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Community Mobilization can reduce HIV/STI risk among female sex workers: E merging evidence from Avahan. Where the Tide will Turn: How is Community Level Participation Most Effective in Turning the Tide? AIDS 2012 (SUSA72 ) - PowerPoint PPT Presentation
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Community Mobilization can reduce HIV/STI risk among female sex workers:
Emerging evidence from AvahanWhere the Tide will Turn: How is Community Level Participation Most Effective in Turning the Tide?
AIDS 2012 (SUSA72)
Tisha Wheeler, Anne Sebert Kuhlmann, Tara Beattie, Narender Kande, Christine Galavotti, Gina Dallabetta, Parinita Bhattacharjee, Sudha Chandrashekar, H L Mohan, M Suresh, Dhanunjaya Rao, Shajy Isac, Lori Heise, BM Ramesh, Stephen Moses, and Charlotte Watts
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Mounting Focus on Structural Interventions and Community Mobilization
…major efficiency gains through community mobilization…
On Ground Scope of Avahan Program
Programcoverage
• 6 states, 83 districts,• 600+ towns
• Combined State Population• ~ 300 million
• High risk groups covered• FSW – 221,000• MSM & TG – 81,000• IDU – 18,000• Men at risk – ~5 million
Prevention Package
• Outreach, Behavior Change Communication
• Commodities (condoms, lubricants, needles)
• Clinical services for STIs + counseling
• Case managed approach to referral - TB, HIV testing, ART
• Community mobilization
• Structural Interventions: Local advocacy, police sensitization, crisis response, community advisory committees
10 Years (2003 – 2013)
44
4
Coverage and Condoms: New Peer Approaches Made a Difference
The Difference• Peer Empowerment • Real time data use• Evolving program design• Leadership beyond services
2005-01
2005-07
2006-01
2006-07
2007-01
2007-07
2008-01
2008-07
2009-01
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
200
400
600
800
1,000
1,200
1,400
Peer educators' share of high-risk individuals contacted through outreachAverage number of condoms distributed per peer educator
Perc
enta
ge o
f con
tact
s by
pee
r edu
cato
rs
Num
ber o
f con
dom
s
Source: Wheeler T, et. Al, J Epi Comm Health 2012
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5
Collective identity Collective efficacy Collective agency0%
20%
40%
60%
80%
100%
71%
26% 30%
80%
36% 42%
Among inconsistent condom users Among consistent condom users
Condom Users Have Collective Power
Collective identity – sense of unity with FSWs they don’t knowCollective efficacy – agreed that all or most FSWs would help to solve a community problemCollective agency – participate in a public event where could be ID’ed as an FSW or spoke to police in last six months
Source: Blankenship K et al, AIDS 2008Behavioral Survey, 2007, East Godavari district, Andhra Pradesh, N=813
AOR=1.61, p<0.05
AOR=1.64, p<0.05
AOR=1.72, p<0.001
0%
1%
2%
3%
4%
5%
6%
5%
3%
Infected with Gonorrhea
Experienced Violence No Violence Reported
0%
20%
40%
60%
80%
100%
55%
76%
Consistent Condom Use
Experienced Violence No Violence Reported
Violence means Less Condom Use, Access and Higher STIs
AOR 1.9 95% CI p<0.02
Source: Beattie T, et al. BMC Public Health 2010
AOR 0.4, 95% CI p<0.001
Integrated Biological and Behavioral Survey, Karnataka, India, N=3852 FSW
0%
20%
40%
60%
80%
100%
85% 90%
HIV program access
HIV program access
AOR .7 95% CI p<0.04
Addressing violence is central for HIV prevention among
FSW
77
7
High-Titre Syphillis
Syphillis Trichomoniasis Chlamydia Gonorrhoea0%
10%
20%
30%
40%
50%
14%
25%
33%
11%5%
3%
12%14%
5%2%
20042006
Changes after Community Mobilization Strengthened in Mysore, Karnataka
CCU occasional client CCU repeat client0%
20%
40%
60%
80%
100%
65% 53%
90%
66% 20042006
Increases in Consistent Condom Use
Reza-Paul S, et al, AIDS 2008Integrated Biological and Behavioral Survey, Mysore-Karnataka, India
Survey 2004 N=525, Survey 2006 N=529 FSW
AOR=4.3, 95%CI, p<0.001
p<0.001p<0.001
p<0.001
p<0.001p<0.03
Significant Reductions in STI’s
88
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Testing Community Mobilization Theory of Change in Avahan
OD• Readiness &
capacity of community
groups, networks• Mature
processes
HRG Intervention
activities
Structural Intervention (SI) activities
Organizational Development (OD) activities
HRG• Reliable
denominators• Increased coverage
& service uptake• Quality
SI• Access to
entitlements• Crisis response
• Advocacy capacity &
practice (media, legal etc)
Social norm &
behavior change
Enabling Environment
Strong community groups and
organizations
Reduced risk &
vulnerability
Sustained community structures
Sustained HIV
Response through
communities
Participation
Participation
ParticipationEnhanced program
outputs Improved outcomes ImpactCommunity-level changes
Stage 3-
Ownership
Reinforces
Stage 1-Identification
w/others
Stage 2-
Collectivization
Source: Galavotti et. al, J Epi Comm Health 2012
Collective identity Collective agency Individual efficacy0
20
40
60
80
100
Know ART available government hospital
Visited STI clinic past 6 months
Ever taken HIV test0
20
40
60
80
100
HIV-1 infection High-titre syphilis Gonorrhoea & or chlamydia (R2)
0
2
4
6
8
10
12
14
16
18
20
Last occasional client Last repeat client Last sex regular partner
0
20
40
60
80
100
Emerging Results: High Exposure to Community Mobilization Drives Results
Increased Collective and Individual Power
Increased Knowledge and
Uptake of Services
Increased CCU Reduced Gonorrhea and Chlamydia
Prevalence
Data Source: Biological and behavioral survey, 2011 with random samples of FSWs in 4 districts in Karnataka, India (Bellary, Bangalore, Shimoga, Belgaum) N=1934 FSW
Beattie et al, THPE275
Low Medium High
** **
**
**
*
*
***
**** ** **
** ***
*
*
*
*AOR p<0.05 **AOR p<0.001
Conclusion
Authors: Tisha Wheeler1, Anne Sebert Kuhlmann2, Tara Beattie3, Narender Kande4, Christine Galavotti5, Gina Dallabetta4, Parinita Bhattacharjee6, Sudha Chandrashekar3, H L Mohan6, M Suresh6, Dhanunjaya Rao6, Shajy Isac6, Lori Heise3, BM Ramesh6, Stephen Moses6, Charlotte Watts3
1 Futures Group, Washington D.C. USA2 Manila Consulting Group, Inc., McLean, VA, USA3 London School of Hygiene and Tropical Medicine4 Bill & Melinda Gates Foundation, India/Washington DC, USA5 CARE, Atlanta, GA, USA6 Karnataka Health Promotion Trust; University of Manitoba, India
www.gatesfoundation.org/avahan
• Start with peer led outreach• Address violence (and other SI)• Mobilize communities• Measure to capture progress