TARGETED INTERVENTIONS a TARGETED INTERVENTIONS India’s pathbreaking approach to address the HIV/AIDS epidemic Key Successes, Lessons and the Future FEBRUARY 2021 Authors: Suresh Kunhi Mohammed Senior Health Specialist, World Bank Ronald Upenyu Mutasa Practice Leader, Human Development, World Bank Ishira Mehta Consultant, World Bank © 2021 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. 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Table of Contents Acknowledgements iv Abbreviations v Introduction 1 Background 1 Targeted Interventions 2 The Journey – the evolution of TIs over the years 4 The Bricks and Beams – a robust data driven and accountability set up 10 Funding for Targeted Interventions 12 What is the Big Deal? – the significance of targeted interventions 12 The Catalysts – key success factors 15 Room for Improvement – areas for consideration 17 Emerging Trends 18 Virtual Population – a dynamic entity 19 Migrants – a layered and complex group 21 IDUs – a ticking time-bomb 22 Looking Forward 22 ANNEXURE A: List of Key Informants  25 TARGETED INTERVENTIONS iii Acknowledgements This case study was developed to document the lessons and best practices that emerged from the World Bank’s 27 year old partnership with the National AIDS Control Organization (NACO) on Targeted Interventions (TIs). The authors of this case study are grateful to NACO, particularly, Alok Saxena - Joint Secretary, Shobini Rajan - Deputy Director General and the entire Targeted Interventions team for providing their guidance, inputs and support to make this case study happen. The authors would also like to thank representatives from key stakeholders of the TI ecosystem such as the State AIDS Control Societies (SACS), Technical Support Units (TSUs), non-governmental organizations (NGOS), community-based organizations (CBOS), community members from key population groups, technical experts and international development organizations for taking out the time to provide their valuable insights to make this case study richer. Please see Annexure A for more details. The authors greatly appreciate the peer reviewers – K. Sujatha Rao, Former Secretary, Ministry of Health and Family Welfare and Director General, NACO, David Wilson – Program Director, Health Nutrition and Population Practice, World Bank and Kees Kostermans – Public Health Specialist, ex-World Bank – for reviewing the case study in depth and providing inputs to further strengthen it. The team is grateful to Trina S. Haque - Practice Manager, Health, Nutrition & Population Global Practice, South Asia, Camilla R. Holmemo - Practice Leader, Human Development India and Sybille Crystal - Senior Operations Officer, Health, Nutrition & Population Global Practice from the World Bank for their guidance and support throughout the writing of the case study. iv TARGETED INTERVENTIONS Abbreviations AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy BMGF Bill and Melinda Gates Foundation CBO Community Based Organization DFID The U.K. Department for International Development DPM Differentiated Prevention Model DSACS Delhi State AIDS Control Society DSRC Designated STI/RTI Clinics FSW Female Sex Worker GoI Government of India H/TG Hijra/Trans Gender HIV Human Immunodeficiency Virus TARGETED INTERVENTIONS v HRG High Risk Group HSS HIV Sentinel Surveillance HWC Health and Wellness Centres ICTC Integrated Counselling and Testing Centres IDU Injected Drug User IEC Information, Education and Communication IPC Interpersonal Communication KP Key Population M&E Monitoring and Evaluation MSM Men who have Sex with Men NACO National AIDS Control Organization NACP National AIDS Control Program NGO Non-Governmental Organization NWO Network Operator ORW Outreach Workers OST Opioid Substitution Therapy PLHIV People Living with HIV PO Project Officer SACS State AIDS Control Societies STI Sexually Transmitted Infection TI Targeted Intervention TL Team Leader TRG Technical Resource Group TSU Technical Support Unit UNAIDS Joint United Nations Programme on HIV/AIDS USAID The U.S. Agency for International Development WHO World Health Organization vi TARGETED INTERVENTIONS Introduction This case study documents how India, the world’s second most populous country, pulled the reins on a global epidemic to stop it in its tracks from growing into a generalized epidemic. Central to the case study is the story of a government body– the National AIDS Control Organization (NACO) that, with the support of international development organizations like the World Bank, deftly collaborated with civil society organizations to engage with communities that had a high risk of HIV infection and were also highly marginalized to implement large scale behaviour change in the interest of individual and public health. Above all, this is a story of courage, resilience and gumption of some of the most hidden and disenfranchised communities of India in taking charge of their destinies with respect to HIV/AIDS and demonstrating that if provided with the right programmatic structure and a supportive ecosystem, they can rise towards a better tomorrow. This case study is the story of India’s fight against HIV/AIDS and the significant role played by Targeted Interventions in this fight. Targeted Interventions are a resource-effective approach to offer HIV prevention and care services to high-risk populations within communities by providing them with the information, means and skills they need to minimize HIV transmission and improving their access to care, support and treatment services.1 2003 the prevalence of HIV was 10.33%, 8.47% and Background 13.15% amongst the FSWs, MSM and IDU populations respectively. HIV prevalence continues to be HIV prevalence in India was identified at a relatively concentrated over the years as reported by the HSS early stage. After the identification of the emergence in 2006 and 2017. The concentrated prevalence of of HIV infections in the late 1980s, initially amongst HIV in India has been in contrast to the generalized Female Sex Workers (FSW), the Government of India HIV epidemic in Africa. This has also led to a contrast (GoI) started designing its response in order to curb in the approaches used to tackle the epidemic. the spread of the disease. On the basis of recommendations by an AIDS Task Given the sexual behaviour of the population, it Force setup under the Indian Council of Medical was largely an epidemic concentrated in certain Research (ICMR) and a National AIDS Committee High-risk Groups (HRGs) such as FSWs, Men who (NAC), the government launched the National AIDS have Sex with Men (MSM), Hijra/Trans genders (H/ Control Programme (NACP) in 1992. Given the TG) and Injecting Drug Users (IDUs). As per NACO’s concentrated nature of the epidemic, the sheer HIV Sentinel Surveillance (HSS) (see Figure 1), in size of India, the heterogeneity of epidemiologic 1 National AIDS Control Organization (NACO) http://naco.gov.in/sites/ patterns, limited availability of resources, the inertia default/files/faq.pdf of government procedures, and last but not least the TARGETED INTERVENTIONS 1 Figure 1: HIV Prevalence Rate in Key Population 2003 2006 2017 ANC 0.8 0.6 0.28 Migrants 1.6 0.51 Truckers 2.37 0.86 FSW 10.33 4.9 1.56 MSM 8.47 6.41 2.69 TG 29.6 3.14 IDU 13.15 6.92 6.26 Source: HIV Sentinel Surveillance (HSS) 2017 taboo associated with the target groups, there was Key Population (KP) includes the groups where the an imminent need to develop and test innovative HIV prevalence has been found to be concentrated approaches to reach and engage with these highly such as FSWs, MSMs, H/TG and IDUs. marginalized and hidden communities engaging in high-risk activities. This complicated set of challenges Bridge population includes migrant labourers led to the design and implementation of Targeted and truckers as they form the bridge from the key Interventions (TI) under the NACP. populations to the general population. In other words, they engage in sexual activity with FSWs, The NACO and State AIDS Control Societies (SACS) MSMs, H/TG or become an IDU, get infected and were established at the central and state levels take the infection back to their spouses and partners. respectively to implement NACP activities. The Figure 2 provides a visual demonstration of the NACP has over the years seen various phases of transmission dynamics across different groups. implementation, supported by the GOI, international development organizations and foundations, with the NACP IV Extension phase currently in Figure 2: Transmission Dynamics implementation. Table 1 gives an overview of the Core Group objectives and focus of each NACP phase. At Risk Population Bridge Targeted Interventions Spouse and Partner Other ‘at risk’ TIs provide a package of prevention, support and linkage services to a focused group of HRGs in a Low Risk defined geography through a peer-led, outreach- based service delivery model in partnership with Non Governmental Organizations (NGOs) and Community Based Organisations (CBOs). TIs primarily reach two sets of groups: Key population Source: National Strategic Plan for HIV/AIDS and STI and the Bridge population (2017 – 2024), NACO 2 TARGETED INTERVENTIONS Table 1: National AIDS Control Program (NACP) Phases NACP I NACP I saw the initiation of a major effort to prevent HIV transmission through a series of (1992-1999) measures and interventions that focussed on the following goals:  Risk reduction measures like behaviour change and protection measures like the use of condoms and safe needles.  Better screening of blood and blood products in blood banks to reduce transmission.  General awareness programs through mass media.  Developing a strong evidence base through a strong surveillance program. NACP II With an objective to reduce the rate of growth of HIV infection in India and strengthen (2000-2006) India’s capacity to respond to HIV/AIDS, NACP II’s focus was on the following measures:  Increased resource allocation and technical support to states for increased decentralization, better micro level planning and population mapping.  Establishing TIs as the leading preventive approach for HIV.  Developing appropriate Information, Education and Communication (IEC) material for the general community and key population. NACP III NACP III improved on the earlier phases with a strong focus on the following: (2007-2012)  Behaviour change in the key population by scaling up targeted interventions to prevent new infections.  Increased care, support, and treatment of people living with HIV/AIDS (PLHIV).  District level implementation and technical support.  Stronger surveillance, standardization and systems development. NACP IV With a view to sharpen the focus on prevention and treatment, NACP IV focused on the (2013- present) following:  Consolidating the gains of the past phases by fine-tuning the targeted intervention approach, by identifying and targeting emerging vulnerable groups and trends.  Expansion of treatment services including the Opioid Substitution Therapy (OST).  Better and focussed capacity building of national, state and NGO resources. Recent TI interventions have tried to reach a wider across the country where the greatest movement group of at-risk population such as spouses and of migrants takes place between villages/districts partners of the key and bridge population. Efforts and cities. Based on this, migrants are targeted at have also been made to reach other groups where 3 locations: high-risk behaviour has been observed such as  Home Base: during home coming periods, prison inmates, informal sector workers and rural through melas and health camps where focus populations through schemes such as the Prison HIV is on awareness and testing e.g., Holi or Chhath Intervention Program, Employer Led Model and Link mela in Bihar. Worker Scheme respectively.  Transit: share IEC material in target trains or Each TI offers a bouquet of services and activities stations on the route. and is characterized by unique features as outlined  Destination: employers, industry, residence. in Boxes 1 and 2. The TI approach to engage with the bridge population is broadly similar to that of the key Truckers are targeted at dhabas, loading/unloading population with some modifications. NACO has done hubs and construction sites by the NGOs in close considerable research to identify migration corridors coordination with the SACS. TARGETED INTERVENTIONS 3 BOX 1: Components of Targeted Interventions (TIs) Community Mobilization:  Reach out to community through Outreach Workers (ORWs) and Peer Leaders Clinical Services  Continuous care and support to key population Behaviour Change Communication: Provision of Enabling Commodities  Interpersonal Communication (IPC) by peers and ORWs Environment  Field level events/melas  Awareness generation workshops HRGs  Trainings on condom usage, negotiation skills, usage of needles (IDUs only) Behaviour Change  Multi-media advertisements Communication Community Mobilization  NACO National Helpline Provision of Commodities: Referrals & Linkages  Free condom and lubricant distribution  Social marketing of condoms Source: NACO  Clean needle/syringe exchange (IDUs only) Clinical Services:  Community based Screening & Treatment of HIV/AIDS and Sexually Transmitted Infections (STIs)  Opioid Substitution Therapy (OST) Referrals & Linkages:  HIV integrated counselling and testing centres  Anti-retroviral therapy (ART) centres Enabling Environment:  Advocacy and Liaison with key stakeholders such as community gatekeepers like dera heads, police, lawyers, local administration, local political leaders and other government programs  Networking The Journey – the evolution of TIs NACO and WHO’s initial intervention was nowhere close to the TI approach. It was instead more over the years focussed on general IEC with an aim to increase awareness and bring about behaviour change Conceptualization of TIs amongst FSWs, promote the use of condoms and focus on reducing STIs. However, this top-down After the launch of the NACP in 1992, a study carried approach met with resistance in the field when the out by NACO and World Health Organization (WHO) project implementers discovered that the FSWs did amongst 450 FSWs in four metropolitan cities of not trust them and found the project’s communication Delhi, Mumbai, Kolkata and Chennai showed that material stigmatizing their community. Above all, less than 3% used condoms, more than 80% had given existing power dynamics, they did not feel STIs and HIV prevalence was 1-3%.2 confident and empowered enough to negotiate condom usage with the client. This was critical as 2 Do We Care? - India's Health System by K. Sujatha Rao, Oxford University Press (pg. 251) and primary interview with Mr. Smarajit Jana. until and unless the FSWs found the confidence to 4 TARGETED INTERVENTIONS Box 2: The Magic Ingredients – the Key Features of TIs There are some unique features that have characterized the TIs approach and have stood the test of time by proving their effectiveness.  Focussed: TIs target key population (KP) groups based on detailed mapping and surveillance data. Detailed micro mapping and surveillance data of the KP collected in partnership with leading research organizations, technical experts, community-based organizations and peer leaders have been strong components of the TI strategy over the years. These help to better target interventions, resources and to evaluate impact.  Community Based Implementation: Working through community-based organizations allows for easier buy- in of target groups as well as program implementation and monitoring. • Peer Led Model: Community as an active participant is a distinctive aspect of the TI approach. As peer leaders and outreach workers are identified and nurtured from the community, they help to reach otherwise hard to reach/hidden communities, build trust and get active community inputs thereby increasing the effectiveness of TIs. • Services at the Door-Step: From training to condom supply to HIV/STI screening, all services are provided to the KP within their community itself. The community based drop-in centres provide a safe and non- judgemental space.  Decentralized Implementation: The states are empowered through the SACs to adapt the TIs to their local contexts, thereby increasing the relevance and effectiveness of services provided by a TI to the KP.  Regular Capacity Building: Regular training programs are planned and delivered by NACO and states to continuously build and reinforce TI effectiveness.  Life-cycle Approach: From outreach to identification of the KP, to prevention, to testing and ART-treatment and regular follow-ups, TIs cover the entire lifecycle of a person at high risk of HIV infection.  Evidence Based with Strong Monitoring: TIs have a strong results-focus, with the success of implementing partners (NGOs/CBOs) being measured on the basis of results in reach, testing and reduction in prevalence of HIV infection in the target communities. Strong checks and balances have been developed through close co-ordination between NACO, SACS and TSU program officers and NGOs/CBOs. negotiate with their clients, condom use rate would with their clients, resulting in behaviour change. A not increase. similar experience was seen with FSWs by the NGO SANGRAM in the Sangli district of Maharashtra. Around the same time, a project implementation team led by Smarajit Jana in Sonagachi, Asia’s largest red- This is how the seed of the concept of TIs using a light district based in Kolkata, West Bengal and funded Peer Educator approach was sown into NACP in by the Department for International Development the early 90s. It is also how the DNA of community (DFID), demonstrated that communication by involvement and participation was embedded into outsiders would not be enough and that there was the program design and delivery of TIs. a need to identify and collaborate with ‘insiders’ who would communicate with the FSWs in their Design and Pilot at a National Level own unique ways. This experiment of working with representatives of the community or Peer Educators Seeing the success of the social contracting to reach, organize and sensitize FSWs bore positive approach in select pockets across the country, results. Not only did condom usage go up from 3% NACO designed a TI pilot to be implemented to 85-90% in 18 months, but the collective power at a national level under NACP II. International of FSWs also gave them the strength to negotiate development organizations like the World Bank, TARGETED INTERVENTIONS 5 DFID, Bill and Melinda Gates Foundation (BMGF), the Scale up of the TI Model U.S. Agency for International Development (USAID), the Joint United Nations Programme on HIV/AIDS TIs have broadly scaled up through the NACP phases (UNAIDS) played key roles in assisting NACO during II-IV (1999-2019) with some ups and downs as depicted this phase. The World Bank team, particularly David in Figure 3. The pilot phase (NACP II) saw a rise in the Wilson, lead HIV Specialist played a critical role in number of TIs, new experiments on the ground and emphasising the need for NACO to be strategic and also provided a good road map for the design, and make a targeted effort based on strong evidence in implementation of the TI model. However, by the end order to control India's epidemic. of this phase, there was a need to bring in greater robustness, systems and resources to ensure that As it was difficult to find or develop an empowered the scale up of the TIs led to meaningful outcomes target community to work directly with, NACO on the ground. developed a model of partnering with NGOs that worked with the KP to implement the TIs. This NACP III (2007-2012) gave the TI model this much was done with a vision to build the capacity of the needed shot in the arm and established it as NACO’s community over time to create CBOs that would take mainstay for HIV prevention. This was possible as over the implementation of the TIs. Using the NGO a result of bold ambitions and sweeping changes route initially was also a deliberate decision as that brought into NACO by a strong leadership in the was the most effective way for a Government body Indian government bolstered by co-ordinated to gain entry into the hard to reach, marginalized and support of international development organizations generally hidden target communities of FSWs, MSMS and foundations. In particular, the scale-up of the TI and TGs and gain their trust for implementing the TI approach was built on the foundations of the lessons activities. However, it is important to note that even and successes that emerged from the Avahan though a beginning was made, the stigma of working program of the Bill and Melinda Gates Foundation with these communities was so high that the initial (BMGF) and the support provided by the World Bank TIs were either general or FSW focussed. It was only at the national level. gradually that the TIs started focussing exclusively on other marginalized communities like MSMs, TGs Some of the key highlights of the NACP III scale up and IDUs. Over the years, with the repeal of Section phase were the following: 3773 of the Indian Penal Code in 2018 and greater  A five-fold increase in NACO’s funding from USD sensitization, the taboos associated with the target 500 million to USD 2.5 billion.5 communities particularly MSMs and H/TGs have reduced. Figure 3: Total number of TIs over the years By end of NACP II, there were nearly 1,100 TIs run by Total Number of Tls (1995-2019) 2000 NGOs across the country that largely emphasised on Information, Education and Communication (IEC), 1500 condom usage and STI awareness.4 Though some guidelines were framed, in the absence of strong 1000 systems, resources and monitoring, the states were pretty much left to figure out implementation on 500 their own. 0 2003 2005 2009 2007 1995 1999 2001 2013 2015 2019 1997 2017 2011 3 Section 377 referred to ‘unnatural offences’ and said that whoever voluntarily had carnal intercourse against the order of nature with Source: NACO any man, woman or animal, shall be punished with imprisonment for life, or with imprisonment of either description for a term which may extend to 10 years, and shall also be liable to pay a fine. 4 Do We Care? - India's Health System by K. Sujatha Rao, Oxford 5 Do We Care? - India's Health System by K. Sujatha Rao, Oxford University Press (pg. 256). University Press (pg. 207). 6 TARGETED INTERVENTIONS Box 3: Behaviour Change Communication (BCC) in Targeted Interventions Effective communication with the key population using behaviour change and inter-personal communication strategies and tools is the fulcrum on which the success of a TI depends as that is what sensitizes, enables and empowers the target groups to make a change – be it usage of condoms, needle-syringe exchange or regular medication. The aim of BCC in TIs has been to provide peer educators, outreach workers and other implementation teams with a tool-kit of materials, approaches and facilities that would help them do their job better. In addition, mass media campaigns have also been conducted to create awareness amongst the general population. Reducing BCC has seen an evolution over the years that the TIs Stigma & have scaled up. While in NACP I the focus was mainly on Discrimination Risk creating awareness about HIV/STI and condom usage, Promotion of Perception Perceptio NACP II saw the addition of counselling services and HIV/AIDS AIDS Act information about testing and treatment. NACP III and IV have seen an expansion of BCC activities across Information Inf India, standardization, adaption to regional contexts and Pre-visit Tool l Seeking S for Testing languages and testing of new approaches such as the Thematic Behaviour Be National HIV Helpline 1097. Areas Annual action plans and related multi-media Reducingg Seek S Unsafe Use se communication materials are prepared at the national Regular Re in IDUs and state levels after conducting communication Testing Te needs assessments on the ground. All communication Correct & Adherence Consistent Use is structured around 9 thematic areas and done using to ART a 360° approach usign a mix of traditional and of Condoms contemporary tools to reach the last mile key population.  A widespread organizational revamp in NACO  Standardization of the TI approach along with to support the scale up including creation the design and development of operational of separate divisions for TIs, IEC, M&E etc., guidelines to ensure the quality and sustainability increased staffing at central and state levels of interventions. E.g., 40 operational guidelines and formation of national level Technical were developed by 2009.7 Resource Groups (TRG) of technical experts and  Development of systems and processes practitioners to better inform the TI design. E.g., for effective dissemination and training of NACO had 18 TRGs by the end of 2009 and a guidelines at the state and field level as well as staff strength of 152 at the Centre as opposed for compliance and monitoring. to 31 under NACP II.6  An evolving Behaviour Change Communication  Establishment of a National Technical Support (BCC) strategy to meet the needs of the program Unit (NTSU) at the centre and Technical on the ground (see Box 3). Support Units (TSU) at the state level with World Bank support to provide technical  Establishment of a formidable surveillance support, oversight and training to TIs to ensure system (see Box 4) comprising of a network of that the key population groups were effectively leading national and regional research, public reached. health, epidemiological and medical institutes. 6 Do We Care? - India's Health System by K. Sujatha Rao, Oxford 7 Do We Care? - India's Health System by K. Sujatha Rao, Oxford University Press (pg. 219). University Press (pg. 220). TARGETED INTERVENTIONS 7 Box 4: Surveillance Systems NACO has developed strong surveillance systems to monitor the state of HIV/AIDS on the ground to better inform its strategy and priorities. HIV Sentinel Surveillance (HSS) is a credible and robust system developed by NACO to monitor the HIV epidemic and is acclaimed as one of the best in the world. The sentinel surveillance provides essential information to understand the trends and dynamics of the HIV epidemic among different risk groups in the country and aids in the refinement of strategies and prioritization of focus for prevention, care and treatment interventions under the NACP. Behavioural Surveillance Survey (BSS) is carried out with the objective of estimating the prevalence of HIV-related risks and safe behaviours, knowledge, attitude, practices and service uptake among key population groups. Findings from the BSS are used to estimate appropriate correction factors for the behavioural component of NACO programs. Together HSS and BSS provide a comprehensive and updated picture of the level and trends of HIV among key population groups and their risk behaviour and help to design more relevant and effective TIs. Source: NACO By the end of NACP III (2011), there were 1821 TIs, exhaustive coverage of brothels and popular a 57% reduction in new infections and provision of cruising sites, there was a need to reach KPs treatment to 75% of those identified as infected.8 beyond as well as within existing TI catchment NACP IV has seen a consolidation and fine-tuning of areas through outreach activities like remote the TI model where even though the number of TIs centres and reaching sexual and sharing partners reduced, their coverage increased. of existing KPs, respectively.  The need for a strong navigation component Fine-Tuning of the TI model to connect a large number of people living with The TI model has, over the years, been fine-tuned HIV (PLHIV) who were not initiated on ARTs to in response to ground realities and observations treatment. emerging from continuous monitoring and evaluation.  The need to develop strategies to reach the NACP III saw a definite move towards incorporating 'new age' KP groups that use mobile and virtual testing and treatment services into the previous TI platforms as well as those that did not identify model in order to provide a comprehensive package themselves as the KP e.g., women working at of services to the KP. massage parlours that catered to clients. NACP IV has seen further consolidation of existing These factors prompted NACO to re-prioritize TIs and the emergence of a Revamped Strategy its focus and develop the revamped TI strategy. for Targeted Interventions to address more current Moreover, a limited resource pool mandated that challenges. The genesis for this was in some instead of taking an expansionary approach, the emerging issues and trends from the field that NACO NACO team had to develop a strategy that gave the took cognizance of: maximum bang for the buck by consolidating past  An imminent need for a new mapping exercise successes while also planning for the future. for overall target numbers as the existing 2009 mapping exercise was out-dated. Consolidation and Revamped  The discovery of KPs with HIV positivity that TI Strategy were not covered by existing TIs. With a near In order to tackle these issues, NACP IV has seen 8 Do We Care? - India's Health System by K. Sujatha Rao, Oxford a different approach being taken, where instead of University Press (pg. 201, 291). focusing on increasing the number of TIs, the focus 8 TARGETED INTERVENTIONS Figure 4: Components of the Revamped TI Strategy Principal Sub-Components Purpose Components Population Mapping & To estimate the HRGs' population size Size Estimates (PM&SE) Community Outreach Strengthen Outreach Activities To increase coverage and cover HRGs by reaching out to the sexual and social networks of HRGs Service Delivery Differentiated Prevention To optimize human and financial resources, decongest the TI and provide client-centred package of services Navigation To improve linkages and adherence to ART and ensure viral-load monitoring Index Testing To test spouses and sexual/injecting partners of HRGs' PLHIV index after ART initiation Community Based Screening To test high risk population living in hard -to-reach and unreached locations Commodity Distribution Secondary Distribution of N/S To improve access to Needle/Syringe exchange Satellite OST Centre To improve access and adherence to OST Community Based ART Dispensing To improve ART adherence through decentralized care Community System Community Score Card To seek feedback from community to continuously Strengthening improve the quality of TI services Source: TI Revamped Strategy, NACO was shifted on making the existing TIs smarter with new HRGs 4 times a month versus only once and more efficient in reaching existing and new a month for a stable HRG associated with the TI for key populations using innovative approaches. many years. Where there was overlap, TIs were consolidated to increase efficiency. These approaches encompass This approach as well as other innovations such as the revamped targeted intervention strategy of community-based testing and enhanced peer outreach NACO launched in 2019 and titled Revamped and approach where Technical Support Unit (TSU) project Revised Elements of Targeted Intervention for officers and peers are incentivised to register 20% HIV Prevention and Care Continuum among Core new HRGs every year, network mapping, index testing, Population.9 community score cards, satellite OST centres, focus on female IDUs etc. are currently being implemented A number of principal and innovative components and tested for their efficacy on the ground. form the revamped TI strategy (See Figure 4). One innovative approach currently being tested on the As a result of this consolidation and streamlining of ground is the Differentiated Prevention Model (DPM) existing TIs, the total number of TIs during NACP IV where HRGs are segmented into 5 categories (new came down to 1426 in 2019, from the highest number HRGs, high priority, medium priority, stable HRGs and of 1873 in 2013.10 At the same time, the concerted PLHIV HRGs) based on their risk and vulnerability and efforts to increase coverage also started bearing commensurate frequency and intensity of resources fruit. Between April and March of the years 2017- (human and financial) and services are deployed to 18, 2018-19 and 2019-20, TIs saw an increase in them. For example, contact would be established coverage of key population by 207000, 229637 and 203389 respectively.11 9 Revamped and Revised Elements of Targeted Intervention for HIV Prevention and Care Continuum among Core Population – NACO http://naco.gov.in/sites/default/files/TI%20Strategy%20 10 NACO Document_25th%20July%202019_Lowres.pdf 11 NACO and World Bank sources. TARGETED INTERVENTIONS 9 Innovation from the Ground Figure 5: TI Implementation Model Over the years the SACS have played a pivotal role NACO in contributing to NACO’s national TI strategy with bottom-up innovations that have been replicated around the country such as:  The Differentiated Prevention Model (DPM), SACS TSU started in Mumbai, by Mumbai SACS.  Delhi SACS developed the Network Operator (NWO) Mapping Approach to identify and engage TI NGO/CBO Program with gate-keepers to hidden communities e.g., Officers massage parlours, virtual solicitation groups.  Mizoram SACS developed the model of Satellite Out Reach Drop-In Centres for IDUs. Workers The Bricks and Beams – a robust data driven and Peer Leaders accountability set up The TIs are held together by a robust implementation, monitoring and reporting architecture. Even though The Technical Support Units (TSUs) the implementation of the TIs is done by the NGOs The TSU is a unique organizational mechanism with minimal state intervention, good checks and developed as part of TIs to provide high quality balances have been put in place by NACO to ensure and independent technical inputs, oversight and that the TIs are implemented as intended on the capacity building support. The TSUs are independent ground. organizations that work closely with the SACS at the NACO, at the centre, largely plays the role of providing state level but are hired directly by NACO. TSUs came strategic leadership, surveillance, developing new into being in 2008 based on the success of similar schemes, models and standard operating procedures, entities called the Project Support Units (PSU) that while the day to day operations are carried out at were piloted in 4-5 states with DFID support in 2006- the state level - helmed by the SACS with support 07. By NACP IV, the TSU support was expanded to all of the Technical Support Units (TSUs) as depicted in SACS through World Bank financing. Figure 5. Hence the SACS and TSUs form the key The TSUs have been central to the success of the TIs. institutional mechanism for implementation and They add great value to TIs in particular and NACO’s monitoring targeted interventions. activities in general in a range of different ways: The State AIDS Control Societies (SACS)  Technical Inputs and Solutions: As a third party organization, independent of NACO and SACS, The SACS are autonomous and decentralised the TSU team of expert Team Leaders (TLs) and organizations established at the state level to Program Officers (POs) have the space and implement all of NACO’s programmes including flexibility to give unbiased suggestions and TIs at the state level. SACS are the hotbed of inputs at the level of each TI to help increase implementation and innovation as they adapt their effectiveness and resolve implementation the TIs to the local needs and contexts using a challenges. The TSUs also work closely with collaborative approach with the communities, the SACs and TIs to ideate, brainstorm, design NGOs/CBOs and TSUs. and implement new ground-up solutions such 10 TARGETED INTERVENTIONS as incentivizing TIs for new registrations, capacity building that was provided by the State network operator mapping etc. that have been Training and Resource Centres (STRCs), housed recognized by NACO and incorporated into the in regional universities and institutes. The STRCs Revamped TI Strategy. were discontinued for this reason and the task  Robust Monitoring: The TSUs undertake handed over to the TSUs. vigorous monitoring of the TIs to ensure they  Cross-functional Support to NACO Divisions: are on track to achieving their targets. The TSU Initially the focus of TSUs was to provide POs visit each TI once a month for a 1-day visit technical support only to the TIs particularly and once a quarter for a 3-day detailed visit and on prevention. But seeing their effectiveness give recommendations for each TI to the TSU and the success of the model, the TSUs have TL and SACs based on the findings of a robust over the years started performing a cross- assessment tool. In order to ensure quality, cutting function and provide support for all each PO is mapped to an average of only NACO divisions including testing, treatment 12 TIs. and laboratories linkage. The TSU teams are  Relevant Capacity Building Solutions: As an also playing a crucial role in the population size organization working closely with the TIs, the estimation exercise currently being undertaken TSUs have a very good understanding of the by NACO under the revamped TI strategy. capacity building needs of the peer educators,  Performance Based: The performance-based outreach workers, drop-in centres’ staff and the model of TSUs wherein they are reimbursed TI management. This allows them to provide by NACO based on delivery and performance, customized and relevant capacity building creates a dynamic environment within and solutions. This is in stark contrast to the academic across TSUs and incentivizes everyone to give and often out of touch with ground realities their best. TARGETED INTERVENTIONS 11 Reporting Mechanisms 2015-1613 to Rs. 2956 crore in 2019-20,14 as shown in Figure 6, the budget allocation and spend on A combination of reporting mechanisms has TIs have pretty much plateaued since 2014-15. been developed to ensure adequate checks and This has also reflected in World Bank’s funding balances on field level activities and data coming for TIs, where the actual disbursements over the from the TIs. last few years consistently fell short of planned disbursements.15 Additionally, NACO’s National The Strategic Information Management System Strategic Plan for HIV/AIDS and STI - 2017-2021 (SIMS), an online system where monthly reports are projects 58% of the budget requirement to be for uploaded by the NGOs/CBOs implementing the TI is prevention related activities of which only 14% is the main reporting tool used by NACO to get field allocated to TIs.16 level information. This is supplemented by quarterly and half yearly reports on the TIs by SACS, a Monthly While one could argue that the TIs have become Integrated TI Report (MITR) submitted by TSU more efficient over the years and coverage of program officers and evaluation reports submitted key population has increased in spite of budget by independent experts. restrictions, given the primacy of TIs in India’s fight against HIV/AIDS, there is a need to objectively NACO cross-checks reported data and incorporates assess if stagnation in budgets has had a qualitative inputs and findings from the evaluations into its impact on the outcome and impact of the TIs. decision on whether to renew a TI’s contract for an additional 2 years or not. What is the Big Deal? – Funding for Targeted Interventions the significance of targeted The funding sources for TIs have evolved over interventions the years. In the initial NACP phases, international A question which naturally comes to mind is - development organizations and foundations such why such ado about the targeted interventions? as the Bill and Melinda Gates Foundation, USAID, Is it not just another health initiative of the Indian Global Fund, DFID, the World Bank, and others government amongst many others? What makes played a key role in providing technical resources the TI model so unique and important? There are and funding pilots and innovations on the ground many compelling reasons why TIs are significant in such as the TSUs. India’s fight against HIV/AIDS in particular and in the Over the years, GoI spending for NACO in general country’s public health and social empowerment and TIs in particular has steadily overtaken the space in general. funding provided by development organizations. E.g., approximately 63% of the NACP IV funding I. Social Contracting at Scale came from domestic sources.12 At the same time, it is The TI approach in India stands out as a global important to keep in mind that India spends far less example of how social contracting as a process has than other Middle-income Countries (MICs) on health been successfully standardized and used at scale (about 1.1% of GDP) and less than the global average as a core element in HIV/AIDS prevention programs. on HIV/AIDS in spite of having the 3rd largest number India’s experience of deeply engaging with the of PLHIV in the world. Additionally, even though NACO’s budgetary 13 https://content.indiainfoline.com/budget/2017/bag7.pdf?_ga=2.266 859466.539288756.1602752162-1872118454.1602752162 allocation from GoI has increased in absolute 14 www.indiabudget.gov.in/doc/Budget_at_Glance/bag7.pdf terms by almost 86% from Rs. 1590 crore in 15 World Bank’s funding model for TIs was designed as a function of funds spent by NACO where the World Bank would match 50% of 12 https://www.avert.org/professionals/hiv-around-world/asia-pacific/ the funds spent by NACO on TIs. india 16 http://naco.gov.in/national-strategic-plan-hivaids-and-sti-2017-24 12 TARGETED INTERVENTIONS Figure 6: TI Budget Allocation vs TI Implementation (2012-2020) Year Wise TI Progress - Program & Budget Allocation 2000 1873 1818 100 1742 86.61 1800 1677 90 1600 1509 80 1450 1443 1426 Population Covered 1400 70 Number of TIs 1200 66.62 60 58.49 60.67 1000 55.02 50 52.56 51.54 800 48.85 40 600 30 379.63 303.71 317.04 325.91 20 400 305.13 302.95 200 10 0 0 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19 2019-20 Financial Year Budget allocation Number of TI (in hundred) Population covered (in lakhs) Source: NACO target communities to co-create and co-deliver As indicated in the Figures 7 and 8, there has been a interventions and services at the door-step of the steady decline in the prevalence of HIV amongst the at-risk population using community-based peers key population of FSWs, IDUs and MSM as well as a and organizations and scaling this approach, stands decline in new infections since 1998. More recently, in contrast to traditional models of independent since 2010, there has been a 37% decline in new facilities servicing a target community. infections demonstrating the key role played by TIs in bringing the growth of HIV in India under control. A Precision Public Health Approach II.  Figure 7: HIV Prevalence Trends in Key Population The TI model, with its focus on the ‘science of 16 delivery’ is an example of how a precision public 14 HRG HIV Prevalence (%) health approach can be practiced through the strong 12 use of data for decision making and optimization 10 modelling. Information on the size of the key population, efficiency of interventions and coverage 8 is combined and used to maximize the number 6 of averted new HIV infections. The knowledge 4 generated from the TIs and their modus operandi 2 can inform other disease programs such as chronic Non-communicable Diseases (NCDs) in India and 0 2002-04 2003-05 2004-06 2005-07 2006-09 2007-11 2009-17 other countries. III. Enabled the Reversal of HIV/AIDS FSW IDU MSM Trends in India Source: NACO TIs have been the catalysts that enabled NACO to  ost Effective Approach for Highly IV. C harness an epidemic that would have otherwise Populated Countries spelt doom for India as without TIs, HIV/AIDS would have spread over time from the key population it In a country the scale and expanse of India, was concentrated in to the general population. identifying and targeting the key population through TARGETED INTERVENTIONS 13 Figure 8: New HIV Infection Numbers (1998-2019) 5.50 5.00 New HIV Infections in lakhs 4.50 4.00 3.50 3.00 37% Decline since 2010 2.50 2.00 0.87 0.09 0.91 0.09 0.96 0.10 0.99 0.12 1.50 2015 0.80 0.06 2017 0.74 0.05 2014 0.83 0.07 2016 0.77 0.06 2018 0.70 0.05 2019 0.65 0.04 1.00 0.50 0.00 2011 1998 1999 2001 2010 2012 2013 2000 2002 2003 2004 2005 2006 2007 2008 2009 Adults (15+) Children (0-14) Source: HIV Estimates 2019, NACO. TIs with a focus on prevention and harm reduction In the absence of a cost-effective approach like has proven to be a cost-effective approach to this, India would have required multiple times the deliver results on the ground. E.g., in 2019, the funds and resources and relied on conventional unit cost of reaching FSWs in India through TIs ($ implementation models, killing the innovative and 20) was less than one-third of the global average nimble DNA of NACO and the TIs. ($65).17 This approach was also more suited to the concentrated nature of the epidemic in India as V. Enabling Environment for Key compared to a generalized epidemic witnessed in Populations other countries. TIs evolved from the proven interventions of An economic evaluation of FSW and MSM TI Sonagachi that adopted a ‘health and human rights groups of BMGF’s Avahan program in South India approach’. Consequently, the TI program deployed estimated that 61,000 HIV infections were averted a community development and empowerment by successfully reaching about 150,000 high-risk approach that gave better outcomes. The individuals at an average cost of US$327/ person over involvement of communities of key populations 4 years.18 Similarly, a global study on harm reduction in mapping, peer-based outreach, advocacy and strategies for IDUs such as needle-syringe exchange networking created an enabling environment for and Opioid Substitution Therapy (OST) showed that these marginalized groups and empowered them the costs per HIV infection averted ranged from to taken on issues beyond HIV/AIDS. E.g., NGOs $100 to $1000.19 working for FSWs such as Aastha Parivar and Swasti were able to address the issue of violence against 17 Estimates (average, global) made by Avenir Health for UNAIDS FSWs, a major structural determinant that increased projections, 2020. their vulnerability. NGOs working for MSMs like 18 Cost-effectiveness of HIV prevention for high-risk groups Humsafar Trust successfully fought along with at scale: an economic evaluation of the Avahan program in south India – Dr. Anna Vassall, Michael Pickles, Sudhashree CBOs for gay rights leading to the repeal of Article Chandrashekar et al https://www.sciencedirect.com/ 377 in the Indian Constitution that had criminalized science/article/pii/S2214109X14702773 homosexuality. It is worthy of mention that NACO 19 The cost-effectiveness of harm reduction – David P. Wilson, itself was at the forefront of the fight to repeal Article Braedon Donald, Andrew J. Shattock, David Wilson, Nicole Fraser-Hurt https://www.sciencedirect.com/science/article/ 377 through the supportive affidavits it filed in the pii/S0955395914003119 High Court and Supreme Court. 14 TARGETED INTERVENTIONS Created an Entry Point for Other VI.  NACO’s TI strategy has fuelled the expansion of OST Government Programs centres (a total of 215 centres20 nationwide) either at a government hospital, TI office or at a satellite Through the TIs, NACO has established deep drop-in centre. networks and trust with the key population groups, which are otherwise hard for most government The Catalysts – key success bodies to reach. As a result, whenever other teams factors within the Ministry of Health and Family Welfare as well as other ministries want to reach the key The India experience stands out as a case-study population for their programs, they approach of a country that got the big picture as well as the NACO for advice or support to get entry into these intricacies of implementation right in its fight against communities. Infact, the Tuberculosis and Hepatitis HIV/AIDS. A program of the significance and scale programs have piggy-backed on the TIs for screening of TIs panning over more than 2.5 decades wouldn’t the two diseases and linking positive cases to their have been possible without the help of some pivotal respective centres for treatment. Other ministries catalysts through its journey: have also approached NACO to brainstorm on how to  Leadership and Political Will: Over the years, reach these communities for initiatives like opening the highest levels in GoI have shown leadership bank accounts and skill development. Additionally, and courage to make a clear and unequivocal some NGOs have also assisted key populations in commitment to tackle HIV/AIDS. Traditionally, accessing government programs they were entitled working directly with NGOs has not been common to as citizens such as Aadhar and ration cards. for most government programs in India. So, for the government and NACO leadership to buy into Replication of Robust Institutional VII.  and support the concept of partnering with NGOs Mechanisms to reach marginalized and hidden populations was a key success factor in the implementation In addition to piggybacking on the HIV program of TIs and India’s overall response to HIV/AIDS. for delivery of their services, other Government departments have also adopted robust institutional  NACP Design as a Central Public Health mechanisms developed by NACO for the TIs. Program: The NACP was designed as a centrally E.g., the TSU model of having independent state funded public health program that aimed to reach level units to provide technical inputs, review and every person vulnerable to contracting HIV. This feedback to programs has been replicated by the prevented the TIs from falling into the trap of a Central Tuberculosis Division and the Ministry of boutique intervention to test a new approach Social Justice and Empowerment. The Out-Patient and instead elevated it to an approach of core Opioid Assisted Treatment (OOAT) centres in Punjab significance that was annually allocated a budget are based on the model of OST centres of TIs where to contain and reverse the HIV/AIDS epidemic in IDUs can come to get services like counselling, India. The entire program design ranging from needle-syringe exchange and OST. mapping, designing of the strategy and estimating the size of the key population to funding and unit VIII. A Leading Voice for IDUs cost calculations of the TI structure was based on the premise of maximizing coverage of at-risk Even though IDUs are traditionally the constituents populations. of other government departments and de-addiction  Partner Support and Collaboration: The programmes (Drug Reduction Program of the conceptualization, design and scale up of Health Ministry and the Ministry of Social Justice India’s HIV response and especially targeted and Empowerment), it is because of NACO and its interventions has been based on an exceptional decision to work with IDUs as a key population group, that the issues faced by IDUs got highlighted in India. 20 NACO TARGETED INTERVENTIONS 15 dialogue and collaboration between multiple implementation of activities and contributed stakeholders and partners ranging from in strengthening the institutional capacity and communities, grass-root level workers and NGOs fostering local ownership and involvement. to international donor agencies, academia, Partnering with community-based NGOs and private sector and qualified experts. Partner CBOs that have passion and commitment support in the form of funding and technical embedded in their DNA could be another reason resources from the World Bank, USAID, UNAIDS for the commitment prevalent in TI teams. and BMGF among others have given great  Creative Behaviour Change Communication momentum to the NACPs over the years and (BCC): The BCC tools and strategies of TIs, have provided the flexibility to try out new ideas that combine a 3600 multi-media approach with and innovations in the TIs. contextualization to target groups, regional  Ownership and Passion Across the Board: The culture and language, have been a silent catalyst work culture, sense of ownership and passion for change. They have over time nudged the that exists across the TI hierarchy, from NACO all key population towards seeking help locally or the way to the peer educators have contributed on NACO’s National helpline, changing their to the success of the TIs, inspite of low behaviour during high-risk activities by ensuring remuneration at the field level. The decentralized condom, lubricant or new needle usage and model of TIs allowed the SACSs the flexibility making themselves available for regular testing to play a significant role in the planning and and treatment activities. Moreover, various mass 16 TARGETED INTERVENTIONS media campaigns by NACO such as the Balbir  Diminishing Marginal Utility of TIs: Although Pasha HIV/AIDS awareness campaign during there was a 66% decline in new infections from NACP II and BBC World’s condom promotion 2000 to 2015,21 this trend has largely flat-lined campaigns during NACP III have also sensitized between 2010 and 2019 to 37%. This is a sign that the general Indian population towards an the effectiveness of the TIs as they are currently erstwhile taboo topic. structured is reducing over time, particularly with  Enabling Funding Structure: The ability of NACO key populations like FSWs and MSMs that have to operate independently has played a significant been engaged for long. In other words, there is role in allowing for innovation and flexibility in a need for NACO to relook at its TI strategy and implementation. The HIV/AIDS program is one make appropriate changes so as not to rollback of the few Central Schemes in India where the earlier gains and ensure a substantive decline in funding goes directly from NACO to the SACS new infections to achieve the 90-90-90 target.22 instead of via state treasuries. Not only has this The revamped TI strategy mentioned earlier is a allowed for swift transfer of funds but also given step in this direction. the SACS a certain sense of autonomy.  Outdated Population Mapping: The last  Evolutionary DNA: TIs have an evolutionary detailed national level population mapping was DNA embedded in them. The collaborative done more than 10 years ago in 2009 which and inclusive spirit of the original Sonagachi has limited the TI program’s ability to reach new experiment continues till date. The design of the locations as well as new key population that TI program has adapted to the ground realities would have emerged over the years. NACO was and evolved over time by taking inputs from in the process of carrying out a new population the SACs and TSUs evaluations as well as from mapping exercise at the time of writing this case the communities. Moreover, best practices and study. lessons learned have been carried forward from  Effective Use of Data and Systems for Greater one NACP phase to the next. E.g., best practices Reach: In addition to population mapping and TI such as computerized financial management level field surveys, NACO can design and execute system, annual performance reviews of NGOs, a strategy to use data from Integrated Counselling continuing support of TSUs and others from and Testing Centres (ICTC), Designated STI/RTI NACP III were adopted and carried over to Clinics (DSRC) and other relevant public health NACP IV. centres/clinics to identify high risk individuals to Over the years, new target communities have target through the TIs. Over time, this will lead to also been identified such as jail inmates, rural the development of a unified and comprehensive populations and more recently, groups operating database of key populations that can be used in the virtual space of chat roots, dating sites and to develop a client focused integrated health social media platforms. The recently developed strategy. TI Revamped Strategy and the currently  Input Based TI Contracts are Self-limiting: “under progress” Virtual Outreach Strategy are Under the current TI model, contracts with testaments to the evolving nature of TIs. NGOs and CBOs are input-based i.e., they are allocated a fixed cost per target person in the key Room for Improvement – areas for population which they have to spend and report on. Field observation suggests that the salary consideration As would be expected with a program that has been 21 National Strategic Plan for HIV/STI 2017-2024. 22 In 2016, the United Nations General Assembly’s Political running for so long and across so many geographies Declaration on Ending AIDS committed countries to the 90–90–90 and communities, there are institutional and targets whereby, by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV individual level struggles as well as areas where infection will receive sustained antiretroviral therapy and 90% of all more could be done: people receiving antiretroviral therapy will have viral suppression. TARGETED INTERVENTIONS 17 structures of the NGOs/CBOs have remained staff, especially program officers to ensure they unchanged over the last 3-5 years, and in are appropriately sensitized in dealing with key some cases, 10 years. This leads to a very high population groups. turnover of key management, outreach workers  Better Integration with Relevant Government and peer educators, thereby putting pressure Schemes: Over time, there is a need for the on implementing teams and interrupting the NACO team to integrate TI services such as smooth functioning of the program. While some testing, condom provision, needle/syringe resource crunch has triggered innovations like exchange with other relevant programs such as the Differentiated Prevention Model (DPM), the the 1,50,000 Health and Wellness Centres (HWC) overall sense is that the quality of work and planned under GoI’s flagship Ayushman Bharat ability of field workers to deeply engage with program. This consolidation to make routine, existing and new communities could be getting embed and institutionalize HIV prevention compromised. There is a need to systematically will allow for a more harmonized utilization of tackle this issue by either modifying existing government infrastructure and also allow NACO contracts to incorporate a component of annual to focus its resources and efforts on outreach increment or additional management support. and on-boarding more members from the key Alternatively, a shift to outcome based contracts populations. could be made.  Access to the TG/H Community Remains While the input-based model was useful thus far Sub-optimal: The Hijra community have a very in bringing standardization and structure to the strong ‘dera’ institutional structure helmed by TIs as they scaled, it has begun to outlive its utility a hierarchy of ‘gurus’ as a result of which field as it restricts and does not incentivise the NGOs teams get access to members of the community and CBOs to use allocated resources innovatively only after the blessing and buy-in of the gurus. for maximum reach and outcomes. The time has Typically, the deras have publicly denied that perhaps come for TIs to adopt outcome-based their members indulge in sexual solicitation, contracts where NGOs and CBOs are given the making it hard to break into their strongholds. flexibility to decide the best use of funds and Moreover, as interventions with the trans-gender human resources are measured for success and community were started after FSWs and MSMs, paid on the basis of outcomes such as behaviour progress in reaching and positively impacting change amongst the key population. This will them has been slower and efforts to engage with infuse dynamism and innovation into the TIs and them need to continue. also create the right incentive to deeply engage with the community. It is worth mentioning that In addition to the above, there are some emerging any restructuring of the model should be first trends in India’s HIV/AIDS landscape (discussed piloted to test its effectiveness, incorporate key more in the next section), where NACO needs to assess its readiness and take appropriate action. strengthens of the older model and be gradually scaled up with appropriate monitoring systems and capacity building. Emerging Trends  Improved Quality Control in Capacity Building: As NACO looks forward to the future of TIs, a Since the closure of the STRCs, there has been complex and layered landscape of transmission an absence of a structured training facility for the dynamics starts to emerge, which is not as cut-and- TIs. While the TSUs have picked up on the work dry as it was in the yesteryears. This raises some and are doing a good job, a need for greater important questions as well as concerns on what it quality control has been observed to ensure a means for the TI model as it stands today and more standard quality of training across TIs. There is importantly what it means for HIV infection rates in also a need for stronger capacity building of TSU the country. Is NACO future ready or is there a real 18 TARGETED INTERVENTIONS danger of reversing decades of hard work done This trend is a game changer for TIs and poses to contain and reduce new infection rates? Some serious challenges for NACO in more ways than one, emerging trends in transmission dynamics that need such as developing a methodology to effectively to be carefully studied and addressed in future TIs map and measure these emerging virtual and new are presented here. age groups. There are some inherent challenges in this task due to the presence of different online and Virtual Population – a dynamic offline identities of the same individual and shifting numbers as a result of experimental temporary high- entity risk behaviour by younger groups. So far, no reliable TIs have over the years been successful in physically model for mapping the virtual population has been reaching key population groups that had been developed globally. traditionally hard to reach. Recently, there has been an increasing trend across key population groups and Another challenge for NACO is to reach the virtual beyond of using virtual spaces for initial interaction population to sensitize them about the need for and solicitation, with physical interaction restricted safe sexual behaviour, teach them negotiating skills only to the high-risk act. There are some unique and create awareness about HIV/STI testing and characteristics of the emerging virtual space such as treatment options. The gate keepers and developers inter-mixing of typologies, emergence of a group that of the online platforms and apps will play a crucial does not identify with the traditional key population role in becoming engagement partners and will need and increased health and security risk. See Box 5 for to be convinced that it is in their business interest for more details on these characteristics. the men and women in their network to be healthy TARGETED INTERVENTIONS 19 Box 5: Key Characteristics of the Emerging Virtual Population Inter-mixing of typologies: The emergence of the virtual world has thrown open a pandora’s box of how, when and where high-risk interactions take place. The key population increasingly reaches out to and negotiates with clients online either via gate-keepers (pimps, massage parlour owners, escort services), through friends or directly (through WhatsApp, social media sites like Facebook and Instagram or apps like Planet Romeo and Grindr). While there might be overlaps between the virtual and physical individual, it is hard to always know as they tend to use false identities online. This also means an increasing diversity in locations where interactions take place – ranging from homes to spas, to public spaces, to hotels. As a result, traditional stand-alone typologies of FSWs operating from brothels, MSMs from cruising sites do not hold anymore. An emerging ‘new age’ group that does not identify themselves with the traditional key population in terms of identity, age group or nature of work: The lure of economic opportunities and city life has led to increasing urbanization from villages and Tier II, Tier III towns to metros in recent years. This combined with modern social constructs, a rise of social media platforms and dating apps like Tinder, Bumble etc. have given birth to a more empowered and liberated youth wanting to discover and explore their sexual identity – be it heterosexual, bisexual, homosexual or any other sexual orientation on the spectrum. Moreover, this group is also sexually active much earlier than previous generations and are often part of the general population such as adolescents, college students, domestic workers, blue- and white-collar workers in IT, industries, call-centres and malls. While this group indulges and experiments in high-risk sexual activity with regular as well as non-regular partners and in some cases even selling sex on a part time basis for money, they do not necessarily identify with the traditional key population groups of FSWs, MSM, H/TG and IDUs. This group also has disposable income and a disposition to experiment with drugs. Increase in sexual as well as security risk: There is an emerging risk of HIV/AIDS and STI infections in this ‘new age’ group as they might not always use condoms. One reason for this is they have access to alternatives to condoms such as contraceptive pills. Another is their knowledge that AIDS is no longer life threatening and can be treated. In addition to high-risk sexual behaviour, interactions that take place without reliable gate-keepers also pose a security risk, especially to women who might be prey to violence, sexual molestation, individual or gang rape in an unknown, unsecure environment. Both these issues are of grave concern as they actively impact the overall health and security of India’s greatest asset – its youth. and disease free. Users of these platforms might NACO, as part of its revamped TI strategy, is trying need to be incentivized (discounts, coupons etc.) to develop means to reach and engage with this to engage with TI related activities. Given the key virtual population. It recently held a national level role of peer-led inter-personal Behaviour Change workshop of relevant stakeholders to discuss and Communication (BCC) in persuading, counselling and receive inputs and ideas on developing TIs for the providing a support structure to the key population, virtual population. In addition, some initiatives and NACO will have to find a way to ensure a balance pilots have been tested for online engagement such between the use of technology and interpersonal as the platform Yes4Me23 that engages with online at- communication in engaging with target groups. risk populations to provide them with information and Moreover, in an age of digital media, short attention access to HIV testing and treatment though private spans and content overload, the broader challenge and public facilities along with counsellor support. for NACO is to develop multimedia BCC strategies The website received maximum traction from the and IEC materials that are tailored to the evolving 23 Yes4me is an integrated virtual service delivery platform funded key population groups and are effective in raising by USAID and PEPFAR, and implemented through Project the flag of HIV prevention amongst them. ACCELERATE, under the aegis of NACO. 20 TARGETED INTERVENTIONS MSM community which is the more educated and respectively were shortlisted and piloted across tech-savvy of the traditional key populations of FSWs, India for six months as part of the Challenge. NACO MSM, TG/Hijra and IDUs. has to now decide on scaling up one of the three innovations. Some SACS have also made small beginnings by trying out different models in this space e.g., Delhi Migrants – a layered and complex SACS has carried out a mapping of digital dating and porn sites and developed a Network Operator (NWO) group approach to reach high-risk individuals in massage While NACO has been actively working with parlours, social media and phone groups as well as migrants, observations emerging from the ground sites. Both Mumbai and Delhi CBOs have attempted reveal that it is a constituency that is more complex to engage with target groups on dating and online than meets the eye. sites like GRINDR, Tinder etc. A person remains a migrant as long as there is an NACO also carried out a Grand Challenge Fund in emotional and financial link to their place of origin, 2018 called RETHINK HIV to identify technology where they will continue to return at least twice innovations to better reach key populations in a year. So far, the definition of migrants, used the virtual space. Three innovations focusing on by NACO, has been that of a single male from a gamification, artificial intelligence (AI) for counselling village working in a city as a labourer in factories, and an app for information and capacity building construction sites and the like. This definition is fast TARGETED INTERVENTIONS 21 changing to include a massive youth population from difference in methodology and is in discussions with villages that demonstrate high risk behaviour. These AIIMS to reconcile the number. Regardless of the youths are highly mobile across cities in search of exact number, the fact is that the IDU population is job opportunities, sometimes with their families. rapidly increasing across the country and has the They work across a range of jobs that support today’s highest HIV prevalence rate of 6.26% (HSS 2017) urban infrastructure, ranging from a neighbourhood amongst key population groups, making it a very coffee shop to being an Uber driver, to working in a high-risk group that needs to be addressed on an mall. This population might not fit into the traditional TI urgent basis. model of working with NGOs and peer educators and might require a new approach to reach. Moreover, it Even though the Government has a Drug Reduction is increasingly common for identities to overlap i.e., Program under the Ministry of Health and Family a migrant could be interacting with FSWs as well as Welfare and the Ministry of Social Justice and MSMs while at the same time also injecting drugs, Empowerment also works with drug users, it is raising concerns about the long-term effectiveness sometimes unclear under whose ambit IDUs come. of stand-alone TIs targeting specific target groups. As NACO has been at the forefront of raising the issue of IDUs over the years and taken on the task The movement of migrants across India post the of reaching them through the TIs and OST centres, COVID-19 lockdown has been an eye opener for it has become the default flag bearer for this group. NACO as they realized that there might be areas that This has an inherent limitation. With a limited budget were overlooked in the current migrant focussed TIs and a mandate restricted to HIV and STIs, NACO such the need to test family (index testing), friends is not able to tackle the other diseases IDUs are and partners at the location of employment as well susceptible to such as Hepatitis C (IDUs are 3 times as source village. more likely to get Hepatitis C than HIV). So far TIs have been working with migrants at the An emerging trend of concern in the IDU population location of their employment in cities and through is an increase in injected drug use and positivity rate melas/fairs and camps in their native villages. In amongst teenage groups. These groups are beyond addition, the Link Workers Scheme (LWS) tries to the reach of TIs today due to an age limit restriction identify and reach networks of high-risk individuals of 18 years for participation. This is a tragedy as in rural areas. But limited resources and a vast rural many youth waste precious formative years in de- spread have made it difficult to increase the reach addiction, when the best strategy to tackle the issue and effectiveness of this program. Keeping in mind would be to prevent the start of injected drug use at these changing dynamics, there is an emerging need a younger age. Considering this critical issue, NACO to develop an innovative approach to tackle migrant is considering including minors within the TI ambit. and rural populations in an integrated manner from source to place of employment. Moreover, there is a clear need to develop an integrated model cutting across ministries to work IDUs – a ticking time-bomb with the IDU population as a whole to ensure all the risk dimensions of IDUs are covered to prevent the The 'Magnitude of Substance Use in India 2019'24 spread of HIV and other diseases. Recognizing the report published by the Ministry of Social Justice scale of the IDU challenge, some initial steps have and Empowerment and researched by the All India been taken by NACO in this direction. Institute of Medical Sciences (AIIMS) estimates the total number of IDUs in India at 850,000. This is about five times the estimated figure of 177,000 Looking Forward being used by NACO. NACO is of the opinion that this vast difference in estimates is due to a TIs have been and continue to be the cornerstone of India’s strategy against HIV/AIDS. They have 24 https://www.aiims.edu/en/national-drug-use-survey-2019.html demonstrated admirable success in using 22 TARGETED INTERVENTIONS prevention-based approaches to contain the spread approaches from the field and incorporate them of the epidemic and lowering infection rates in into its national TI strategy. key population groups. Today, keeping in mind the emerging trends in the key population as well as the NACO’s senior management is aware of the gaps and limitations of the model as elucidated in challenge ahead and is cognizant of the need earlier sections, the TIs are at a critical juncture in to allocate a large portion of its budget towards their journey. developing and testing innovations in the emerging online space while at the same time not diluting the Overall, there is a need for NACO to increase the effectiveness of the existing TIs. How will the key focus and resources of TIs towards migrants, IDUs features of TIs like peers, community participation and TGs that traverse across the transmission and involvement be replicated when dealing with the fault-lines of high-risk sexual and drug usage virtual population? Only time will reveal the answers activity. Building on the success of empowerment to these questions. Any new model will require a and positive outcomes with the FSW and MSM rethink of the organizational structures, IEC needs, key population, future TIs might want to consider capacity building and counselling needs as well as prioritizing working with FSWs and MSMs only in the nature of services offered. NACO might even want areas with a prevalence rate of higher than 1%. to consider a hybrid payment model where services offered to certain groups are chargeable versus the The emerging dynamics across key population fully free classic TI model. groups clearly indicate that ‘high-risk mixed cocktail’ situations are here to stay where the lines In addition, a strong push to operationalize and sometimes blur within the key population groups as monitor the revamped TI strategy across the well as between the key and general population. A country, a decisive shift towards an outcome based person indulging in multiple high-risk activities might contractual and implementation model with NGOs/ indicate that the age of the classical stand-alone CBOs, creation of a unified data system of KPs and TIs, each focused on one key population group, better use of field level data for decision making, might be coming to an end and that there is a need increase in use of technology for data collection for a composite and integrated approach with an and processing and regular population mapping emphasis on prevention. The current structure of TIs exercises would all contribute towards greater also does not allow them to effectively deal with the effectiveness of future TIs. online space. NACO is also planning to test the concept of Hence, there is an urgent need to develop a Integrated Global Service Centres across 70 Hybrid Targeted Intervention Model that will have locations to provide integrated prevention, an integrated strategy for the virtual as well as on- counselling, testing and treatment services for key ground space as well as a BCC strategy that will populations, general population as well as non- use a combination of technology and interpersonal injecting drug users. Communities in virtual spaces approaches. The upcoming NACP V is a good will also be directed to these centres. Integrating opportunity to bring in some fresh ideas and bold better with other government programs and changes to ensure that India achieves its 90-90-90 infrastructure could be another effective way to target, effectively uses its resources and above all provide integrated and resource efficient services. doesn’t reverse the gains of the last two decades. The It however remains to be seen if vulnerable and Revamped TI strategy and related new approaches marginalized communities will be comfortable such as community based testing, Differentiated going to such common centres. Prevention Model (DPM), NWO approach that have led to an increase in reach to key populations, is a NACO will need substantial technical, financial and beginning in the right direction but there is a long leadership resources in order to make the necessary way to go. NACO needs to create incentives to help strategic, programmatic and organizational changes unearth, test and scale more of such innovative to meet the needs of the future, including testing and TARGETED INTERVENTIONS 23 scaling innovations. Unlike the earlier NACPs where for India’s HIV/AIDS program in the coming years and international funding and technical expertise were whether the Indian government will able to solely readily available, NACO today is largely dependent shoulder the weight of the disease. on the resources it receives from the government. With TI budgets stagnating in recent years, there is a Last but not the least, in the midst of myriad changes and challenges, bureaucratization of processes need to objectively assess if this has had a qualitative and a focus on service delivery and data collection, impact on the outcome and impact of the TIs. While, NACO faces the critical task of ensuring that the globally, funding priorities for HIV have shifted away core elements of community empowerment and from traditional prevention strategies towards new self-actualization that have set the TI model apart prevention options like PrEP and treatment, in a and greatly contributed to its success, do not resource constrained setting with a concentrated get lost. epidemic, there will always be a need for a healthy mix of classical preventive and treatment-based All eyes will be on India to see how the HIV epidemic strategies. With the emergence of new epidemics is tackled in the coming years and what role TIs play like COVID-19, it is unclear how funding will evolve in that story. 24 TARGETED INTERVENTIONS ANNEXURE A List of Key Informants Key Stakeholders – Individual Interviews S.No. Name Designation Organization 1. Mr. Alok Saxena Joint Secretary NACO 2. Dr. Shobini Rajan Deputy Director General, BTS, TI and SI NACO 3. Dr. Bhawani Singh Kushwaha Deputy Director, TI NACO 4. Dr. Rajesh Rana National Consultant (IEC & Mainstreaming) NACO 5. Dr. Pradeep Kumar Programme Officer, Surveillance NACO 6. Ms. Vinita Verma Programme Officer, Evaluation and NACO Operational Research 7. Dr. Ravindra Rao Additional Professor of Psychiatry (NDDTC) All India Institute of Medical Sciences (AIIMS) 8. Dr. Parveen Kumar Additional Project Director Delhi SACS 9. Dr. J. K. Mishra Joint Director, TI Delhi SACS 10. Dr. Shrikala Acharya Additional Project Director Mumbai District AIDS Control Society (MDACS) 11. Mr. Sachendra Katkar Joint Director, TI Mumbai District AIDS Control Society (MDACS) 12. Dr. Purnima Parmar Team Leader, TI Delhi TSU 13. Mr. Manish Kumar Project Director Punjab and Haryana, TSU 14. Dr. Smarajit Jana Principal Sonagachi Research and Training Institute 15. Mr. Shiv Kumar Co-Founder Swasti 16. Ms. Nandini Kapoor Dhingra Senior Programme Advisor UNAIDS, India 17. Ms. Deepika Joshi Associate Director for Sciences and Lead, CDC, India Epidemiology & Surveillance 18. Ms. Kachina Chawla Senior Strategic Information Advisor USAID, India 19. Dr. James Blanchard Director, Centre for Global Public Health University of Manitoba, Canada 20. Ms. Tanya Gupta Financial Management Specialist The World Bank, India Office TARGETED INTERVENTIONS 25 NGOs and CBOs Implementing TIs – Focus Group Discussions S.No. Active TIs 1. Drishtikon 1 New Delhi 2. Kinnar Bharti New Delhi 3. Mitra Trust New Delhi 4. REWS New Delhi 5. Sharan 1 New Delhi 6. Sharan 2 New Delhi 7. Humsafar Trust Mumbai 8. Aastha Parivar Mumbai NACO TI Team – Focus Group Discussion 1. Mr. Abraham Lincoln Technical Expert (Harm Reduction) 2. Dr. Arpit Parmar Technical Expert (Harm Reduction) 3. Mr. Dew Stanley Ephriam Programme Officer - Targeted Interventions 4. Mr. Ginmung Ngaihte Consultant - IDU 5. Dr. Govind K Bansal National Consultant - DNRT 6. Mr. Lalit Singh Kharayat Programme Officer, Targeted Interventions 7. Mr. Samresh Kumar Programme Officer, Targeted Interventions 8. Mr. Rajeenald T. Dhas Programme Officer, Targeted Interventions 9. Mr. Rohit Sarkar Programme Officer, Targeted Interventions 26 TARGETED INTERVENTIONS 28 TARGETED INTERVENTIONS