The first phase of an Indian initiative for HIV prevention—named Avahan—has seen an estimated 100,000 infections averted over 5 years. However, the initiative was much more effective in the heavily populated southern states than in the remote northeastern states. The findings are reported in an Article written by Dr Marie Ng, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA, and University of Hong Kong, China, and Professor Lalit Dandona, Public Health Foundation of India, New Delhi, India, and colleagues.
Avahan was launched in 2003 with US$258 million funding from the Bill & Melinda Gates Foundation, and came in addition to the Indian Government's own efforts on HIV prevention. The foundation also announced an additional $80 million in 2009 to support the transition of this initiative to merge with the government's HIV control effort by 2013. Avahan aims to slow the transmission of HIV in the general population by raising the coverage of prevention interventions in high-risk groups—ie, female sex workers and their clients and partners, men who have sex with men, injecting drug users, and truck drivers. The interventions include peer outreach for safe-sex counselling; clinical services including treatment for sexually transmitted infections; distribution of free condoms; needle and syringe exchange; and community mobilisation and advocacy activities.
Avahan has been implemented in four large states in south India—Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu—and two small states in the northeast—Manipur and Nagaland. These six states were estimated to have the highest HIV prevalences in India in 2003, and a total population of 300 million. 80 (61%) of 131 districts in the six Avahan states received funding from Avahan for HIV prevention, as the only or shared source. Greater intensity of Avahan, measured as amount of grant per HIV population, was significantly associated with lower HIV prevalence in Andhra Pradesh, Karnataka, and Maharashtra states; this association was not significant in Tamil Nadu, Manipur, and Nagaland. An estimated 100 178 HIV infections were averted at the population level from 2003 up to 2008 as a result of Avahan. The HIV prevalence in the general population was reduced between 2003 and 2008 with the implementation of Avahan, ranging from 2.4% in Maharashtra to 12.7% in Karnataka.
The authors conclude: "The results of our analysis suggest a strong association between the large-scale Avahan HIV prevention programme in India and reductions in HIV prevalence at the population level, which is the ultimate goal of the programme…This beneficial effect of Avahan is encouraging but the heterogeneity in the effect across the states indicates the need for better understanding of which aspects of Avahan have been successful for adoption on a larger scale."
In a linked Comment, Dr Ties Boerma, WHO, Switzerland, and Dr Isabelle de Zoysa, Lungarno Guicciardini 17, Florence, Italy, say: "To learn from evaluation, it is necessary to unravel the causal pathway and carefully consider the implementation successes and failures of the main interventions…The Avahan evaluation has only just begun and the first results are encouraging. Effective collaboration between all the scientists involved should further improve understanding."
For Dr Marie Ng, Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, WA, USA, and University of Hong Kong, China, and co-authors from IHME, please contact William Heissel T) +1 206 897 2886 / Mobile: +1 206 612 0739 E) wheisel@uw.edu
For the PHFI in New Delhi contact Ms. Vijayluxmi Bose T) +91 11 4604 6000 / Mobile: +91 98114 15443 E) vbose@phfi.org
Dr Ties Boerma, WHO, Switzerland. T) +41 792173426 E) boermat@who.int
Journal
The Lancet