Prevention has been and will continue to be the mainstay of the strategic response to HIV/AIDS. With 99 per cent of the adult population of the country uninfected, Gujarat has a window of opportunity to reverse the progression of this infection and reduce the overall levels of prevalence.
The strategy to achieve the objective of reducing the overall level of the epidemic will consist of a three-pronged approach.
Saturation of High Risk Groups through Targeted Intentions (TIs):- In areas with high concentration of core populations like commercial sex workers (CSWs), injecting drug users (IDUs) and men having sex with men (MSM), exclusive interventions for comprehensive packages of preventive services will be developed. At most of the places such interventions are in existence. Still through revalidation of mapping data any new sites with concentration of new population, if found, will be covered as first priority.
Expanding the coverage of bridge populations through TIs:-Highest priority will be given to saturate HRGs. However in a state like Gujarat where Sex workers and MSM populations are scattered and living together with other bridge populations, the strategy is to target bridge population along with the sex workers and MSM. Truckers and single male migrants are categorized as bridge populations and are already prioritized after the three high-risk groups who are already being addressed in Gujarat. In phase III NACP same strategy will be continued. In state of Gujarat Composite Interventions are those interventions where Single Male Migrants engaged in different occupational categories are targeted where risk-taking behavior is very high. Target interventions with lower /negligible risk are never taken as a strategy in the state. However reassessment will be carried out to develop focused strategies for better outcomes and impact.
HIV Prevention among the general population: saturating the highly vulnerable populations, women, youth and children:-
HIV transmission among general population often occurs through their sexual partners, who also have an infected sexual partner(s) among the high risk groups. Interventions for general population are about raising their awareness of HIV. Among the general population, women, youth and adolescents are seen as most vulnerable. High risk groups who are in scattered numbers in rural areas will be also covered with other highly vulnerable population groups namely HIV affected children, youth & women through intensive rural program involving various village level institutions and identifying Peer Educators (PEs) from these institutions to coordinate these activities. Link workers will be developed to take care of high risk groups at the village level.
One of the most important components of the NACP-III is the Targeted Intervention project that aim to interrupt HIV transmission among highly vulnerable populations. Certain populations are at a greater risk of acquiring and transmitting HIV infection due to more frequent exposure to HIV, higher levels of risky behavior and insufficient capacity or power to decide to protect themselves. Such population groups broadly include sex workers and clients, injecting drug users, men who have sex with men, truckers and migrant workers.
Rationale for Targeted Interventions
Directing HIV prevention efforts among groups with a high rate of partner change, whether sexual or needle-sharing partners, is a proven cost effective strategy as it has the multiplier effect of preventing many subsequent rounds of infections amongst the general population.
Targeted interventions among these groups involve multi-pronged strategies such as behavior change communication, counseling, treatment for STIs and provision of condoms, along with activities that can help create an enabling environment for behavioral change.
TIs in Gujarat
Gujarat is in moderate HIV prevalence state with 6 out of 25 districts in A category and other four being in B category. The recent trend of epidemic indicates that the epidemic has moved to the generalized population as well. For these reasons, the principle strategy for TI is total saturation of HRG in the state.
This will be achieved through expanding the reach of TI through
NGOs and CBOs for urban areas and for places with high concentration of HRB and
Link Workers and Village Level Volunteers for villages having 5000 population.
A new mapping of the HRB is to be completed by 2008-09, as previous mapping attempts were not able to provide accurate statistics. On the basis of NACP-III guidelines, total saturation of HRGs in Gujarat will be achieved:
Highest priority and saturation of three high risk groups (HRG) – Commercial Sex Workers (CSW), Injecting Drug Users (IDU) and Men having Sex with Men including transgender (MSM). Composite programs will be initiated where numbers of any one of the HRB is low. Creation of enabling environment and saturated coverage (80%) of all key populations by 2012 would help achieve the set objective of halting and reversing the epidemic.
Second priority targeting the truckers and migrants. Most of Migrant and all trucker's projects were closed following NACO directives but will be started after the mapping of the state is complete and will be realigned to follow new NACO guidelines of NACP III. It is envisaged that at least 60% coverage of bridge populations will be achieved by 2012.
Reaching to high risk groups scattered in rural areas through Link Workers and Village Level Volunteers.
Currently, 58 TIs are operational in the state (excluding Ahmedabad City) covering different HRGs.
The Targeted Intervention (TI) strategy in Gujarat under NACP III focuses on coverage of key population (HRG) groups with a suite of comprehensive prevention services – viz. behavior change communication (BCC), STI services, condom promotion and enabling environment. While the TI’s have delivered significant results, evidence from the ground suggests that the mere provision of services have not resulted in risk reduction and sustainable behavior change among HRG. Therefore, it is proposed to have a shift in the approach by:
Shifting away from a top-down service delivery approach, by focusing on changing HRG norms and developing positive peer pressure to generate demand and uptake of services.
Building competencies of the HRG community to assume ownership of focused prevention interventions and effectively manage programs (including using evidence based approaches for program management).
Facilitating the creation of supportive structures and an enabling environment that will be conducive towards sustained behavior change leading to lower levels of risk and vulnerability among HRG’s.
Adopting a "program-based" approach at the district and state level (as opposed to a "project-based" approach) to strengthen coordination and collaboration between various partners to achieve a set of common objectives and outcomes at the district level.
Following the tenets of the Three One’s Framework at the state and district-levels.
District-wide programming approach for impact.
Establishing systems for community-level, project-level and program-level monitoring and feedback.
