response in Davanagere District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010 HIV/AIDS Situation and Response in Davangere District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust: July 2010 Ibid. Ibid.

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Local Solutions to a National Problem

Trainings should be conducted for the new staff on the following: 1. Basic induction on HIV/AIDS and understanding the FSW/MSM/TG community and the dynamics of sex work 2. Skills in identifying and building rapport with FSWs/MSM/TGs and methodology of site validation (2007: 59, bolding added). Capacity building can be achieved through a variety of methods, but some approaches leave staff critically lacking in comprehension of real life circumstances facing FSWs. Outreach Worker (ORW) Renuka remarks, The non-community staff members were finding it hard to completely understand and relate to the community, so [CBO managers] decided to do Stepping Stones. The following case study details Mahila Sanghas innovative application of Stepping Stones a unique training module for organizations implementing HIV/AIDS projects for its TI staff.

5.1. Stepping Stones for CBO Staff


Stepping Stones was originally developed to ensure that HIV prevention education is delivered to community members in a way that stimulates exploration of and long-term changes in ones attitudes and behaviours related to high-risk sex25. Authors from ActionAid India and KHPT adapted the Stepping Stones manual to be relatable to HRGs (including FSWs) within India in the hopes that the training will achieve a greater behavioural change than abstinence-based campaigns or isolated condom distribution services. In December 2008, ActionAid Bangalore administered red Stepping Stones training in Shimoga and Davangere. For 13 days, 60 SHG leaders, taluka-level committee members, and district board members of FSW CBOs, took part in the residential training Programme. Results were found to be highly beneficial for these smart and motivated FSWs, but concerns arose within Mahila Sangha that changes in CBO leadership every two years might diminish the benefits of Stepping Stones. Trained leaders are rotated out of the top positions, taking knowledge gained during the training with them. Thus, a decision was made to run Stepping Stones training for TI staff to ensure the retention of trained leadership within Mahila Sangha, regardless of the CBO leadership cohort in place. Mahila Sangha sent three staff members CBO Staff Engage in Stepping Stones Activities
25

Operational Guidelines to Implement Stepping Stones in the Community Karnataka Health Promotion Trust.

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(one FSW and two non-FSW) to an 11- day training session delivered by KHPT in February 2009. Now, when new committee leaders are elected, they are trained by ORWs or Counsellors in Stepping Stones. ORWs also administer the training to Peer Educators.

Transitioning Stepping Stones for Staff While all Stepping Stones modules are tools for making HIV prevention strategies more holistic and effective for the community, the following four sessions are particularly important for building the capacities of the TI staff.
Lets Communicate. Participants exercise their ability to listen and communicate with others around them. This is necessary for FSWs, as many are young, marginalized women who feel like they do not have a voice or that they are not properly heard26. For TI staff, lessons learned from participating in this module are twofold. First, for future administration of Stepping Stones or other group work, staff will personally experience the effects of power dynamics within groups which can hinder or modify ones participation. Any social worker must learn how to mitigate, as much as possible, the powerful effects that age, religion, caste, or life experiences can have on the interactions between peer groups. Second, ORWs normal work includes weekly check-in meetings with Peer Educators (PEs). Because PEs are necessarily members of the FSW community, and therefore experience social marginalization, the communication skills that non-FSW staff members learn through Stepping Stones can sensitize their regular interaction with PEs. Our Perceptions. The goal is to challenge trainees to think about the way in which their perceptions of others influence their actions towards them. Employees working with women involved in largely taboo or illegal income generating activities must be especially conscious of their internal biases and preconceptions about sex workers. This session reinforces the importance of treating FSW and non-FSW staff as equals. Body Mapping and Sex. Activities in Body Mapping and Sex sessions help women to push through embarrassment or insecurities regarding the male and female anatomy. Administering this activity in India can be discomforting, as many women, especially those who are young or deeply religious, are either uneducated about their bodies or feel extreme uneasiness discussing sex and sexual body parts, despite their work as FSWs. Their business as sex workers, however, is precisely what makes familiarity with the human body so important, so that they may recognize and treat troubling symptoms early. Staff administering this module must be sensitive to the delicate nature of these topics, and experience firsthand how uncomfortable discussing
ORWs and Peer Educators Meet and Learn Stepping Stones
26

Ibid

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Local Solutions to a National Problem

personal anatomy can be. This help to improve staffs empathy for sex workers struggles with their body and the difficulties they have expressing related issues. HIV/AIDS, STI, and Condoms. Finally, complete and accurate knowledge is crucial for those working to scale back HIV infection among vulnerable populations. It is necessary that FSWs are given clear and updated information so they are better prepared to protect themselves. It is even more important that TI staff retain and frequently refresh their understanding of these topics, as they are permanent resources to multiple FSWs for HIV prevention techniques and tools.

Embedding individual modules into regular meetings with Peer Educators ORWs meet weekly with PEs to discuss the progress and activities of the TI. Now, during these meetings, ORWs transfer knowledge learned from Stepping Stones sessions to PEs, either to improve their understanding of certain concepts or to endow them with the skills to administer individual Stepping Stones modules with one or more SHGs. These meetings emphasise role-playing and activities that dont involve much reading or writing. Renuka explains, I give the same training to PEs which I receive myself, but sometimes I will focus more on the role playing activities. This is for two reasons: One, some uneducated women come, so they will learn more when they are made to interact. And two, because sometimes Peer Educators dont have lots of time to spend doing Stepping Stones, so we focus on the big issues. Wrapping these modules into regular meetings with PEs allows them to be trained in Stepping Stones at a pace that is viable for their schedules. In this way, Mahila Sangha staff guarantee that at least some ORWs and PEs are qualified to administer Stepping Stones at any given time.

5.2. Impacts of Administering Stepping Stones with CBO Staff


Honed skills for administering Stepping Stones TI staff who have undergone Stepping Stones training feel decidedly better equipped to administer the modules to other staff or community members. This could be for a few reasons. Because staff have firsthand experience participating in each module, they can empathize and understand how emotional and affecting it can be to share personal, and sometimes tragic, stories. Also, FSW staff have applied Stepping Stones lessons in their lives, so they can guide others in similar processes (see Box 5.1). They feel empowered to change their situations and bring the knowledge of having transformed module activities into real outcomes to the more vulnerable members of their community when training them in Stepping Stones.
Box No 5.1: Staff Apply Stepping Stones Lessons One Peer Educator detailed the story of how she decided to take steps to ensure her familys security after death given her HIV-positive status. As difficult as it was, Stepping Stones helped Majula face the reality that she may die at any time and helped her plan for her childrens futures. After participating in future planning activities during Stepping Stones training, Majula has written a will, leaving possessions separately in her sons and daughters names. She also now has a personal bank account, as well as accounts in both of her sons names. She has filed a land title deed in the name of her daughter and has purchased a Life Insurance Policy. As a result, Majula is comfortable in the knowledge that her children will be better taken care of in the event of her demise.
Source: Interview with CBO Leadership, 23 Nov 2011 Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 37

Expanded networks to key stakeholders


A poignant Stepping Stones session is a role play exercise in which trainees locking arms and crossing a pond filled with crocodiles or potentially dangerous objects. Crocodiles symbolize negative forces police, goondas, violent clients, and the adverse reactions of society that sex workers experience throughout the course of their lives. During this exercise, people of different backgrounds join hands to help each other face the challenges of life. This is transformative in the lives of FSW and non-FSW TI staff, as they can visualise the need for creating and relying on networks of people with different skills and capabilities such as the media. TI staff and FSW leaders better understand the importance of networking with stakeholders outside the community to improve their life situations.

Strengthened Crisis Management team


Sex work is not a legal income generating activity in India, but police officers arresting FSWs frequently abuse their authority by harassing them without cause, demanding free sex, and acting violently. CBO staff therefore inform sex workers about where they should avoid working and loitering, for example within 200 meters of public places like temples and schools. Further, increased networking skills as endowed by Stepping Stones have created a forceful group of CBO leaders who are on-call at all hours to demand release of FSWs held unlawfully. These members feel empowered to threaten exposure of police wrongdoings to the media and are often highly successful at working together to ensure the safety and release of FSWs wrongly held. When we are together, we are stronger. This is something that we learned from Stepping Stones. When just the group was there, [the employees] used to focus only on health, ICTC checkup, STI, condomsNow, they think about the need to be a group, to be together to face other issues
-Renuka, ORW

Improved confidence in work-related behaviour Renuka, an ORW with six years of experience with the CBO, has now trained two groups of PEs in Stepping Stones. She was proud to report, The district coordinator said that there have been some changes in me, in my body language. Whenever colleagues have a problem, I try to follow up with them and solve their problems. Community members who have been arrested or are in trouble now feel they can come to me for help. The respect I get gives me a greater sense of responsibility. I want to learn more so that I can build the respect even more. Renuka is not alone in feeling that Stepping Stones training has increased her confidence and skills as an ORW.

5.3. Challenges and Opportunities


In administering Stepping Stones to Programme staff, a few challenges exist. Peer Educators, who earn primarily through sex work, face a time constraint both in participating and administering Stepping Stones. Even separating sessions by administering only one module each month requires more time than some Peers can afford to give, as many cannot forgo earning in order to spend the time required to give due

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attention to the sensitive issues discussed in Stepping Stones. As with most TIs, the inability to remunerate PEs sufficiently to forgo clients for stepping stones is a constant difficulty. Funds are also required to provide tea and snacks for the women and their children who attend training sessions. TI staff unanimously desire more training in Stepping Stones. All seven PEs and four ORWs interviewed felt they could benefit from extra training in Stepping Stones modules. They strongly support this methodology for use within their community, not only to help FSWs protect themselves from HIV/AIDS but also to increase their quality of life by reducing their vulnerability. They agree that Stepping Stones strengthens their group force as a CBO. Yogeshwari, an ORW, sums this up perfectly by saying, I really feel responsible now and like I am a part of my community. Administering Stepping Stones to CBO staff has created an environment in which both FSW and non-FSW leaders are endowed with the skills to help vulnerable women make real changes in their lives to help their families and themselves.

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Chapter 6 Building Solidarity among FSWs

Innovative Cultural Mobilisation by Rakshane Zilla Mahila Okkoota in Gadag


Before I felt isolated, lost, and would often cry. But when I attended an event held at the DIC, I danced and celebrated the festival. I felt very good! - FSW Member of the Programme Management Committee

In the fight against the HIV/AIDS epidemic, sex workers are considered to be a high risk group (HRG). A recent study conducted across four south Indian states, found that HIV prevalence amongst female sex workers (FSWs) was 14.5 percent27, vastly exceeding the rate of 0.36 percent28 found amongst the general population. Indias National AIDS Control Organisation (NACO) leads a programme of targeted interventions (TIs) aimed at HRGs, which focus on raising awareness of the health implications of unsafe sex and HIV/AIDS issues. Under the latest guidelines of the National AIDS Control Programme (NACP-III), NACO advocates for community-led responses to HIV prevention, whereby ensuring greater ownership of TI planning and implementation by the target community themselves29. To this end, community-based organisations (CBOs) have been formed, with support of NGOs, to provide community members with a vehicle for effective self-mobilisation and outreach service provision. One such example of this trend is Rakshane Zilla Mahila Okkoota30, a CBO formed by FSWs of Gadag District in northern Karnataka. This case study documents the experience of the CBO in using cultural events to better mobilise the female sex workers. Gadag district31 lies in Northern Karnataka and is divided into five talukas. It is the 26th largest district in the state in terms of the population and the 23rd largest in terms of land area. According to the Census of India, 2001, the total population of the district is 9.7 lakhs with a sex ratio of 969 females per 1000 males. The overall literacy rate is 66% with 79% of the males and 53% of the females being literate. The HIV prevalence among the low risk general population in Gadag district is low at 0.48% (PPTCT, 2009) and among high risk females was high at 11.99% (ICTC walk-in females, 2009).
27

Ramesh. B.M. et al (2008) Determinants of HIV prevalence among female sex workers in four south Indian states: analysis of cross-sectional surveys in twenty-three districts, AIDS, Vol. 22, No.5, pp.35-44 NACO (2007) Annual HIV Sentinel Surveillance Country Report 2006. NACO (2007) NACP-III guidelines, p.142: The targeted intervention design of NACP-III aspires to initiate and strengthen community led or community owned programming. This is intended to enhance the utilisation of services as well as create sustainable impact among high risk and vulnerable populations. This helps to make a transformation from service provision to demand generation, leading to greater utilisation of services and commodities. Hereafter referred to simply as Rakshane. District profile information from: HIV Situation and Response in Gadag District: Epidemiological Appraisal Using Data Triangulation, India Health Action Trust, July 2010.

28 29

30 31

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Rakshane Zilla Mahila Okkoota was formally registered as a society in 2008, assisted by the NGO Samraksha, which had been implementing a TI Project Namjeeva - with FSWs in the area since 2004. The focus of the TI is not just on reducing the risk of HIV, but also on mobilising and empowering the communities to question the larger issues of marginalisation and discrimination which make them vulnerable to HIV 32. Since the formation of Rakshane, Samraksha has dissolved much of its control over the TI. Coordination and management of the programme now rests with Rakshanes Programme Management Committee comprised of elected FSW community members.

6.1. Evolution of Project Namjeeva


Successful implementation of TIs with HRGs rests on behaviour change communication (BCC) strategies. In any efforts to influence the attitudes and behaviour of the primary stakeholders, a necessary pre-requisite is identification and mobilisation of the target group. In the early stages of the TI implemented by Samraksha, FSW community members were associated with the intervention as volunteers or key informants during population mapping and needs assessment. From these exercises it became evident that the FSW population in Gadag district, estimated at 1,976 women in 2004, was geographically diffuse. Over 50 percent were found to reside in rural communities and the population was highly diverse in terms of language, religion, caste and socioeconomic status. In addition to the heterogeneity of the population, the widespread stigmatisation and criminalisation of sex work forces FSWs underground. Rarely do women openly advertise their services, thus ensuring that they are difficult to identify, track and monitor33. In the case of Gadag district, less than 30% of the women were openly operating as sex workers and even amongst them less than 10% knew each other34. The hidden or partially hidden nature of sex work clearly has implications for dissemination of vital information and delivery of services pertaining to HIV/AIDS prevention. Initially, Samraksha took the lead in attempts to reach-out to and mobilize FSWs in the programme area. In each of the five talukas in the district, four paid staff members assumed the role of outreach workers (ORWs) and supervised five peer-educators (PEs) drawn from the FSW community. These outreach teams assumed primary responsibility for identifying FSWs within their defined locality and developing regular contact with them. This proved to be a challenging task. At the point of first contact, the outreach teams would attempt to build rapport, explain the programme, motivate women to attend the drop-in-centres (DICs) and visit clinics for testing. They would target brothels and lodges and try to persuade the madams or owners to allow access to the FSWs operating there. Additionally, PEs would regularly visit known hotspots and, in the case of hard-to-reach home-based sex workers, they would make visits to FSWs houses.

6.2. Cultural Events for Increased Mobilisation


These conventional outreach strategies - though no doubt essential - are laborious, since they rely primarily on one-to-one mobilization where it takes time to disseminate information to the wider target population. Moreover, individual or small-group interactions are slow in creating a sense of community solidarity and ownership over the programme. In response, the outreach teams hit upon an innovative strategy to bring together the dispersed community. From 2006 onwards, they started organising monthly cultural events in each taluka-level DIC. Peer educators
32 33 34

Samraksha (n.d.) Samraksha: Adding Years to Life. Available online: http://www.karmayog.org/ngo/Samraksha/upload/3096/Samraksha%20Folder%20final.pdf Website of AVERT, http://www.avert.org/prostitution-aids.htm, accessed 10/12/11 Rakshane, internal documentation.

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began consulting the community to plan suitable dates and activities. It quickly became apparent that many of the women had skills in cookery, singing, dancing, drama and artwork, and that these could be utilized to help them unite and open up to one another. Advertisement of the events occurs through word-of-mouth, building on existing networks of contacts created through earlier outreach strategies.

Celebration of Major Festivals In months where a major festival occurs, such as Lakshmipuja, Diwali and Ramadan, the community members come together to celebrate in a customary manner. For instance, in the case of Nagarapanchami, women will prepare sweet ladoos to share.
Traditionally, women would go home at this time to celebrate with their mothers. However, since many FSWs are ostracized from their families, celebrating with other community members now represents a social space where they are able to legitimately and openly celebrate their culture. Additionally, although not a festival as such, each year the community organises taluka-level events coinciding with World AIDS Day on the 1st of December. Attendance at these events is variable, with some 30 to 80 women participating.

Community Planning and Peer-Learning


Even in the absence of a festival, the community finds other reasons to celebrate and will gather to eat, dance, sing and enjoy the day in each others company. A Fashion Show and Childrens Day are examples of events that have been suggested by community members during planning meetings and which have subsequently been adopted. In the latter, women attended with their children and organised simple games and other activities. Games such as acting out roles e.g. be a drunkard, policeman, bharatnatyam, gunda, minister, etc. are played to help women overcome their initial inhibitions and relax in the environment. Peer-learning through skills sharing also occurs and basic literacy classes and training in tailoring have taken place from time to time.

CBO Members Light Candles to Celebrate Nagarapanchami

Rakshane Members Celebrating Childrens Day 42 Local Solutions to a National Problem

Awareness-Raising A critical function of these events is the opportunity to spread awareness of the risk of HIV-AIDS and other sexually transmitted diseases, to address fears about testing (see Box 6.1) and to demonstrate and distribute condoms. To dispel myths such as government supplied condoms are of poor quality, they are too small and they break easily, women have been given condoms and instructed to blow them up as big as possible and then display them with their names or other designs. In another activity, PEs pour water into a condom and show it to the women saying see it does not break even if water is in it. Women are also encouraged to utilise clinical services provided through the programme.
Box No 6.1: Addressing fear of testing To tackle a common fear of the speculum examination, ORWs use a game known as Jadoo. Here, each woman would be instructed to stick a bindi at the centre of their hand and then fold their hand so it resembled a vagina. The women were asked if they could see anything inside to which they would all reply no. Then their hand would be opened as if using a speculum to reveal the bindi. This would demonstrate the importance of the procedure for allowing careful internal examination.
Source: Interview with Rakshane Programme Manager, 14 Dec 2011

District-Level Events The success of the monthly taluka-level events inspired Samraksha and the community to establish bi-annual district-level events that would bring together FSWs from all five talukas. Each year, on March 8th, the women gather at the DIC in Gadag town or district office to celebrate International Women Days. Later in the year, a Friends Mela or community get together is arranged. These events are much larger in scale, frequently attended by 300-500 women, and cost considerably more to organise. Whereas the budget for a single taluka-level event is only Rs.400, for district-level events it is in the region of Rs.25,000 - 30,000, which is spent on covering travel costs and providing food and beverages for all participants. The importance of these events is to scale-up solidarity building efforts and assist in forming and maintaining a district-wide community identity.

6.3. Overcoming Early Obstacles


A number of obstacles confronted the outreach team in the early stages of implementing the new strategy. These included facilitating associations between home-based and street-based FSWs, reaching out to women who were relatively new to sex work, and ensuring that women located in rural villages felt able to participate in the events.

Bringing Together Different Types of FSWs Home-based FSWs, who are more secretive in outlook, were concerned about revealing their identities and associating with street-based FSWs who are more open about the nature of their work. Understandably, they fear the judgement and stigma that typically accompanies such openness. For these reasons, encouraging home-based FSWs to attend the cultural events was difficult to begin with. Overcoming this barrier required PEs to invest time in explaining about their own personal circumstances and experiences with the programme, and conveying the message that: Youre not alone! We are all with you.
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 43

Motivating New FSWs to Attend


Since they would not yet accept their identity, new sex workers are often suspicious and resent the interference. Young sex workers are particularly problematic since they are able to earn a relatively higher income, especially in urban locations, and therefore tend to be less willing to consider the risks involved in their work. Again, PEs would address the problem through dialogue telling them: Come once if you get interested you can sit, otherwise you can get up and leave. If you like it, then continue to come. Events specifically for young sex workers have been organised around New Year, Diwali and Ugadi. Activities like dancing and singing competitions were suggested by community members as ideal to attract younger women. Generally, women who attended taluka-level cultural events have perceived the value of the programme and have continued to attend meetings and utilise the services.

Bridging the Rural-Urban Divide


Many of the villages in Gadag district are not close to a DIC (which are located in the primary urban centre of the corresponding taluka). FSWs from the villages were hesitant to come to the events as the DIC was perceived to be too far away. This problem was tackled by PEs who would go to the villages, collect women together and motivate them to travel as a group to the event. After attending these events once, women are frequently willing to come to the DIC by themselves and, also, to introduce their friends (other hidden sex workers) to the programme.

6.4. Impacts
The use of cultural events has proven highly successful in meeting the objective of increasing mobilisation of the target population. Solidarity and social capital has been enhanced and this in turn has positively impacted on the scale of service delivery achieved.

Increased Community Solidarity


Perhaps the greatest outcome of holding regular events has been the solidarity created amongst FSWs operating across Gadag district. One should look no further than the formation and successful functioning of Rakshane CBO to witness the true magnitude of this transformation. At the outset, the community was fragmented and dispersed: the largest affiliated group [of FSWs in the area] had less than 25 members35. Today, Rakshane has a registered membership of approximately 1,700 FSWs who are organised in a society imbibed with democratic processes at its core. Responsibility for implementing the TI now rests almost entirely with the community itself. Moreover, this collectivization process has been accompanied by a change in perspective about sex work, increased self esteem of members, and a strong sense of ownership over community issues. It cannot be claimed that cultural events alone could have produced such a phenomenal outcome. Organising cultural events relies heavily upon pre-existing and complementary outreach strategies e.g. PEs conducting house visits, site-level meetings, etc. - that are more intensive and necessary to establish the trust and confidence required to bring the community together. Nevertheless, it is hard to envisage alternative strategies that could, so successfully, have knitted the community together over a relatively short time period.

35

Rakshane, internal documentation.

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Enhanced Social Capital Community members themselves report increased confidence and self-esteem. The space provided by the events has proven to be highly valued for facilitating dialogue and collective problem solving. Discussion of issues such as stigma and discrimination, self risk perception and self esteem occur frequently. Earlier, while sex work remained largely hidden, FSWs felt isolated living lives that were fraught with difficulties. Indeed, suicide attempts were reportedly quite common, as women sought a way out of situations where they felt they had nowhere to turn.
Now however, through mobilization and solidarity building, FSWs feel part of an extensive self-help network. Strategies for dealing with harassment from police and goondas (which manifest in false arrest, rape, violence and robbery) and abuse from clients (in the form of beatings, refusals to wear condoms or to pay for services rendered) have been developed through discussions and role-plays. In turn, this has helped the women feel that they are not alone and that there is a whole community standing with them. Graph 6.1: Severity of abuse by Stakeholde (April 2009 March 2010) 5 Severity of Abuse 4 3 2 1 0 Police Gundas Clients Perpetrators of abuse Lodge Owner Before After

Source: Participatory Scoring Exercise with Rakshane ORWs and PEs, 27 Nov 2011

A participatory scoring exercise conducted with FSWs and PEs in the Gadag district office revealed benefits in terms of their collective capacities to deal with harassment and abuse (see Graph 6.1). Levels of maltreatment from police, gundas and clients identified as very severe in the past - have declined significantly as the community has collectively learned what we need to say and do to deal with these situations. Today, when rare instances of harassment and violence do occur, social networks are mobilized in a way that was not possible in the past; community members acting in the capacity of a crisis management team will come to the aid of the victim, approach the perpetrators to
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 45

express their displeasure and insist that such events do not recur. Initiatives to sensitize government agencies, the police department, auto drivers and others to the issues and needs of the FSW community are now an ongoing process, driven by the community itself.

Improved Outreach and Service Delivery According to Rakshanes Programme Management Committee members, the impact of the events strategy has been profound. Although difficult to quantify, committee members insist that levels of regular contact have increased through monthly get-togethers. Events have helped in reaching out to FSWs of all types from both rural and urban sites. The social bonding that has taken place through games and other activities has led to women really warming up to the PEs; indeed, invitations into homes and close conversations about very personal issues are reported to have increased in frequency as a result. Another positive trend observed is that, if an FSW attends an event for the first time and feels comfortable, then not only is she likely to return but may also bring other hidden and hesitant sex workers with her thus creating a snowball effect. Establishment of regular contact with an increased number of women is also reported to correlate with an increase in the uptake of condom use, clinical testing and treatment, and counselling services offered through the programme.

6.5. Challenges and Opportunities


This cultural events strategy appears to be highly cost-effective and far-reaching; it should be easily replicable by other NGOs/CBOs who have already established networks of HRGs through more conventional outreach methods. The only note of caution that should be sounded relates to the sustainability of holding district-level events in the face of possible funding cuts. While Rakshane appears to possess the low-level financial resources required to continue organising events at the taluka-level, continuation of the far more expensive district-level events without external support would demand greater internal capability to raise funds. To this end, CBO members have already begun to consider ways to build fundraising capabilities. One possible avenue being discussed is the establishment of collective income-generating activities like opening a hotel, where profits would be channelled into CBO activities. Alternative avenues could include capacity building of staff in proposal writing and effective administration of social projects (e.g. accounting, documenting, etc.). These strategies for building long-term financial sustainability require greater exploration and additional investment in the CBO may be necessary.

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Chapter 7 Reaching Rural MSM for HIV Prevention in Bijapur

Navaspoorthi CBOs Volunteer Peer Strategy

We can reach more community members through volunteer peers. They help also people in getting social entitlements they help with bank accounts, ration cards. They help in solving crisis. They are the backbone of our CBO Imam Attar, Navaspoorthi Outreach Worker

Current projections of the number of men having sex with men (MSM) in India are likely to be grossly underestimated36 for a number of reasons. Indias largely conservative attitude towards sexual behaviour, especially strong in rural areas, creates a fear of social stigma for MSM if their sexual status is revealed37. Furthermore, given that many MSM do not view themselves as homosexual and have intercourse with women as well, underreporting of sex with men is probable38. Lastly, there is an assumption that MSM activity is restricted to urban settings, causing inaccuracies in official figures of the number of men having sex with men in rural communities. Outreach and education to rural MSM-Ts is thus essential, as they are less likely to be informed about how HIV is spread and the methods to protect themselves and others from transmission39. Bijapur district40 lies in the north-eastern part of the Karnataka state and is almost 70% rural41. According to the 2001 census of India, the total population of the districts five talukas is approximately 18 lakhs, the most populous being Bijapura. For every 1,000 males in the district, there are only 950 females. Male literacy (70%) significantly exceeds that of females (43%). HIV prevalence among the low-risk general population in Bijapur is moderate at 0.60% (PPTCT, 2009). While official mapping estimates 5 MSM-T per 1,000 adult populations in urban areas, this is likely an underestimation of the true MSM activity figures for both rural and urban areas of the district. Men who have sex with men and transgenders (MSM-T), under the National AIDS Control Organisation, are considered a High-Risk Group (HRG) for HIV infection42. Because of their perceived inexistence, rural MSM-Ts risks may be even greater than that of their urban counterparts, as they are largely ignored by official policies.
36 37 38 39

Increasing the coverage of sexual health services for MSM in Andhra Pradesh, Karnataka, Tamil Nadu and Uttar Pradesh, India a pilot project The Naz Foundation: April 2007. Ibid. Ibid. HIV/AIDS in India Worldbank, Feb 2009, Increasing the coverage of sexual health services for MSM in Andhra Pradesh, Karnataka, Tamil Nadu and Uttar Pradesh, India a pilot project The Naz Foundation: April 2007. District profile information from, HIV Situation and Response in Bijapur District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010. Census of India. http://www.censusindiamaps.net NACO (2007) NACP-III guidelines

40 41 42

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This case study documents Navaspoorthis strategy of using volunteer peers to increase outreach and service delivery to rural MSM-Ts in Bijapur district. AIDS Nava Spoorthi Sangha (hereafter Navaspoorthi), a community-based organization (CBO) of MSM-Ts, has been working with MSM since 1994 to counteract the violent treatment of sexual minorities by police officials. Supported by the Naz Foundation, Navaspoorthi developed site level groups of MSM and organised a variety of outreach and service activities, including HIV testing and sexual awareness workshops. In 2010, Navaspoorthi was chosen to implement Karnataka Health Promotion Trust's (KHPT) MSM Targeted Intervention (TI). Currently, offices cum drop-in centres (DICs) are located in three talukas of Bijapur: Bijapura, Sindagi, and Muddebihal. Since the implementation of the TI began in 2010 it has become clear that local estimates of MSM activity were far too low. Navaspoorthis outreach target of 1029 has been exceeded by at least 300 MSM in the district. Furthermore, mapping carried out in 2007 estimated zero MSM in two rural talukas, Indi and Basavana Bagewadi, which are now home to CBO site level groups of 48 and 65 MSM, respectively. Navaspoorthi employs a network of people to carry out the MSM TI for HIV prevention, including a Programme Manager, Monitoring & Evaluation Officer, Counsellors, Outreach Workers (ORWs) and Peer Educators. Additionally, their work relies on help from 36 volunteer peers members of the MSM community who do some amount of work for free and assume leadership positions in their community. Volunteer peers are particularly necessary due to the inaccuracy of MSM projections creating a shortfall in funding for project staffing. Furthermore, Bijapur district spans over 10,500 square kilometres of rural landscape, making travel for fieldwork by paid staff difficult and costly. For these reasons, Navaspoorthis success in outreaching to and providing services for MSM cannot be disconnected from their use of volunteer peers. As seen in Diagram 7.1, the peer workforce consists of 17 paid peers (working in three talukas) and 39 unpaid volunteer peers (covering all five talukas). Site level groups in Indi and Basavana Bagewadi talukas are managed exclusively by volunteer peers, with supervision from ORWs. Diagram 7.1: Volunteer Peers & Paid Peers (percentages of total peer workforce)

Paid Peers 30%

7.1. Choosing and Training Volunteer Peers


Volunteer peers are chosen from the MSM community members that are associated with Navaspoorthi CBO site level groups. Therefore, Navaspoorthis process involves preparatory steps like (a) setting up site level groups and (b) interacting with potential volunteer peers. Once those conditions are met, (c) selecting and training volunteer peers is the final step.
48 Local Solutions to a National Problem

Volunteer Peers 70%

Source: Interview with ORWs, 29 Nov 2011

Setting up site level groups Since 1994, setting up site level groups has been a regular activity of Navaspoorthi CBO. These groups have become key operational units in the expansion of Navaspoorthis outreach and service provision to rural communities who are otherwise underserved in official HIV prevention programmes. Site level groups are of particular importance in Indi and Basavana Bagewadi, where no paid peers work, as volunteer peers and community members can rely on a prearranged meeting time during which information sharing occurs and condoms are distributed. Because the volunteer peer acts as a liaison between the community and the TI employees, their job is made easier by the organization of the CBO at both the grassroots (site level groups) and administrative (ORWs at the DIC) levels. Also, all volunteer peers have been selected from site level groups, so each new or existing group is comprised of multiple CBO members who could potentially be trained as volunteer peers. Interacting with Potential Volunteer Peers There are multiple settings in which Navaspoorthi employees interact with CBO members. One way that ORWs meet the community is by visiting hotspots usually public areas, including cinemas, parks, or bus stands where MSM go to socialize and sometimes engage in sexual activity43. During routine visits to Bijapurs urban hotspots, paid employees have found that up to 30% of the MSM live in rural areas within the district, but visit city centres regularly for business. ORWs approach these new MSM to build friendships with them, and over time, invite them to visit the DIC and CBO meetings. Local college campuses provide another venue for Navaspoorthi employees to meet and organise young MSM. Moreover, CBO groups inform Navaspoorthi ORWs when new MSM become visible in their area. So even if coverage by paid employees (e.g. in rural areas) is sparse, the CBO structure provides a channel for employees of the Navaspoorthi TI to reach extended populations of MSM in Bijapur. All of these avenues introduce Navaspoorthi to potential MSM CBO members, and thus by extension, potential volunteer peers.
ORWs and paid peers regularly attend site level group meetings, arrange health camps, hold events, and supply testing services for the community. In these ways, Navaspoorthi employees reach out to and provide services to the MSM community. General engagement with the community allows them to develop relationships with CBO members and recognize natural or potential leaders among groups of MSM.

Selecting and Training Volunteer Peers Volunteer peers are either self-selected or invited to perform voluntary duties by a Navaspoorthi employee. The TI Programme Manager or an ORW will attend meetings of the taluka-level groups at least once a month. In areas where leadership is necessary, but funds prohibit hiring, the Programme Manager will ask if anyone is willing to donate their time as a volunteer peer. Additionally, Navaspoorthi employees look for certain characteristics in volunteer peers, including natural leadership abilities, men that the community already respects and views as someone of authority. It is also helpful if they are willing and able to travel to the DIC often, both to coordinate with TI staff and to collect supplies. Most crucially volunteer peers must be actively engaged with, and committed to helping, their local community.
Once a volunteer peer is selected, they are given five days of training by the Programme Manager, with refresher courses every six to eight months or when necessary. Training for volunteer peers closely mirrors that of paid peers. Topics covered include facts about HIV infection and transmission, ways to prevent spread of HIV, and operational training, including briefing on scheduling of events, testing, and health services.
43

Increasing the coverage of sexual health services for MSM in Andhra Pradesh, Karnataka, Tamil Nadu and Uttar Pradesh, India a pilot project The Naz Foundation: April 2007.

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7.2. Using Volunteer Peers to Fill Coverage Gaps


Volunteer peers are essential in filling gaps in outreach and service provision to the community. Close relationships with both community members and Navaspoorthi staff members enable volunteer peers to circulate pertinent health information and prevent fissures in service provision.

Understanding and Relating to the Rural MSM Community


Rural volunteer peers are members of the wider village community and so do not face the same physical or emotional barriers that paid employees from urban areas might encounter. First, rural MSM hotspots are less obvious to outsiders and span greater geographical distances. Volunteer peers, as MSM themselves, are familiar with local hotspots and community gathering places. Second, they understand the deep fear of social stigma attached to non-traditional sexual Group Meetings and Training of Volunteer Peers behaviour in villages and the need for high levels of trust necessary for conversations regarding sexual status. Because of their physical proximity and shared realities, volunteer peers more easily build friendships and establish trust with rural MSM. Frequent interactions allow community members to feel secure in expressing any difficulties or illness they are facing. [As peers], we are responsible for way over the 60 MSM- Ts that is supposed to be for each peer. The volunteers do help us with the excess. In case of rural areas, the volunteers will help mobilize the community. The volunteer knows how to interact with the rural people. [Community members] might be shy, they may not want to interact with the peers, so the volunteer becomes imperative then to help with outreach. - Peer Educators

Informing the Community about TI Events


Volunteer peers convey details, such as time and location, of Navaspoorthi events, health camps, and meetings. With only four ORWs spread between five talukas, volunteer peers are important sources of information for community members about Navaspoorthis organizational plans. Details are communicated well in advance to volunteer peers, either through their twice-monthly visits to the DIC or by telephone conversations. Volunteer peers then publicize the event to the local community to convey details such as date, time, and location of Navaspoorthi events, health camps, and meetings.
50 Local Solutions to a National Problem

Ensuring that Medical Schedules are Met


Medical services for HIV prevention require repetition and precise scheduling. For core high risk groups, NACO guidelines require biannual HIV testing44. Similarly, STI and syphilis screenings should occur every three months. Anti-retroviral therapy (ART) and other medications prescribed to treat STIs or their associated complications also require adherence to strict schedules for maximum effectiveness. Restricted by vast distances between DICs and rural areas, Navaspoorthis four ORWs rely heavily on volunteer peers to remind MSM of their medication timetables and testing requirements. Volunteer peers, in turn, inform ORWs or counsellors in cases of poor reaction to medicines and inadequate tablet supplies.

Transporting Supplies
Volunteer peers have become a vehicle by which supplies are transported on a regular basis from DICs to local communities. Volunteer Peer Distributing Condoms to a Rural MSM While visiting city centres for work purposes, volunteer peers meet with ORWs at the DIC and make requests for supplies of condoms and gel, based on the requirements of the community. Multiple weeks worth of supplies are then sent back with volunteer peers. Alternatively, ORWs will send packages of condoms on buses or trucks heading for rural areas and volunteer peers will pick them up at local bus stop. This is done in order to compensate for large lapses in time between ORWs visits to villages. One ORW comments, Condoms and gels and clinic services reach the community through the volunteers.

Assisting Rural MSM Migrants


Often, rural MSM consider moving to urban centres. This is especially appealing for sex workers attracted to increased earning potential in large city centres. For those who decide to migrate, volunteer peers are an invaluable resource for connecting rural MSM to the urban community (see Box 7.1). Not only do volunteer peers help migrant sex workers secure jobs, but they also link new city dwellers to the DIC and other MSM who can help them navigate the city.

44

Targeted Interventions Under NACP III: Operational Guidelines National AIDS Control Organization Ministry of Health & Family Welfare, Government of India

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Box No 7.1: Assisting Rural Migrants (April 2009 March 2010) Some MSM subsist mostly on money earned from sex work. Many rural sex workers express a desire to migrate to urban areas in hopes that they will earn more there. If any groups want to migrate to the urban areas, volunteers will educate them about migrating, they tell them about HIV/AIDS and how the risk is higher in urban areas even if they want to earn more. They also help the migrants who do decide to move. For instance, if they want to go to a hammam and the hammam doesnt want to accept them or wants bribe money, the volunteer peers will help with interactions between the hammam madam and the migrant so they can get in. They bring them to the DIC. That individual will be educated about whats going on in town, because hes new. In case of areas which are high risk in crisis, they will tell them not to go to those hotspots.
Source: Interview with Navaspoorthi Peer Educators, 29 Nov 2011

7.3. Impacts of Using Volunteer Peers


Employing volunteer peers has had tangible impacts for the Navaspoorthi TI, surpassing the obvious connection they provide between the rural community and CBO services.

NACP-III Targets are Regularly Exceeded


From April through September 2011, Navaspoorthi reached over 100% of its monthly outreach expectations for unique MSM contacts and registrations, exceeding the target by 25%. During the same time frame, actual percentages of attendance at STI clinic surpassed set targets. Since April 2011, 658 (64%) registered MSM have visited ICTC for HIV testing. Navaspoorthis success in meeting these targets is believed to be due, in some part, to the help of volunteer peers. Volunteers help in bringing the community members to the clinic, remarked an ORW.

Increased Knowledge of HIV & STIs in Rural Areas


A focus group discussion with MSM community members who are organised by volunteer peers indicated that they were receiving correct information about HIV/AIDS, STIs, and ways to prevent infection. Of 16 community members interviewed, all but one were able to identify how HIV is spread, what activities make people vulnerable to infection, and methods of protecting themselves from infection and preventing transmission. Most reported that they had not known about condoms or HIV/AIDS prior to meeting with Navaspoorthi volunteer peers or site level groups. Most were quite willing to share the various protection techniques they had learned from their volunteer peer. I cannot read, so I cant see the expiration date on a condom by looking at it. Instead, I move the condom around inside of the package. If the gel inside is dry, the condom is expired. These are the kinds of things we talk about for HIV prevention with the volunteer peers -Rural MSM
52 Local Solutions to a National Problem

Social Entitlements are Made Accessible to Rural MSM


Volunteer peers also help the community access a wider range of social services beyond HIV and health. These may include assistance in acquiring IDs or ration cards, or in setting up bank accounts. Volunteer peers assist with applications for government entitlements either directly or by connecting the community to people in DICs or other offices who can better facilitate these processes. Community members view volunteer peers as well-connected and knowledgeable on ways MSM can improve their quality of life.

7.4. Challenges and Opportunities


An enduring challenge of the volunteer peer strategy is the lack of funding available to sustain their work. Because volunteer peers have regular jobs that they rely on for income, their paid work holds priority. Navaspoorthi has been able to capitalise on most volunteer peers regular business-related travel to and from city centres by giving them condoms and gels to simultaneously transport. However, volunteer peers are required to meet with ORWs at DICs at least twice a month, which may not coincide with their work travel. Expenses for extra travel or mobile phone communication to the DIC are incurred at the personal cost of volunteers. For this reason, money saving techniques, such as low-cost telecommunication, might make volunteer-based programming easier, as volunteers could check in regularly with ORWs without making an extra trip in to the DIC. A demonstrated benefit of the volunteer peer strategy has been the inclusion of more MSM-T, especially rural dwellers, to Navaspoorthi CBO. This increasing visibility of MSM, however, means that more resources and time are required to organise new contacts. Most volunteer peers are donating as much of their free time as possible, yet additional leadership remains necessary. This issue could be mitigated by training more volunteer peers who can share some of the leadership burden of current volunteer peers. Establishing a training workshop for new volunteers might work to scale up the strategy by allowing for multiple leaders to be trained at one time. In addition to replacing one or more visit to DICs with more frequent telecommunication, these workshops could work to ensure some sustainability to volunteer peer strategies. While the volunteer peer strategy has been successful for Navaspoorthi and many other groups aiding MSM-Ts and other sexual minorities, the reality remains that there are more MSM-Ts in India than perceived by academic literature and the national government45. Stereotypes of MSM as only living in urban areas, even as reflected in policies meant to help and reach this community, are damaging because they prevent messages of safe sex and a sense of community from reaching the many rural MSM who have little to no exposure to HIV prevention, STI or AIDS treatment, or other reproductive services. Despite these challenges, Navaspoorthis volunteer peer strategy offers a lesson for the future. Because volunteer peers are seen as a precious resource by Navaspoorthi ORWs and management-level staff, paid employees adapt their management style to be more accepting and responsive to the needs of the volunteer peers. One ORW remarks, We have to mobilize volunteers softly, because if they move away they will not look back. This kind of organizational empathy has created a more inclusive working atmosphere in Navaspoorthis TI. This lesson learnt by Navaspoorthi is broadly applicable to groups engaging in either service delivery to or organisation of marginalised peoples and presents an opportunity for other TIs to adapt as well in treating these populations with care.
45

Increasing the coverage of sexual health services for MSM in Andhra Pradesh, Karnataka, Tamil Nadu and Uttar Pradesh, India a pilot project The Naz Foundation: April 2007.

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Chapter 8 Changing Outreach Strategy and Innovations in Service Provision in Bijapur

BCT Experiences in Yeshwantpur


Approaching the migrant community is very sensitive...Time difficulties...The labour contractors will not give us time to talk....if a group of 30 or 40 people talk with us, there can be an accident, so it wasnt possible it was a safety issue. At the site, they are busy at work... they also feel ashamed to talk about it because everyone will know... When they are at home they are more relaxed, they listen more and also will speak more openly. - Outreach Workers in Focus Group Discussion on 15th November 2011, in Yeshwantpur, Bangalore

In India, the construction sector employs an estimated 40 million migrants 46. The majority of these live in very poor conditions, are unable to educate their children or access health or subsidised schemes 47. Since 1996, the Bhoruka Charitable Trust (BCT ) in South India has been focused on providing services relating to HIV/AIDS prevention, health care, and support to the infected and affected families of workers to female sex workers, long distance truckers, migrant garment and construction workers and orphaned and vulnerable children. The trust was established in 1962 to work to uplift underprivileged sections of the society in the states of Rajasthan, Karnataka, Andhra Pradesh and Tamil Nadu. This case study documents the Targeted Intervention (TI) programmes for HIV/AIDS with destination migrant construction workers conducted through two TIs in Yeshwantpur and Yelahanka in Bangalore Urban district. Together, they reach out to 20,000 male and female migrants. Bangalore Urban district48 is located in the South eastern part of Karnataka and is divided into four talukas. It is the largest district in the state in terms of population and 28th in terms of land area. Bangalore is the administrative headquarters of the state. According to the 2001 census of India, the total population of Bangalore Urban district is 65.3 lakhs with a sex ratio of 908 females per 1,000 males. The overall literacy rate is 83%, and is higher among males (88%) than females (77%). The HIV positivity among the low risk general population in Bangalore Urban district is low at 0.43% (PPTCT, 2009). The HIV positivity among male STD patients in the HIV Sentinel Surveillance site was high at 30.10% (HSS-STD data, 2008). The Yeshwantpur TI focuses on 18 construction sites which have migrants from the states of West Bengal, Bihar, Orissa, Jharkhand, Chhattisgarh, Uttar Pradesh, Madhya Pradesh, Andhra Pradesh, Karnataka, and Tamil Nadu. They typically have no information about health issues such as STI and HIV/AIDS, are not knowledgeable about condom use, are ignorant about the available medical services, and ways to access them. The
Deshingkar P. and Akter S. Migration and Human Development in India: Human Development Research Paper 2009/13. UNDP, April 2009 ibid 48 District profile information from HIV Situation and Response in Bangalore Urban District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010
46 47

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group is predominantly young49 and illiterate and characterised by high turnover every three to six months. Migrants with different skill sets arrive depending on the progress of the construction work. This case study describes the challenges faced by the Yeshwantpur TI in outreach and service delivery at the beginning and how a change in outreach strategy improved programme delivery outcomes.

8.1. From Work Site to Labour Colonies Shifting Intervention Points


The HIV/AIDS intervention with the migrant population in and around construction sites in Yeshwantpur started on 15th September, 2008. The outreach strategy at the beginning involved outreach workers (ORWs) visiting the migrants at their work site, during the day, between 9.30 a.m. to 5.30 p.m. This posed difficulties as the contractors and the work site project managers refused permission for the TI staff to conduct sessions with the migrants or hold health camps. During work hours, the migrants were engaged continuously and had no time to spare. The wage payment was time bound and led to loss of pay if the work was not completed in the stipulated period. Hence, the migrants were not interested in meeting with the ORWs. Also, the TI staff knew only the local language Kannada, which led to ineffective communication with the migrants as they were a multilingual group and a resultant lack of trust from their end. These challenges further impacted unfavourably on conducting outreach clinics, in low footfall in the outreach clinics, and low testing rates at ICTC. In response to these challenges, the intervention location was changed from the work site to the labour colonies. Repeated discussions with the Voluntary Peer Leaders (VPLs), the construction company management and the migrant community themselves, on ways to better reach the migrant workers with services.These continuous advocacy efforts with the company and site level management resulted in outreach being conducted in labour colonies from January 2010. The labour colony in-charge was contacted for permission to meet the migrant workers. The ORWs identified the days and time of availability of migrants at these sites. Then, VPLs were identified in these colonies to inform the TI about new migrants, provide services to the community and assist the ORWs in their efforts. Further, in two labour colony sites, empty sheds were converted into Drop-In-Centres (DICs) to establish the presence of the TI among the migrants and to provide services. For successful service provision and spread of messages, the team evolved multiple strategies. Building Rapport with the Management Rapport building with the management of the construction company was initiated to enter into a work site. The security officer and safety supervisor at the construction site were approached first to explain about the project, its goals and the issues being addressed through it. A letter about BCT and the project was also given. This information was then passed on to the project manager, labour contractor and company management by the safety supervisor. It usually takes two to three visits to establish rapport, after which outreach and service provision can be done with much more ease. Use of Voluntary Peer Leaders Active migrants are chosen to serve as Voluntary Peer Leaders (VPLs). The VPLs are chosen using set criteria, and are bi or multi-lingual50. They inform the TI about new migrants, which facilitates faster identification of new migrants and their integration into the programme. At present, four safety managers, two contractors, three labour shed in-charges, and four migrant labourers work as VPLs. The peer leaders are given a one day individual training on the project goals and objective by the TI Project Manager and Outreach Worker (ORW). They are also trained in HIV/
49

The programme managers reported most of the migrants to be between 18 to 30 years of age. The case study is about the TIs work with male migrants as the intervention with female migrants started just a year ago. NACO guideline allows for those who are illiterate to be recruited as peer leaders if he/she is supported by a literate person. The Yeshwantpur TI criteria for selection of peer leaders differ from the guideline and only literates are considered for this role. This is because communication with the multi-lingual migrant construction worker community is very important to win their trust and the peer leaders have to be able to explain the Information Education Communication materials along with other messages to the workers.

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AIDS and STI in detail concept, symptoms, and myths, TI and ICTC services, and condom demonstration. The enrolment of VPLs has helped to increase the outreach among the migrant worker community at the site, resulted in better mobilisation during the health camps as well as improved provision of services. Change in Intervention Timing The migrant workers were hesitant to meet the ORWs from 9.30 a.m. to 5.30 p.m. for fear of reprimand from the site management and loss of pay. The intervention timing was changed from 1 p.m. to 9 p.m., which allowed the team to meet the migrants after 5 p.m. in the evenings. During this time, not only are more migrants available in the colonies, they are relaxed, and willing to listen and talk, thereby resulting in improved outreach, and better absorption of prevention messages. Also health camps were organised on Sundays or other public holidays to enable more migrants to attend. Developing IEC materials in Hindi As migrants are not considered a core group for targeted HIV/AIDS prevention efforts, migrant specific Information, Education and Communication (IEC) materials are unavailable. The project team used IEC materials meant for other high risk groups to explain about HIV/AIDS and STI to the construction workers. BCT translated these materials into a brochure in Hindi - Aapke Surakhsa, Aapke Hath (Your Health in Your Hands), which focuses on concepts and issues of STI and HIV/AIDS and condom use. The availability of IEC materials in Hindi and its sharing within the community has resulted in its widespread use and broader reach of messages. Establishing DIC, STI clinic and ICTC Camps in Labour Colonies Two drop-in-centres (DIC) one in Namma Metro site in Jalahalli Cross and the other in the Vaishnavi Constructions colony in Yeshwantpur Mine Road have been established in the labour colonies. Since June 2011, STI clinic and ICTC camps are held in the DIC. Recreational games and IEC materials are available in the centre. The DIC can be used till 8 p.m. during which counselling services are also provided. In colonies, where there are no DICs, the security room or safety room at the construction site is converted into spaces for conducting STI and ICTC camps. The DIC serves as a space for resting and sharing, for awareness generation about the TI, the services provided and about HIV/AIDS, STI and condom use. Making Clinical Attendance Attractive through Games and Cultural Events Games and cultural events are held during the health camps to boost the mobilisation of migrants for outreach clinics. In addition, IEC materials with prevention messages are exhibited at the venue, condom use demonstrations and recreational games are conducted. The winners of the games are gifted with daily use items such as shaving sets, toothpaste, talcum powder, and tiffin box among others. Around five to six games are played repeatedly in batches to keep the workers engaged till sufficiently large number of them undergoes testing. On any given day of health camp, about 200 gifts get distributed among the migrants. A Migrant Worker Undergoing Testing in an ICTC Camp
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Securing Financial Assistance from External Stakeholders The project team mobilises money from the construction company to buy medicines from wholesale pharmaceutical agencies. This is to ensure continuous access to STI treatment for the migrant workers. Out of a total of 18 sites, the management pays for the medicines in 10 sites. In three sites, the management has refused to pay and money is mobilised from the migrants. In the remaining five sites, the intervention is focused on awareness generation, sensitisation and provision of basic services, as the management is yet to extend support for conducting health camps. Mobilising Medicines for Free Supply to Workers The BCT team mobilise 20 types of medicines from two wholesale pharmaceutical companies. There are nine types of STI medicines and the rest are for general ailments such as back ache and stomach pain, acidity, fever, iron tablets, anti-fungal ointments, and B-complex among others. The list of medicines is suggested by the BCT doctor. As both STI and general ailments are treated, besides ensuring continued access to STI treatment for those affected, it also helps to bring more migrant workers into the camps.
When we announce about health camps at the sites or colonies, we dont announce it as STI specific camps. Everyone is invited to these camps. So, they dont come only for STI treatment. Many of them come with non-STI ailments and we have to cater to them too. - Project Manager

8.2. Impacts of Shifting Sites Use of labour colonies as a space for contacting and delivering clinical services has facilitated increased outreach, improved awareness generation and mobilisation of workers for provision of services. Indirect outcomes have been a broader sharing of prevention messages, mobilisation of medicines, space and human resources during the camps. Increase in Outreach In all three years, the outreach has exceeded the target set for the year51. However, there has been an almost four times increase in regular contact since the beginning of the programme in September 2008. The increase has been highest immediately after the introduction of the new strategy, moving from 134.7% of migrants regularly contacted in 2008-09 to 514.5% 2009-10. This proves that meeting the migrant construction workers at the labour colonies has been very effective in expanding outreach among this group. Effective Awareness Generation Efforts When the ORWs visit migrant workers in their sheds after work, the workers are more ready to engage with them at length. The success of these efforts is also driven by the Voluntary Peer Leaders (VPLs), who are from the migrant worker community and hence more approachable for the labourers. The construction workers share a sense of camaraderie with the VPLs. They are available at the work site and colonies at all times, and can be met throughout the day. The workers are met twice a day by the peers, with whom they share both their health and other personal problems, and seek solutions for the same.
51

The outreach target was 5000 migrants for the first and second year and 10,000 for the third year. In the third year, the programme includes targeting both male and female migrants. The data represented on the graph is only for outreach with male migrants.

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Percent (%) Regular Contact of Migrants 600 500 % Contacted 400 300 200 100 0 Sep 08 - Aug 09 Sep 09 - Aug 10 Sep 10 - Aug 11
Source: BCT Yeshwantpur TI, CMIS Reports

514.5 404.2

134.7

Improved Mobilisation of Migrant Construction Workers The labour colonies provide a much easier space for mobilisation of construction workers to provide services. The construction work site management is under the control of the labour contractor and the work site supervisor. Earlier, despite having good infrastructural facilities for services in these sites, the migrants would refuse to come and access them as they were shy or feared the authority. Now in the colonies, the labourers freely discuss their issues, listen attentively, and are more open to receiving messages. Also, the labourers were dispersed across various areas in work sites resulting in the ORWs having to individually meet most of them for service provision. In the colonies, the labourers are together and can be easily brought together in a single shed. Thus, the colonies provide a more conducive environment both for easier mobilisation of the workers and their fearless participation in the programme. Wider Dissemination of Prevention Messages The mobility of the migrant worker community makes them a key route for a broader diffusion of HIV/AIDS prevention messages. They are potential carriers of information and messages to other migrant workers, their families, and friends in their native villages. The migrant workers stated that they would carry the awareness messages with them to new sites and also to their families and friends back home. Better Management of Health Camps A good rapport with the management helps in securing their assistance for procurement of medicines, sponsoring travel allowance for the doctors, as well as food for ORWs and doctors during the camps. They also recommend the TI team to the management of other sites thus
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When we first meet them (workers) we talk to them casually, interact with them in a friendly manner and focus on building the relationship. The initial discussions are about general health and hygiene. We introduce HIV and STI only after 2 to 3 meetingsthe reactions are positive from their end. They are very interested. They come to us with many issuespayment problem, stress at work, personal issues. They trust us and are ready to hear what we tell them -Peer Leader paving the ground for intervention at those locations. As the companies pay for the medicines at the health camps, the site level management advise the migrants to attend these camps. There is no point in just knowing about issues. We have to use that information. If we have information, we will make others understand about these issuesif they dont we will do something else to address it -Manik, Migrant Worker, West Bengal

8.3. Challenges and Opportunities


The strategy of providing services at the labour colonies has not been without challenges. The programme suffers from the high drop-out rate of voluntary peer leaders. The construction workers are a transitory group, changing locations frequently depending on the requirements for their skills. In addition, during times of election and personal emergencies, they return to their native village. According to the programme manager, the attrition rate of VPLs varies from anywhere between 10-20% every three months resulting in lower frequency of peer leader (PL) sessions and gaps in identification of new migrants. Also, continued communication with a migrant group is difficult. For e.g. if an Oriya speaking PL leaves, then access to the Oriya migrant community at the site is hindered. When the work site and labour colonies are far from each other, the ICTC, STI and other health camps are conducted in a shed in the labour colonies. These are small closed spaces, without proper ventilation, lighting, chairs and tables. Also, the small space cannot be demarcated to serve as separate testing and counselling cabins. Counselling suffers as the migrants are unwilling to share their personal problems in the presence of a large group. Also, most counsellors are proficient only in Kannada, and just three out of eighteen sites have Kannada speaking migrants. As a result, counsellors cannot communicate effectively with migrants from outside the state. This prevents the migrants from discussing their STI problems with the counsellors. The project needs at least two visits in a month by the ICTC lab technician and counsellor to meet the target for ICTC testing and counselling. The majority of construction workers can be reached with services on Sundays or after 5.30 p.m. in the evenings. However, the government ICTC staff are unavailable on Sundays, which is their weekly holiday and 5.30 p.m. is beyond their daily work hours. As a result, the programme is struggling to achieve those targets. Depending upon the type of STI treatment, the workers have to shell out between Rs.30 to Rs.40 for medicines. The construction workers get paid once a month and most often, the money is sent home to their parents by the contractor. This means that the workers have very little disposable income with them to either buy condoms or STI medicines. In sites where the medicines are not sponsored by the construction company, the team uses the Rs.40,000 revolving fund from KSAPS to buy medicines and hopes for it to be reimbursed from the companies. In
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short, lack of free condoms and STI medicines combined with an absence of ready cash with the migrant workers has an unfavourable impact on the effective condom use and continued treatment of STI. Despite these challenges, the BCT experience is proof of an effective and replicable outreach and clinical service delivery mechanism with destination migrant construction workers. Meeting the workers at a time and place of their comfort, in the labour colonies away from the presence of authority, has helped to increase the number of migrants contacted. In the provision of clinical services, efficient planning such as collecting information about the total number of days, the time of migrant availability in the site and the organising of health camps on Sundays and holidays has proven effective. Further, creative strategies such as integrating ICTC camps with outreach clinics, holding games and exhibitions during these camps and mobilising safe spaces in the labour colonies for the clinics have aided in better delivery of clinical services.

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Chapter 9 Preventing HIV on Dry Land

Peer Leaders Help HKNS Reach Migrant Fishermen in Mangalore


We are friends so they listen to us. They wont listen to staff from HKNS. We have a sense of who can and cannot be spoken to and speak only to those who can be talked to - Peer Leaders, in a Group Interview on 22nd November, 2011

Fishermen constitute a key migrant group found to suffer from HIV prevalence rates five to ten times higher than those in the general population52. A multitude of interlinking causes located in a context of poverty, insecurity and marginalisation increase the vulnerability of fishing communities to HIV/AIDS53. These factors include the mobility of many fisherfolk, the time fishermen spend away from home, their access to daily cash income in an overall context of poverty and vulnerability, their demographic profile, the ready availability of commercial sex in many fishing ports, the subcultures of risk taking and hyper-masculine behaviour among some fishermen, including alcohol and drug abuse 54. The risk of infection is further aggravated by their exposure to water-borne diseases, malaria, poor nutrition and sanitation facilities, and limited access to medical care55. This case study documents the creative strategies employed by the HKNS team for outreach and service provision with the fishermen migrants in Mangalore. Mangalore is the largest taluka in South Karnataka district56, comprising 47% of the total district population of 19 lakhs. The overall literacy rate of the taluka was 87%, and as per the 2001 census, the sex ratio was more than 1000. It is part of one of the most industrialised districts in Karnataka with fishing being a major occupation. The HIV positivity among the pregnant women tested at the PPTCT centre in Mangalore taluka was low at 0.19%, whereas among the bridge populations, it was found to be 4.79% (2009) among ICTC walk-in males. The HIV/AIDS intervention with migrants in South Karnataka district was started in September 2008 by Hind Kusht Nivaran Sangh (HKNS). Its mission is to improve the health and well being of underprivileged, marginalized and downtrodden rural and urban communities57. It aims to facilitate collective action for social change and promote well being of all sections of society. In an initial assessment conducted in 2008, most migrants in
52 53 54 55 56 57

Food and Agriculture Organisation of the United Nations. Impact of HIV/AIDS on Fishing Communities: Policies to support livelihoods, rural development and public health ibid ibid ibid District Profile information from HIV/AIDS Situation and Response in Dakshina Kannada District: Epidemiological Appraisal Using Data Triangulation. Indian Health Action Trust, July 2010. Project Proposal for Migrant Intervention September 2010- August 2012: Supported by Karnataka State AID Prevention Society (KSAPS); Implementing NGO Hind Kusht Nivaran Sangh

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the district were identified to be from the construction and fisheries sectors. The fishing sector migrants were from the states of Kerala, Andhra Pradesh, Tamil Nadu, Orissa and neighbouring South Karnataka districts. The Targeted Interventions (TI) team found ground breaking and rapport building with the fishing community difficult at the start.

9.1. Creating Peer Support Groups for Better Outreach


The HKNS programme with migrant fishermen at the destination port was started in September 2008. Since then, the focus has shifted from single male migrants to include both female and male migrants in 2011. The priority group for intervention in the current year is the high risk migrants. The programme has a target of reaching 10,000 migrant fishermen and women, spread across three sites, with HIV/AIDS prevention education and services. The key strategies have been to include stakeholders from the local community, and to select, educate and involve peer leaders from the migrant group for effective outreach and service provision. From 2008-2011, these strategies have steadily been fine tuned for improved outreach (figure below).

Rapport Building with Local Fishing Community


2008 - 2009
yy Focus: single male fishermen migrants yy Understanding this community yy Inclusion of local stakeholders yy Introduction of Voluntary Peer Leader (VPL) Concept yy Seeking the help of VPL in outreach and prevention services

2009 - 2010

2010 - 2011
yy Inclusion of female migrants yy Focus on high risk migrants yy Peer Leader role change from voluntary activity to being paid work

yy Firming up the Peer Leader strategy yy Shift of VPL role from assistance to outreach workers to being part of otureach team

Identifying and establishing a relationship with the main stakeholders in the fishing community is the entry point to start prevention efforts. The outreach workers (ORWs) repeatedly visit the port and locate influential persons such as the president of the fishermens society or the manager of the boat association to explain about the project. Once trust and general rapport is built, these individuals act as a support group, helping the TI team to locate and establish connection with the key informants. They also assist the TI team in mobilizing space and resources for conducting STI and ICTC camps. Until and unless you have support of the local fisherman community, you cannot do outreach with the migrant fisherman. Because the local community is very powerful and whatever you need to do in that area you need to get their buy in - Praveen Kumar, Programme Officer, TSU KSAPS
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Categorisation of Migrant Fishermen


To fine tune the outreach plan, the fishermen were classified into groups based on their work timings. The grouping was done with the help of the stakeholders, as a ground breaking activity. The migrants are classified into: (a) single day fishing boatmen (those who return from the sea in a day), (b) deep sea fishing boatmen (those who return once a week or after 15 days), (c) those engaged in loading and unloading activities, (d) those engaged in fishing oil sector, (e) those involved in dry fish business and as mechanics, net cleaners, ship repair and other labour activities. The classification helped to make a micro-plan and map the availability of each sub-group at the port, thus making the outreach more efficient.

Stakeholder Analysis
The TI team conducted stakeholder analysis to better identify relevant people in the community who could act as key informants about the migrant fishermen (Box 9.1). From this exercise the following information was collected: (a) number of boats, (b) number of boat owners, (c) time of leaving and arrival of fishermen migrants, (d) how many fishermen go in one boat, (e) number of migrants in the boat, (f ) who can be the key informants at the port, and (g) locate the auctioneers, loading and unloading personnel, and local fishermen among others. Once, the key informants are found, the team focuses on rapport building and educating these individuals about the programme objectives, significance and activities. Box No 9.1: The Importance of Stakeholder Support Stakeholders Auctioneers Boat Owners Significance Provides information about the number of days the boat is in the shore; has contact with boat owners and driver Help build rapport with the boat drivers

Loading and Unloading Personnel Predominantly migrant group, hence an important target group Informs about time of leaving and returning of the boat, number of fishermen in the boat and Local Fishermen suitable days to hold ICTC camps
Source: Interview with Praveen Kumar, Programme Officer, TSU KSAPS, on 22 Nov 2011

Changing the Time of Outreach The TI team changed the outreach time to match the availability of migrant fishermen on the shore. At the start of the programme, ORWs arrived at 6a.m. and stayed until 9 p.m. The micro plan was revisited after a week and outreach timing was rescheduled spot wise and boat wise. The outreach team started visiting the port in the morning between 8 a.m. and 11 a.m. and 4.30 p.m. and 6.30 p.m. in the evening. This enabled them to meet more migrants to provide information and awareness about HIV/AIDS, STI, condom use and services.
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Involving Voluntary Peer Leaders From the beginning of the programme, the outreach was done with the help of the Peer Leaders (PLs) chosen from among the local fishing community or migrant fishermen. The strategy helped the TI team to build rapport and gain acceptance with the community. Those migrant fishermen or identified stakeholders, who know at least two languages, have good relations with the community, possess good communication skills, with an interest in the work are chosen for the role. From 2008 to 2010, the role of the PLs has shifted from being mere informers assisting the ORWs to conducting outreach activities by themselves (Box 9.2).
Box No 9.2 : Shifting Peer Leader Role from informer to active participant in outreach 2008 2010

Inform about the arrival and departure of ship Introduce the migrants to the TI Inform about the arrival of new migrants and introduce them to ORW Inform the migrants about the TI project Provide information to the migrants about HIV/STI symptoms, Assist the ORW to conduct ICTC & health camp awareness, modes of transmission, condom use and clarify doubts Orient the migrants to ICTC and health camps, arrange the health Help ORWs to conduct stakeholder and migrant meetings camp and facilitate ICTC linkages Collect and provide information about high risk migrants to the TI team
Source: Interview with Praveen Kumar, Programme Officer, TSU KSAPS, on 22 Nov 2011

Immediately after their selection, the PLs are given half day training by the counsellor about the project, services provided, as well as on HIV/ AIDS, STI, and condom use. Further training is provided based on the identified gaps in their knowledge during the monthly visits to the TI office. Training is a continuous process due to high turnover of PLs, as there is frequent departure and arrival of new fishing boats.

Inclusion of Locals Individuals from the local community, who work along with the migrants, were made part of the outreach team as volunteers. They informed the TI staff as and when migrants returned from deep sea fishing, helped build links with the migrant boatmen, and took responsibility for creating awareness about STI and HIV/AIDS. Change in Peer Leader Selection and Remuneration Terms The programme focus over the years has moved from single male migrants to high risk migrants (HRMs). As a result, PLs are now selected from HRMs instead of stakeholders (who were mostly permanent residents in the fishing village at the port) at the beginning of the programme. Earlier, the voluntary PLs were paid once in six months (Rs.120) but now they are compensated on a per session basis (Rs.50). This has provided more flexibility in recruiting peers as well as incentivised them to work better.
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Before, we couldnt force people to work because they were volunteers. Now they are getting paid, so they can be monitored to work. They are more willing, so the information gets to as many people as possible. They get paid per session, so they are motivated to work as much as possible. - Outreach Workers

Use of IEC Materials in Native Language


The migrant fishing groups arrive at the destination port from different states. For effective communication of messages with these multilingual groups, the TI sourced IEC materials from other states (Kerala and Tamil Nadu) and used it to inform them about HIV/AIDS, STI, condom use and other services.

9.2. Impacts
The use of Peer Leader strategy has resulted in more contact and service delivery with fishermen migrants, and awareness about HIV/AIDS, STI and services among the community.

Increased Outreach
The strategy of using Peer Leaders from the stakeholders and the migrant community has helped overcome the challenge of low contact with the target group. The first year of the strategy resulted in a high unique contact of 8753 fishermen migrants, which subsequently reduced to 6099 in 2009 -10 and 4265 in 2010 -11. The reduction was a result of the fishing ban which was operational from May to September 2011 and for fifteen days each in November and December 2011, due to cyclones.

Improved Service Delivery


The involvement of stakeholders and proactive Peer Leaders has helped in reaching the services to more migrant fishermen. As shown in the graph, service access clinical and ICTC attendance, counselling - by migrants has shown a significant increase from the first to the second year. Factors that influence this performance include (a) gathering of migrants by Peer Leaders for the camps, (b) stakeholders urge the migrants to attend the camps, (c) mobile ICTC vans bringing the service to the migrants overcoming the challenge of them having to travel a long distance for testing.

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Services Accessed by Fisherman 87 ICTC 0 Services COUNSELLING 0 CLINIC ATTENDANCE 0 53 500 220 313 Number of Migrants 1000 1500 2000 2500 3000 335 1705 2721 2010-2011 2009-2010 2008-2009
Source: HKNS Migrant TI, CMIS Reports

Accurate Identification of High Risk Migrants


The focus in the third year of intervention has been on high risk migrants (HRMs), defined primarily as someone (a) who has or had STI (b) is a MSM, or (c) has sexual contact with MSM or FSW. At the beginning of the year, the TI team had informal discussions with the Peer Leaders to map the high risk migrants (HRMs). Most of the MSM activity happens in the boats while away at sea, and migrant fishermen will not openly talk about it. Hence, cooperation of stakeholders and Peer Leaders are important for the identification of HRMs.

Effective Communication with Migrants


The migrants tend to listen more when PLs provide information and services, as the PLs speak their language and share a good rapport with them. The PLs have credibility among the migrants and know the best time to converse with them, when the messages would be best absorbed. They initiate and facilitate discussions on risky HIV/AIDS related behaviours and encourage the peer group to access services.
A street play promoting ICTC for Migrant Worker 66 Local Solutions to a National Problem

Better Awareness among the Target Group


The migrant fishermen reported having improved knowledge about HIV/AIDS, routes of transmission, methods of prevention and ways to lead a healthy life if found to be HIV positive. They are more aware about the importance of testing, safe sex and condom use. In their words, the street plays, games, IEC materials and outreach services have helped as, most of us from the fishing community are not educatedwe dont know how it happens and how it can be preventedwe dont get any information unlike others who get it through paper, media, net58

Mobilisation of Infrastructure and Human Resources for Health Camps


Participation of the local community onshore helps to feed local knowledge into programme planning and actions. The stakeholders help to mobilise space at the port that can be converted into a temporary clinic for testing and counselling. For instance, the President of the fishermens association donated the space for drop-in-centre. They direct the ORWs to potential Peer Leaders, and community members who could be at risk. The PLs advertise the camps, mobilize migrants, and liaise between the ORWs and stakeholders to locate space for conducting them. the stakeholders are motivated to help us because it is better to have the migrants healthy...it saves them time of getting medicines for migrants if they are sickwe are not only working on HIV prevention but also on malaria and paralysisso its a really good thing for both of us to have their involvement - Outreach Workers

9.3. Challenges and Opportunities


The creative strategy of using Peer Leaders and integrating it with services that provide access to condoms, HIV and STI testing, medical care, and voluntary counselling has generated demands for HIV/AIDS prevention services in the migrant fishing community. However, the programme is not without its share of challenges. As the fishing boats dock only for a few days at the port, this mobile population group likes to go to the cinema or visit the city during their limited free time on shore leaving little time available to conduct outreach with them. Lack of a proper place to conduct health camps is another difficulty. Health camps are mostly conducted in open spaces and many migrants are reluctant to come because of this reason. While outreach is done mostly in the boats or at the auction spot, health and ICTC camps cannot be conducted in these places. At times, the team finds it challenging to mobilize the fishers out of the boat to access clinical services. Migrants tend to be under the influence of alcohol while on shore and outreach is difficult and ineffective during these times. Also, the ORWs who mostly know only Kannada have to depend on stakeholders and Peer Leaders for engaging with the migrants. Availability of the mobile ICTC van may not always coincide with the presence of the boat at the port and vice versa. A minimum of 15 ICTC tests is mandatory on a single visit of the van. Though the number maybe mobilized with the help of boat owners, stakeholders and Peer Leaders, they may not necessarily be new contacts. This is because, for any one migrant, service provision follows initial meeting and awareness education. However, contact with the migrant is lost before the stage of testing as they leave the port.
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Migrant fishers in a Focus Group Discussion on 22nd November 2011

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The staff reduction effective from May 2011 has meant that there are only five ORWs and one counsellor for a population of 10,000 migrants (earlier it was 10 ORWs and two counsellors). As a result, the workload per staff member has increased. Also, to classify an individual as a high risk migrant, information on 19 criteria has to be collected. Each time a new boat docks at the port, these details have to be collected from the boatmen, for which there is insufficient time. Further, the migrants may not be able to provide all the information sought, and they refuse to spare time out of disinterest. Additionally, the increase in workload and the set outreach target is not commensurate with the travel allowance causing ORWs to often spend from their own income. The allocated amount for office expense (Rs.1000 per month) is also insufficient for the volume of work to be done. The TI team recommended shifting from a mobile clinic to a fixed clinic which will be visited by the doctor and the lab technician three times in a week. A permanent clinical space will help establish presence in the community better, and clinical visits will be independent of migrant turnover. New migrants can be directed to the clinic at any time. Currently, there is one private doctor who moves from site to site and most migrants are reluctant to visit the fixed ICTC centre which is in town. An increase in the number of counsellors is also suggested in order to conduct simultaneous camps in different sites.

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Chapter 10 Filling Internal Communication Gaps

Low-Cost Mobile Phone Strategy Used by Prawarda, Bidar


When the community isnt receiving treatments or medicines on time, they can call rather than waiting for an ORW to come around. Our mobile phone strategy saves time, saves money, and may save a migrants life. -Sadhana, Prawarda Migrant TI Outreach Worker

Census data shows that 440,623 males migrated to Karnataka, while 345,298 left the state, during the period from 1991-200159. Districts with high levels of in-migration and those with frequent out-migration report larger numbers of HIV-infection, indicating that migrants may be at increased risk for contracting and spreading HIV60. This is because migrants are likely to engage in high-risk sexual behaviour (including unprotected sex with female or male sex workers) while away from home, even if they do not practice the same behaviours in their native environment. This case study documents the innovative changes in internal communication strategies made by Prawarda to improve their HIV prevention efforts among the migrant population in Bidar. Bidar61is the northern-most district of Karnataka state and is divided into five talukas. It is the 17th largest district in the state in terms of the population and 18th in terms of land area. As per the 2001 Census of India, the district has a total population of 15 lakhs and a sex ratio of 949 females per 1000 males. The overall literacy rate is 61% with 49% among females and 72% among males being literate. HIV prevalence among the low-risk general population in the district is low at 0.28%, but positivity rates among ICTC walk-in males is much higher at 8.47% (PPTCT, 2009). Prawarda has been actively engaged in rural development in Bidar district of Karnataka since 1994. Project areas include watershed, rehabilitation and livelihood promotion;62 mean that Prawarda employees work one-on-one with some of the most vulnerable communities in the state. This close contact with rural farming and production workers exposes Prawarda to the robust migrant community living in Bidar. Migrants most often come from Maharashtra, Andhra Pradesh, Bihar, as well as from other cities in Karnataka to work mainly in the sugar industry, but also in construction, paper mill, and stone crushing.

59 60 61 62

Saggurthi, Verma, Achyut, Ramarao, and Jain Patterns and Implications of Male Migration for HIV Prevention Strategies in Karnataka, India Population Council India: June 2008. ibid District profile information from HIV Situation and Response in Bidar District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010 http://www.ispwdk.org/Partners/Prawarda/about

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While HIV prevention efforts for migrants have historically focused on males, the National AIDS Control Programme III extended coverage of its Targeted Interventions (TI) to both male and female migrants63 and Prawarda has responded by expanding their outreach strategies and services. Prawarda staff have identified 25,051 migrants in the five talukas of Bidar, 10,000 of whom are considered to be at high risk for HIV infection and transmission. Each taluka is managed by one Outreach Worker (ORW), who is supported by the Migrant Project Manager and the Prawarda TI Project Director. ORWs are in regular contact with 2000, 4582, 2276, 5327, and 4367 migrants, respectively in each taluka. Part of Prawardas institutional effectiveness is tied to the frequent communication between management staff (Project Manager and Project Director) and field-level employees (ORWs). ORWs are required in daily attendance and status meetings in the district-wide Drop-In Centre (DIC), located in Bidar taluka. However, the close contact with local communities that gives ORWs serious advantages in working with migrant populations also hinders their ability to travel the long distances required for office visits. Also, limited funding means that most telecommunication and travel expenses are paid for out-of-pocket by management and field staff. Bills for such purposes totalled up to Rs. 2000 per person each month. As ORWs are compensated at a lower rate than management staff, much of the burden of communication costs fall on the managers, who would receive missed calls from ORWs as a signal when telephone calls were necessary so that the ORWs did not have to pay for potentially lengthy conversations.

10.1. The Way to Low-Cost Communication


Prawarda staff felt that solutions were needed in order to improve internal communication strategies and distribute the costs more evenly in the hopes of lessening the financial burden for all TI staff. The following section details the process of identifying and selecting affordable telecommunication.

Analysis of Costs Involved in TI Work


Prawarda staff met in October 2010 to discuss the cost of communicating by using missed calls to indicate to managers that talking is necessary. Each ORW and project manager detailed their monthly expenses for mobile communication, which ranged between Rs. 250 to Rs. 300 for ORWs and Rs. 600 to Rs. 1000 for management staff. Field-level staff also considered the high cost of travel every month, which was not reimbursed by the office, in order to meet with management staff in the DIC. The entire office agreed that low cost communication was necessary.

Surveying Local Options


Project Director Ramchandra Sherikar researched the costs and coverage areas of local mobile providers. It was important that mobile service covered all five talukas so that all field-level staff would be within range of communication. MTS, a subsidiary of Russian telecommunication company Sistema Shyam TeleServices Limited, turned out to be the lowest-cost provider whose services cover not only all five talukas of Bidar, but also the entire state of Karnataka. Sherikar invited a representative of MTS to an office meeting at the DIC where the Samsung Style mobile phone model was introduced to Prawarda employees. For Rs. 599, MTS users get a handset for basic calls and SMS, with Rs. 115 of talk time included in the package price. After that, for Rs. 52 top-up, users get unlimited MTS to MTS calls for 30 days, including
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NACO Online http://www.nacoonline.org/National_AIDS_Control_Program/Prevention_Strategies/

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conference calling. Low-cost top-ups for talk time to other service providers are available with MTS as well, meaning an overall reduction in mobile costs for work and personal calling for TI staff.

Purchasing in bulk
Prawarda employees were happy to sign on for MTS's services. Migrant TI staff were asked if they would like an MTS phone and all of them opted in. In order to ensure that telecommunication coverage began simultaneously, Sherikar covered the Rs. 599 cost up front for all employees. All ORWs have repaid the initial cost of the phone.

Prawarda Migrant TI Staff with their MTS Phones

10.2. Impacts of Using Low-Cost Mobile Communication


The increased ability to communicate remotely has seriously impacted not only Prawarda staff, but also the migrants that rely on Prawarda for outreach and services. Now, Prawarda staff are able to communicate at drastically reduced personal cost to both managers and ORWs. Besides cost, this new telecommunication strategy has changed the way that field-level staff report to managers. Instead of time-consuming and expensive daily travel to the DIC for short attendance and update meetings, ORWs simply call the managerial staff to check in. Furthermore, mobile phones are now being used for planning purposes between field-level staff and external service providers to Prawarda.

Reduced work-related expenses for Prawarda Staff


A tangible benefit of using the MTS phones has been a reduction in the personal income spent for work-related activities of Prawarda staff. For the Project Director and the Project Manager, this means that employees no longer have to rely on giving them a missed call to indicate that communication is needed. As calls are now made and received by TI staff, the financial burden is thus shared between all employees, instead of falling heavily on the management staff. Furthermore, not only is the cost shared among all TI staff, but it has been reduced to just Rs. 52 per month for official calls. For management staff, who were previously paying Rs. 1000 to Rs. 1500 per month on mobile phone bills, this represents an average of 95% savings per month! ORWs are now saving an average of over Rs. 175 per month on mobile phone bills (see Diagram 10.1). However, for ORWs, savings associated with MTS mobile service extend beyond communication. Because daily travel to the DIC is no longer necessary, and coordination for events such as health camps can now affordably be done over the phone, travel costs have also decreased by as much as Rs. 800 for some.

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Diagram 10.1: ORW savings for mobile phone expenses 400 300 200 100 0
ORW 1 ORW 2 ORW 3 ORW 4 ORW 5
Source: Prawarda Migrant TI, CMIS Reports

Mobile costs monthly prior to MTS Mobile costs monthly with MTS

Reduced travel for Prawarda Staff Reduced travel for field staff has had a larger impact than simply saving money for ORWs. Field-level staff are now able to save themselves the stress and time of travelling daily to the DIC and to other coordination meetings. This has improved the quality of life for field staff living and working far from the DIC. Magala, an ORW in Bidar taluka, says, We are no longer stressed by needing to travel so much. Further, less travel means that ORWs have more time to spend covering their sometimes-vast talukas to meet with migrants face-to-face. Increased field presence of Prawarda ORWs
For ORWs, one of the greatest felt benefits of using low-cost mobile services has been the increased amount of time they are able to spend in the field working with migrants. Previously, daily attendance meetings meant that ORWs were available on site only after 11:00am, well past the time that most migrants start work for the day. This meant that conversations or status updates from migrants had to wait until their short lunch breaks. Sensitive conversations regarding STI infection or HIV/AIDS prevention were unable to happen in such limited timeframes. Furthermore, each ORW is responsible for multiple migrant sites, so even the small amount of available time for meeting with the community was divided and this made waiting around for lunch and tea breaks difficult. Successful outreach and service provision strategies are usually characterized by considerable investments of time between field staff and target populations and Prawarda ORWs are pleased to use their saved time to work directly with migrants. We are happy because of this. We can save money, and we can also spend more time with the migrants. Before, there would be a three to four days gap [between meetings] but now we can spend more time with them so they believe us, expresses Parshuram, an ORW for Humnabad and Basavakalyan talukas. The reduced cost also helps migrants directly reach ORWs or the TI counsellor in cases of emergency (such as poor responses to medical treatment) or for sensitive discussions regarding sexual health or behaviours. ORWs are happy to answer calls from migrants at any time, no matter how long the conversation may take, because they know that the cost will be low.

Faster communication between TI staff and external providers Planning events (such as condom demonstrations, health camps, World AIDS Day activities, and other festivities) is a large part of ORWs work. These important events are attended by local figures outside of the Prawarda team, including doctors, DAPCU officials, TSU programme officers, and other service providers, many of whom have quite busy schedules. Furthermore, migrants are most easily reached at their work sites, so
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events held there require the cooperation and assistance of construction- or labour- site managers. Previously, ORWs would have to secure potential event dates from work site managers and then travel to preliminary meetings with each service provider, which frequently resulted in scheduling or logistical difficulties. This planning process could take a week or longer. Coordinating between Prawarda staff and external stakeholders is much easier with low-cost mobile services (see Box 10.1). Now, ORWs do not have to wait until meetings or visits to the DIC to arrange dates for events with TI management and other stakeholders. At planning meetings with construction- or labour- site managers, ORWs obtain a list of possible event dates, and call other external stakeholders to immediately secure their attendance. Box No 10.1: Increasing planning efficiency for Prawardas Health Camps A cornerstone of Prawardas HIV-prevention services to migrant populations is work-site health camps. These camps provide an opportunity for migrants to get tested for HIV & STIs and receive general care and health information. Because the camps are held at work sites and are administered by doctors and DAPCU officials, ORWs need to coordinate with multiple stakeholders in order to successfully plan and facilitate these events. Previously, this process could take up to 15 days to arrange, as face-to-face interactions were needed to coordinate schedules. Often times, doctors or other external providers would not be available by the time they were approached by ORWs with the few dates offered by work site managers. This caused major delays in both the planning and execution of migrant health camps. Now, ORWs can directly call doctors, counselors, and other providers directly from the meeting with the work site manager. This way, there is instant communication regarding availability and scheduling. The planning process that would take up to 15 days now can be done in just a few. ORWs now save time, money, and stress to make arrangements with various providers.
Source: Interview with Prawarda Migrant TI ORWs, 30 Nov 2011

Increased communication between migrants and Prawarda Staff


Using low-cost mobile services has not only improved communication internally, but it has also made outreach and service provision to migrant communities easier. First, mobile phone usage has created an avenue to ensure that female migrants receive adequate attention and health services. Often, female migrants are too shy or uncomfortable to discuss sexual or other health matters with male ORWs. In Bidar, two talukas are serviced by male ORWs who can now quickly and easily call one of three female ORWs to assist with female migrants needs. Second, counselling staff are now more accessible to the migrant workers. Most migrant labourers find it difficult or too expensive to leave their work
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Prawarda Work-Site Health Camp

and home sites, so ORWs mobile phones have become a way for the target population to communicate with counsellors. This means that STI and HIV symptoms or complications can be identified faster and treated easier. ORW Akheel Khan (Aurad and Bidar talukas) remarks, Before the [migrant] could not be brought to the office directly, they could not leave work. Now, we can get them to call the doctor or the counsellor, so in that way, it helps in getting them treatment faster. Counsellors can then refer these patients directly to doctors who will consult with them over the phone. Treatment options are relayed in a much more rapid manner without requiring migrants to leave their work sites. Also, complications with treatment or lack of medication, time sensitive matters, are remedied using the cell phone to call the counsellors and doctors. Lastly, MTS phones have provided a means for ORWs to quickly check up on specific migrants locations during testing appointments or health camps. If certain migrants are due for services or meant to attend meetings but are not present, ORWs can directly call the migrants or their peer educators to assist in contacting them. Given that work and home sites are often large campuses, this saves time in coordinating absent service beneficiaries.

10.3. Challenges and Opportunities


Prawarda employees enjoy the benefits provided by more affordable communication with both internal and external stakeholders, as well as the very population they seek to service migrants. Challenges remain, however, in using this strategy. One potential concern for managers looking to replicate Prawardas low-cost mobile communication strategy is that some employees may respond better to frequent face-to-face communication rather than more unsupervised check-ins via mobile phone. Monitoring of all field-level staff is key for successful interventions, so Bidars management strategies might need to be altered in order to ensure that staff are fulfilling the expectations and meeting targets. A combination of mobile phone check-ins with occasional office visits may counteract this problem. On the other hand, wide-spread usage of inexpensive telecommunication could provide major benefits to all TIs for HIV/AIDS prevention aimed at migrant men and women. For example, migrant populations by definition live in various locations throughout the year and are highly mobile people. NACO defines three physical points in which engagement with migrants are possible: source (home), transit (while travelling between home and work areas), and destination (work) locations. Bidar is a destination location, and ORWs envision the benefits that could come from increased communication between all migration points. Coordination with TIs in source locations provides information about individual migrants their HIV status and/or treatments, STI problems or treatments, testing due dates, or any other general health information that could be shared rapidly through mobile phone usage, and saves time in reaching and meeting migrants needs. Beyond just migrant TIs, low cost communication between all KSAPS TIs would allow for quicker information sharing and knowledge dissemination. TIs staff could frequently relay information regarding which TI innovations are working and which are not. Rather than waiting for yearly Learning Point conferences, recommendations from experienced staff can reach wider audiences in a more timely manner. Changes in national policy could also be relayed in a more efficient way using frequent communication, and key lessons learnt from initial implementation could disseminate to all relevant stakeholders. Furthermore, outreach would be made easier with increased communication, as many high-risk populations overlap and organizations could coordinate and work together to reach the most at-risk groups. Overall, low cost communication has paved the way for more efficient administration of Prawardas migrant TI. Lessons learnt from this innovation could save other implementing organisations time and money, meaning significantly improved service delivery and outreach for HIV prevention.
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Chapter 11 Improving Public Health Outcomes

PSIs Waste Disposal Management Creates a Safer Environment in Urban Bangalore


In my role as peer educator, by collecting the used needles and syringes, I save people from dying by preventing infections through blood. I protect the health of not just my friends but also the larger community. I can identify new fixers, know how HIV spreads and how I can help the society to reduce its spread. - Mosses J, Peer Educator

Injecting drug use (IDU) is today recognised as a primary route of transmission of HIV in India and elsewhere. The IDUs have one of the highest rates of HIV among the High Risk Groups (HRGs) with a HIV positivity rate of 7.2%64. The Needle Syringe Exchange Programme (NSEP) is a key component of the Targeted Interventions (TI) implemented by the National AIDS Control Organisation (NACO) to address HIV prevalence among the Injecting Drug Users (IDUs)65. The goal of NSEP is to ensure that every injecting act is covered with a safe needle/syringe 66. It involves both distribution of new needle/syringe to the IDU client as well as safe collection and disposal of used needle/syringe. NACO has identified multiple hazards67 associated with improper collection and disposal of used needles and syringes (N/S). These include (a) greater risk of the outreach workers (ORWs) or peer educators (PEs) involved in collection being pricked by the used sharps; (b) scattered N/S in public places resulting in reuse of contaminated N/S by the IDUs; (c) children playing with these scattered sharps; (d) danger of these scattered N/S being resold to prospective users; and (e) the scattering of used N/S can antagonise the larger community towards the IDUs and increase their resistance to the overall programme with the IDUs. The first four dangers can increase the risk of IDUs, PEs or ORWs, children and members of the larger community to HIV and other blood borne infections or diseases including Hepatitis B and C. This case study describes the used needles and syringes disposable management system at the Green Dot DIC, of KSAPS PSI IDU TI, in Bangalore Urban district of Karnataka. Bangalore Urban district68 is located in the South eastern part of Karnataka and is divided into four talukas. It is the largest district in the state in terms of the population and 28th in terms of land area. Bangalore is the administrative headquarters of the state. According to the 2001 census of India,
64 65 66 67 68

NACO. Draft document Implementation of Opioid Substitution Therapy in Government Health Care Facilities for Injecting Drug Users NACO. Guidelines on safe disposal of Used Needles and Syringes in the Context of Targeted Intervention for Injecting Drug Users. June 2009 NACO. IDU A Manual on Working with Injecting Drug Users a Trainers Manual NACO. Guidelines on safe disposal of Used Needles and Syringes in the Context of Targeted Intervention for Injecting Drug Users. June 2009 District profile information from HIV Situation and Response in Bangalore Urban District: Epidemiological Appraisal Using Data Triangulation India Health Action Trust, July 2010

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the total population of Bangalore Urban district is 65.3 lakhs with a sex ratio of 908 females per 1,000 males. The overall literacy rate is 83%, and is higher among males (88%) than females (77%). The HIV positivity among the low risk general population in Bangalore Urban district is low at 0.43% (PPTCT, 2009). The HIV prevalence among IDUs in the district has been at 2% from 2007 to 2009. The HIV/AIDS prevention programme among IDUs in Karnataka state was initiated by Population Services International (PSI) in August 2008. PSIs work with injecting drug users involve programmes to help reduce drug-related harms, to prevent the initiation into injecting drug use and to promote the cessation of drug use with opioid substitution therapy69. The two TIs in Bangalore Urban district one in Lingarajapuram and Shivaji Nagar and the second in Chamrajpet - reach out to 494 and 423 IDUs respectively. The Green Dot DIC programme70 currently reaches out to 500 IDUs, among which there are 65 sexually active male IDUs, and one female sex worker (FSW). There is one HIV positive IDU undergoing ART treatment. The DIC has a monthly regular contact of 460-480 IDUs. The outreach is done through two outreach workers (ORWs) and 12 peer educators (PEs). The used needle and syringe (N/S) waste disposal programme was started in 2009, to address the potential health hazards to both workers and the larger community due to improper storage of used N/S.

11.1. Waste Disposal Management Process


The waste disposal management in the Green Dot DIC strictly follows the NACO guidelines on the safe disposal of used N/S. The various stages involved in waste disposal management as per NACO guidelines are as follows: (a) Collection of used injecting equipment (b) Storage of used injecting equipment at the centre (c) Disinfection of used injecting equipment, and (d) Final disposal from the centre.

Collection of Used Needles and Syringes The ORW or PE, during daily visits to the hotspots, carries a bag containing two puncture proof plastic boxes with a detachable lid, forceps and hand gloves. The box for used needles has a biohazard warning sign on its body, denoting the infectious materials inside. The ORW or PE first wears the thick, orange coloured gloves. Using the forceps the used N/S is picked from the syringe end. Only the needle with the hub is separated from the syringe using the opening of the box and deposited into it (Image 1). Once the box is filled to capacity, the lid of the container is secured tightly. The dismantled syringes are collected in a separate box for used syringes.
Image 1: Needle being separated from the syringe
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http://www.psi.org/our-work/healthy-lives/hiv All factual details of the programme sourced from Interview with M. Nagesha, Programme Officer, IDU-TI project, PSI on July 26, 2011.

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Storage at the Drop-In-Centre At the DIC, the filled boxes are handed over to the counsellor, who is primarily in charge of collection. The counsellor first puts on the mask and gloves and takes the boxes from the ORW or PE. The used N/S containers are large, sturdy and closed with a lid. They have a label indicating the content inside and a do not touch sign on its body. The containers are kept at a distance from each other, securely in a closed, well-lit room away from easy access. In the event of any damage to the gloves, forceps or boxes, returned by a PE or ORW, they are replaced with new stock. It is a precautionary measure to protect the ORW or PE from the risk of infection from needle pricks during their next round of collection. It is mandatory for a PE to carry gloves, forceps and boxes used for collection on every visit to the DIC to drop the used N/S. Disinfection at the DIC At the DIC, the disinfection process is done by the counsellor once every week. The counsellor wears a mask and gloves and prepares the disinfectant solution. Initially, a paste is made by mixing 15gms of bleaching powder in 10ml of water. Then, the remaining 990ml of water is added to the paste slowly while continuously stirring with a forceps to make the disinfectant solution. The needles with the hub are emptied into a blue perforated plastic bin, which is then dropped into a red bucket with the solution. The syringes are disinfected separately. The N/S are soaked for 1.5 hours. The solution is occasionally stirred, using forceps, to activate the treatment process (Image 2). First, the syringes are cleaned followed by the needles with the hub. The disinfected needles and syringes are then transferred for storage into separate containers with lids. On removal of the used N/S, the same evening, these boxes are placed in a bucket with soap water and bleaching powder till next morning. The following day, the boxes are cleaned with a brush and dried in the sun before being reissued.
Image 2 : Counsellor disinfecting used N/S

Disposal from the Drop-In-Centre For the final disposal of waste, the DIC has tied up with a private waste collection agency - MARIDI ECO INDUSTRIES PVT. LTD. On the first or second Thursday of every month, around 4000-5000 disinfected needles and syringes from the DIC are collected by the agency. The cost for final disposal is Rs. 2000 per month for up-to a maximum of 40kgs of needles and syringes. For every kilogram above that, the rate is fixed on a per kg basis.
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11.2. Ensuring Effective Collection and Disposal of Used Sharps


In addition to strictly following the NACO guidelines, strategies such as a systematic inventory management system, regular staff training and monitoring, and community sensitisation aid the TI process of waste management.

Stock Management System Inventory management, boxes for collection of used N/S, forceps and gloves are key components of a successful waste disposal programme. To avoid stock out, the DIC at any time has a stock of all these materials for a period of six months. Further, when the new boxes are issued, they are labelled with the name of the ORW to whom it is issued and the date of issue. This helps to avoid possible loss of boxes and ease the process of counting of the boxes.
Additionally, the counsellor maintains a record of the number of boxes received, collected and distributed. Once the boxes are deposited at the DIC, the counsellor along with the ORW counts and enter into the register the number of N/S collected. This is done on the same day or latest on the following day. The information entered into the register include: (a) the date of receiving the filled boxes, (b) the name of the PE/ORW/ Counsellor/Community Member from whom it is received, (c) the number of used syringes and needles collected from these boxes, and (d) a column for remarks if any. In the absence of the counsellor, the responsibility for collection and maintenance of records is undertaken by the ORW or Programme Manager.

Staff Training and Monitoring The ORWs and PEs are trained by the Programme Manager using NACO guidelines, supported by guidance from the Technical Support Unit (TSU). The one day training involves a field visit to demonstrate the safe method of collection of used N/S, its subsequent storage and disposal at the DIC, along with practice sessions to familiarize staff with the process of collection, storage and disposal. The Programme Manager visits the field along with ORWs every alternate day, thus monitoring the adherence of the staff to the waste disposal procedures. A PE is always accompanied by an ORW for the collection of used N/S. Further, staff meetings held during the visit of the Project Director to the TI discuss issues such as a delay in the procurement of materials required for the disinfection process, non-compliance from the TI staff on mandatory guidelines to be followed during waste disposal and peer calendars not being filled by the peer. Monitoring at different levels ensures rigorous following of procedures and timely response to problems that arise.
They (ORWs) will stand separately and observe what we do. They will not interfere with our work. They will see if the way we collect the syringe is right, whether we take the whole set of needle and syringe or just the needle. They will notice the new IDUs we interact with, the messages we give them and their responses -Saif. S, Peer Educator

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Community Sensitisation During field visits, discussions are held with IDUs to sensitise them and raise their awareness about the dangers of randomly throwing away used N/S. Twice a month, DIC level meetings and four times a month, hot spot level meetings are held where information about services, safe injecting, HIV/AIDS, and disposal of used N/S are provided. Repeated sessions are conducted as IDUs tend to be in a state of intoxication. Reinforcement of messages is important in such a context for it to be assimilated by the IDUs. The Programme Manager, ORW, Counsellor and some PEs take turns to conduct the training.
Also, to ease the process of collection of used N/S, the ORWs and PEs along with the IDUs fix definite spots where the used N/S will be kept. This aids in easier collection of used N/S, and reduction of potential health risks for the larger community. we are getting protection from disease. If the needles are thrown around, children will play with it and be harmed. Also, those who dont have money may take these needles and use them. Sometimes, people get curious about these needles and start experimenting by injecting themselves with it. This will lead to new people getting into drug use. Now, we collect the needles and syringes, return to the madam at the DIC, and get new ones - Aejaz, Peer Educator

11.3. Impacts
Numerous studies have established the effectiveness of the needle syringe exchange programme (NSEP) in achieving marked decreases in drug-related risk behaviour (e.g., sharing of injection equipment, unsafe injection practices and frequency of injections) by as much as 60%71, and decreases in HIV transmission by as much as 33-42% in some settings72. The IDU community articulated many benefits that have accrued to them and the larger community as a result of the targeted intervention programme73.

Improved Community Awareness The IDU community actively cooperate and participate with the ORWs and PEs to help find and collect used N/S. The locations or spots for injecting themselves with drugs are carefully chosen, away from those frequented by the general public. A fixed spot is decided for disposal of used N/S. This reduces the chance of used N/S being strewn around unnoticed by the collection agents (ORWs or PEs), avoiding a potential hazard for larger community members, especially children who tend to play with these sharps. It also serves to limit community opposition to IDU programmes that aim to reduce reuse of needles and syringes. Further, prior to the start of the NSEP, a single needle was shared by five to six IDUs, while now a new N/S is used for every shot.

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Institute of Medicine. (2007). Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. Washington, DC: National Academies Press cited in The U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR). Comprehensive HIV Prevention for People Who Inject Drugs , Revised Guidance. July 2010 Wodak, A., & Cooney, A. (2006); World Health Organization. (2004) cited in PEPFAR, July 2010. Focus Group Discussion on the benefits of Targeted Intervention programme, specifically of the Needle Syringe Disposal Management , with 8 IDUs in Shivaji Nagar TI.

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Sustained Collection of Used Syringes and Needles Better awareness and involvement of the IDU community from planning to disposal of used sharps has resulted in the TI consistently collecting used N/S from the beginning of the programme. On an average, the TI has been able to achieve 50% collection of used syringes and 53% collection of used needles in all months from September 2010 to August 2011 (See Diagram 11.1 below).
Diagram 11.1: Collection of Used Syringes and Needles
70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00
10 0 10 11 1 11 1 10 t/1 11 1 1 l/1 /1 p/ c/ n/ r/1 /1 No v/ Fe b ay / n/ Au g ar /1 1 M
Source: PSI, CMIS Report

% Collection of Used Syringes % Collection of Used Needles

Oc

De

Ap

Ja

Se

Lessening Economic Burden of Drug Use


In addition to the obvious health benefits, the IDUs see a clear economic advantage from the programme. As part of the comprehensive HIV/ AIDS prevention intervention with IDUs, they are provided with new needles and syringes to prevent reuse and limit the spread of infection. A single needle and syringe unit costs Rs.5 to Rs.6 from a medical shop. On an average, the IDUs take a minimum of 4 shots in a day. Today, they save the cost of these units (Rs.20 to 24) per day as they get sufficient number of N/S either from the DIC or from the peers or ORWs.

11.4. Challenges and Opportunities


Needle Syringe Programme is an important public health practice, as syringe exchange provides an opportunity for sustained contact between NSP staff and the person exchanging the injection equipment74. However, there are challenges that peer educators, outreach workers and the counsellor face while engaged in collection and disposal of used sharps. Community reactions and opposition to the collection of used N/S is a common problem faced by the peer educators (PEs). The PEs reported that they face strong negative responses from general community members who are curious about the presence of discarded needles and syringes in their locality. Although the PEs explains about the programme, most often the community believes they are condoning and promoting drug
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The U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR). Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance. July 2010

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Ju

Ju

use through such initiatives. In addition to facing the immediate wrath of such people at the time of collection, the PEs also fear the disclosure of their IDU identity to their family as a result of such interactions. Awareness, sensitisation and resulting cooperation from the IDU community members is integral to the success of the programme. However, most times the IDUs tend to be in a state of intoxication, and do not internalise the messages provided by the PEs or ORWs. As a result, they continue to discard the used N/S outside the fixed spots, thereby reducing the effectiveness of the programme. Increased collection of used N/S is also affected by the constant shift in the spots chosen by the IDUs. The change of location is determined by various factors such as drug availability, presence of friends, and threat from police and rowdies. As the community member has to compulsorily meet a TI staff member for new N/S equipment, the PE or ORW will enquire about the chosen spot on the previous day and collect it from there. The fear of police action during work is a real concern of the PEs. This is aggravated by the fact that the IDUs reached through this programme are mostly found around the railway tracks. The PEs get reprimanded and arrested for possession of needles and syringes citing illegality, and falsely accused of other anti-social activities for which they have not been responsible, such as throwing stones at the trains, tampering with the track lines, robbery and such. The needles are also thrown on the tracks as the IDUs try to run when they see the police approaching them while they are injecting the drugs. Sometimes, the PEs themselves are intoxicated at the time of collection of used N/S. In such situations, they do not remember where they kept the collected N/S and the stock gets lost. Additionally, some IDUs also throw the used N/S in places from where it is difficult to collect, such as inside the drainage and public toilets, and bushes from where it is difficult to locate. Also, the rag pickers and cleaning staff of Municipal Corporation tend to pick the needles and syringes. All these factors affect the amount of used N/S collected. For the counsellor, there is the fear of being infected through needle pricking either through damaged boxes or during transfer or disinfection. The lack of adherence to protocols of collection of sharps by PEs is also an issue. When intoxicated, the PEs tend to bring the N/S in plastic carry bags instead of the designated collection boxes. Sometimes, due to the high content of blood in some of the syringes, the counsellor will have to manually clean them using toothbrush even after soaking them in bleaching solution. At other times, the needles and syringes are brought to the office without being separated, which increases the work burden and risk of counsellor to infections. Even with these challenges, the PSIs IDU TI has managed to follow the NACO guidelines on the process of collection and safe disposal of used N/S. This is significant considering the public health impact of such an intervention. More so because evaluation studies of NSEPs have confirmed that these programmes increase the availability of sterile injection equipment, reduce the quantities of contaminated needles and other injection equipment in circulation, reduce the risk of new HIV infections, and result in referrals to other services, such as Anti-Retroviral Therapy (ART) for those eligible75.

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Institute of Medicine (2007); Wodak, A., & Cooney, A.(2006); Normand, J., Vlahov, D., & Moses L. (1995); and Farrell, M., et al. (2007), cited in PEPFAR. July 2010.

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Chapter 12

Conclusions

NACP III's emphasis has been on scaling up of Targeted Interventions. The case studies in this compendium demonstrate that this scaling up has been accomplished through effective outreach, formation of community-based organizations and fostering of community-driven solutions. The outcomes of these best practices has manifested in behavioural change, improved service delivery and the creation of an enabling environment for sustained change. However, it is precisely the strategy of building ownership through community based organizations that pose challenges on issues related to sustainability. In this context, investment in technical capacity of these institutions is required to go beyond just the TI activities and serve the multiple needs of their members.

Increased Outreach
Behaviour Change Communication (BCC) in the NACP III guidelines has encouraged HRGs to put HIV/STI intervention messages into practice in their specific local contexts. The guidelines also emphasize using a two pronged approach - Dialogue Based Inter-Personal Communication by and for HRGs. BCC is also expected to encourage analytical thinking and problem solving among core HRGs. The BIRDS case in Tumkur is an innovative method that makes the best possible use of an Inter-personal Communication (IPC) opportunity. This has resulted in outreach targets being exceeded. Out of those contacted, 75% have been converted into regular contacts which is a strong indicator of a locally rooted IPC strategy. For FSWs, the creative use of cultural events by Rakshane Zilla Mahila Okkoota in Gadag is an IPC method which has resulted in improved, regular contact, outreach and service utilization. Shri Durgashakthi AIDS Thadegattuva Mahila Sangha in Davangere targets FSWs using Stepping Stones for staff and the community to facilitate changes in attitudes and behaviours related to high-risk sex. The primary impact has resulted in increased staff capacities, many of whom are FSWs themselves and in strengthening of the CBO. This in turn has increased their effectiveness in terms of networking and crisis management.

Improved Service Delivery


Service delivery refers to ensuring (a) regular outreach contacts with more than 80% of the population on a monthly basis, (b) regular monthly STI uptake for the population, and (c) condom availability and accessibility.
82 Local Solutions to a National Problem

Prawarda has used an innovative low-cost mobile service that has enabled better coordination between migrant construction workers, staff and service providers. This has resulted in reduced travel and communication costs as well as reduced the time required to schedule health camps where migrants receive testing services for HIV and STIs along with general care and health information. Bhoruka Charitable Trust (BCT) has established two drop-in centres in labour colonies in Yeshwantpur providing STI clinic and health camp facilities as well as counselling services. BCT also has developed ingenious resource mobilization methods to provide free medicines through funds generated from construction companies. One component of HIV prevention among IDUs is the Needle Syringe Exchange Programme (NSEP) which facilitates safe injecting practices and disposal of used equipment. Green Dot DIC of Population Services International has created a needle syringe exchange programme. This has resulted in improved collection of used needles (53%) and syringes (50%) and easier access to new needles. Bhoruka Charitable Trust (BCT) and Hind Kusht Nivaran Sangh (HKNS) both use site specific interventions and peer support groups targeting migrant workers through meetings at labour colonies or on boats respectively, operating around their work-shifts. These strategies aim at identifying populations that tend to remain hidden or are otherwise invisible and using safe friendly methods to disseminate information and link them to service providers. The methods include use of vernacular languages, flexible timings and peer educators working on sites where HRGs and bridge populations work or meet. In the case of dispersed populations who feel socially excluded these strategies help build solidarity networks, reduce isolation and create social capital.

Creation of an Enabling Environment In the case of dispersed populations who feel socially excluded these strategies help build solidarity networks, reduce isolation and create social capital.
One of the specific aims of NACP-III which began in 2007 was to initiate and strengthen community led or community owned programming to achieve scale and coverage, improve quality of services and ensure sustainability of the TIs. The major outcome has been a more pro-active seeking and utilization of services by the HRGs themselves. This is evidenced by a much higher clinical service uptake (24% and 60% more using STI and ICTC services respectively) by FSW members of Soukhya Samudaya Samasthe, Chitradurga, as compared to non-members. Another result of strengthening CBOs is the decrease in vulnerability of members as a result of increased solidarity, enhanced self-esteem creating a stronger personal and social identity and improved collective bargaining power. Sustained change in risky behaviour of core HRGs requires also addressing the barriers to these changes by creating an enabling environment. This necessitates addressing two key vulnerabilities a) those stemming from socio-economic disparities and b) those from within the sex circuit such as violence and exploitation. FSWs in Soukhya Samudaya Samasthe in Chikballapur district through an enhanced capacity to access social entitlements have reduced vulnerabilities such as deprivation, homelessness and social discrimination. Providing a package of services that addresses a more comprehensive set of needs has expanded membership and increased service utilization. The overall impact of these strategies has been increased regular contact with the HRGs, enhanced membership of some CBOs, and in certain instances, the increased use of services. One unintended outcome of both outreach and community mobilization has been the surfacing of
Innovations in Targeted Interventions for HIV/AIDS Prevention in Karnataka, India 83

hidden populations previously undetected by expert mapping, originally conducted to set targets. For instance, in Tumkur BIRDS has registered 25% more MSM-Ts of the set target of 845. In Bijapur, Navaspoorthi has consistently reached over 100 percent of its monthly outreach estimates of MSM-Ts. Similarly Rakshane Zilla Mahila Okkoota has also identified more FSWs than the mapping figures.

Challenges and Recommendations One challenge surfacing from the TIs was that bridge populations are not treated on par with core HRGs and do not have equal access to condoms and clinical services. Bridge populations are demonstrated to be a high risk group for two reasons. First, because of their increased vulnerability due to high exposure to HRGs and second, due to their mobility, they act as a conduit for transmission of HIV and other STIs to the general population. The current policy assumes that bridge populations will pay for services, unlike HRGs. In reality several of these populations either do not have liquidity (like construction migrants whose contracts and payments are between their families and the contractor) or they do not prioritize spending on condoms and services (as in the case of fishermen migrants). Given comparable levels of risk to HRGs it would be important to treat these populations on similar terms to achieve the long term of objective of combating HIV/AIDS.
The major challenges that emerged from the study relate to funding, both in terms of limited resources for certain activities and lack of flexibility of use of funds. For instance, one challenge reported in these outreach strategies included insufficient remuneration of travel and communication expenses, which often become out-of-pocket expenses for outreach workers and peer educators. When measured against set targets for outreach and service delivery these allowances are not commensurate with the volume of work. A second issue relates to unpaid or under-paid human resources employed for outreach and service delivery. For instance, salaries of peer workers have reduced from Rs.2,300 to 1,500 per month, which has led to de-motivation and high attrition rates. These issues have strong implication for the sustainability of the TIs. Sustainability of the TIs, while a function of community ownership, in turn depends fundamentally on the financial and technical capacity of the CBOs themselves. Building financial sustainability could take multiple forms which include: a) developing CBO capacity to seek, manage and execute projects b) building income and revenue generation streams and c) establishing core corpus funds to manage the functions of the CBO. Therefore building these capabilities should be a major focus to accomplish NACO goals of achieving scale and widespread coverage.

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Local Solutions to a National Problem

KHPT
Karnataka Health Promotion Trust

KARNATAKA STATE AIDS PREVENTION SOCIETY, #4/13-1, Crescent Road, High Grounds, Bangalore-560001. Ph: 080-22201438, Fax-080-22201435, Toll Free Number:1800-425-8500 www.ksaps.gov.in