Connecting local responses around the world
Executive Summary of Evaluation, Findings and Recommendations in preview of NACP-IV (2011-2012)
The Rajasthan State AIDS Control Society had assigned Maharishi Dayanand Vikas Samiti, Shikshit Rojgar Kendra Prabodhak Samiti, Vishakha Group For Women's Education & Research , Society For Conscious Over All Progress, Gramin Vikas Evam Paryavaran Sansthan the responsibility of spreading the awareness, ways and means of prevention and care/ support about HIV/AIDS in four districts of the state, i.e. Sriganganagar, Hanumangarh, Churu and Sikar. They were given the specific focus to concentrate on strengthening the HRGs (FSWs, MSMs and IDUs). Core Indicators of the Project it can be well-gauged that the Plan accords top-primacy to what it calls a Prevention Package for High- Risk / Vulnerable Population, constituting principally of what are called
"Targeted Interventions" (TIs). TIs are euphemistic abbreviation for the strategy of:
"Non-interfering, non-judgmental" identification, mobilisation and association into organisations of "high-risk" persons to receive selected services termed "comprehensive" seeded and nurtured through NACP-I, II & III.
NACP-IV is to cover around 24 lakh HIV positive cases with a national prevalence of 31 per cent. A majority of the patients (83 per cent) are in the productive age of 15-49 years while children under 15 years account for 3.5 per cent of all infections, according to the latest statistics available with National AIDS Control Organisation. Even though the legal framework is still absent, the Centre plans to expand the scope of stigma-reduction interventions in the fourth edition of National AIDS Control Programme (NACP-IV), which will be launched in 2012, aim of NACP-IV is to strengthen the following components:
Community Involvement and Ownership
• Representation of community in all policy making bodies at NACO, SACS and DAPCUs.
• Processes such as M & E system and indicators, advocacy, capacity building should be reviewed/ designed, through active engagement of community groups and organizations.
• Networking and network building at the state and national level should be supported for effective participation of sex worker community, Inclusion of clients and regular partners of sex workers in the sex workers TI.
• Focus on clients, regular partners, lovers, babus, including local power structures (such as pimps, goons, local police) integral to TI e.g. Regular partners’ and lovers’ capacity building, involvement as peer educators for the male clients, services for STI, ICTC for these groups.
• Customers care centre model - Guided by experience, literature review, operations research, and evidence from different setting.
• Peer Model to continue and be flexible to suit local context e.g. geographical dispersion and population density of the FSWs, density and other operational issues.
•• Parity of honorarium
Parity of honorarium of the PEs with Anganwadi workers and other frontline health care functionaries.
• Design should allow peers to work in the community in such a way that they get maximum time for quality interaction rather than data collection
• Strategies for reaching young new and hard to reach need a special attention in NACP IV. STI management and condom promotion.
• STI management:
• Program linked clinic should continue at the TI
• Mixed clinic approach should be considered
• Other Clinical services should also include treatment of general illnesses
• Provision of services for partners of FSWs should be part of the approach so that re-infection of the FSW can be prevented
•• Periodic studies to generate evidence on STI pattern, geographical variation, time trends including changing disease patterns etc need to be undertaken. This calls for STI protocols that address the different needs in different settings.
• Places where qualified doctors are not available, trained nurses could provide STI services.
• Community counsellors should be the standard approach across all TIs.
• Free condom supply should continue, supplemented by social marketing where desired
• Lubricants should be made available for female sex workers also, as there are studies to show that 20% of commercial sex involves anal sex.
• Supply chains should be strengthened for condoms, STI drugs and for STI drugs, NGOs should be allowed to purchase these drugs temporarily during stock outs.
Creating Conducive environment
• Creating an conducive environment needs further strengthening at national, state, district and TI levels and role and strategies for NACO, SACSs, DAPCUs NGOs should be defined and implemented.
• Develop Linkage with all partners and networks involved in the rights of FSWs including legal networks, activists, anti-trafficking systems and groups.
• To strengthen community led advocacy work, NACO should support national, state level networks.
• Legal service provision at TI level should be strengthened with increased budget.
• Anti-trafficking activities should be included in the purview of the TIs.
• Self-regulatory board should be an integral part of FSW TI and it should coordinate with all the committees existing at the district level for the protection of rights of the victims of human trafficking.
• Health insurance for community members should be explored and
strategies to be developed for social and economic security of HIV positive FSWs.
• Community to community learning should be the cornerstone of the NACP IV.
• This should follow the principle of decentralized capacity building particularly in the case of PE
• Over the period the TSU role has become monitoring.
This needs to be revisited so that the TSU can either be a monitoring unit or a technical unit for capacity development.
• The terms of reference of TSU and STRC should be looked into and the necessity for two structures has to be reviewed from the point of cost, function and usefulness. State specific solutions to be found.
• A committee constituted for this purpose can table a report in the run-up to NACP IV after consulting the stakeholders and end users.
• Role of STRC should be redesigned through incorporation of community advisory board, who will be entrusted to support needs assessment, designing implementation etc.
• The community resource pool concept is reinforced so that the group working on CB will amplify the sameM & E and Budget.
• Community sensitive monitoring system has to be put in place which should not hinder the utilization of services.
• The approach of M & E should be to find the effectiveness of the programme and to assess as to how much it is of useful to the implementers on the ground level.
• The indicators should be fewer and sensitive and the process of monitoring should not take away precious time for program implementation.
• Qualitative indicators should be introduced in programme monitoring.
• Formats need to be simplified and should be relevant.
• Privacy and confidentiality of the HRGs should be protected and redressal mechanism for the breach of confidentiality should be in-built in the programme
• Maximum care should be taken to protect their rights, while improving the coverage of health services.
• Framing of guidelines for the researchers and other workers.
• Code of conduct of all staff should be developed and adhered to.
Needs In-depth Discussion on following HRGs and Services:
• Young and Hard to reach sex workers
• Bar Girls and other typology
• Female IDU who are in sex work
• De-criminalization of sex workers
• Overall flexibility of TI
• Salaries of Health Care Providers
• Mixed clinic model
After evaluating the TI Projects under the above service delivery mechanism I found that all the projects took off well and the baseline surveys conducted by the respective teams contain valuable information. The evaluation of the project indicates that the project has properly organised various activities. They have adequate infrastructure including the staff. They executed the project with financial transparency and have decentralized the supervision mechanism. The NGOs looked after their assignment independently. I found that:
The gender sensibility with reference to HIV/AIDS however requires special attention.
The mainstreaming activity with Municipal Corporation, Panchyat, Faith Building Organizations, Education Department, Police and Judiciary was found to be good. But some improvement could have strengthened the advisory and advocacy level for long term benefit of the project.
The activities undertaken in the period under report sensitize the core group and help them to visit STD Clinic and ICTC. However, the strongest part was Peer Educators and Client Outreach workers addressing CSWs , MSMs and IDUs.
STI Management and Condom Promotion were found satisfactory. Condom use by FSWs and MSMs and IDUs found to be consistent but regular follow-ups are required to establish CBOs as per NACP-IV. Female Condoms are still not accepted by the people in these areas,
Regular IEC activities are required and developed on the need based local IEC material. Visibilities of IEC in the offices are satisfactory but wall writings, displays need more attention.
They have HR policy for regular employees but no such policy for contractual project staff.
Few organizations are able to work for Rehabilitation of PLHIV and Sustainability of the Project but needs technical support guidelines from State.
During the evaluation, it is felt that the projects are implemented in isolation. They should also reach the mainstream social set up.
As we are aware the Parliament Standing Committee examining amendments to the Immoral Traffic Prevention Act (ITPA) had categorically asked NACO to ensure the above in future plans, stating that there was need for NACO "to broad-base its current approach to include important aspects such as rescue, skill-building, rehabilitation and reintegration of vulnerable populations". It called on NACO to "revisit the strategy and evolve suitable methodologies", including an "inbuilt component" for work with Women and Child Development Ministry (WCD). Recent national study supported by the GOI/WCD highlights a disproportionately high rise in prostitution in the last 10 years, while, the WCD is on record protesting the NACO programmes at cross-purposes with its anti- trafficking work. Recent Supreme Court and Ministry of Home view on HIV/AIDS motivates to think again for modus of operandi for mainstreaming. Therefore we can build our capacity accordingly.
Many of the HRGs face legal and structural impediments to adopting safe behaviours such as criminalization and violence. Unless these constraints are removed at grassroot at, State and national level it will be difficult to adopt and sustain safe behaviours. Strategies to change attitudes and behaviors and support to HRGs facing legal and structural constraints have to be detailed out.
Members of the community and civil rights activists can contribute a lot to the process.
"Cost Effective" Strategies is badly needed - Fortunately, at this juncture we have the gift of hindsight. The Thai-experience reveals "pragmatic" "cost-effective" "rapid-blanket-saturation-TI- methodologies" are at very best a temporary reprieve carrying expensive end-tags, most particularly for future generations. As with environment-issues, tampered inner-environments—of which sexuality is an intrinsic core-element—carry individual/social costs, most severe to the poor, gender and inter-generational interests.
In NACP-IV, I propose to conduct a study to assess the various kinds of stigma that persist with regard to People Living With HIV. This includes finding out more about self stigma, rural and urban stigma--all of these can differ from each other.
The project requires to strengthen the following areas for the effective implementation of the programme:
1. Mainstreaming of Targeted Group for Holistic and Sustainable Development (Community Development Approach)
2. IEC Activities according to needs of the community in local language
3. Consistent and effective Condom promotion and development of new reachable outlets for condom promotion/ intervention
4. Regular Support and Monitoring of all the components
5. Regular orientation and capacity building of the staff with special reference to ITPA.
6. Legal literacy to HRGs and implementers
7. Developing SHGs of Vulnerable Sections for Sustainable development for mainstreaming.
8. Development of IEC material of different State / Centre Schemes concerning PLHA and Target Groups.
9. Advocacy of Publication and Action Research
10. Networking with different concerned institutions
11. Sharing of Experience, gained knowledge at all levels is required
12. Regular meeting and orientation of Programme Partners
13. Consolidation and removal of isolation in preview of Holistic development through Social Work.
14. Linkages and capacity building of PLHAs require great attention
It is assessed that Stigma and discrimination still remain a part of life for numerous HIV/AIDS patients even after more than 25 years of detecting the human immunodeficiency virus in India. The information flow and advocacy from the government and voluntary outfits had a limited impact.
Fear component that’s because stigma comes from three domains – fear, shame and judgment. Knowledge reduces the fear component, but pushes the other two factors – shame and judgment – up. In the beginning, people feared HIV/AIDS because of myths associated with the disease like transmission of the virus through mosquito bites. Flow of information in the last two decades bridged the information gap, no doubt, but it also brought new aspects to stigma like moral judgment and shame.
While never attending school and misconception about HIV transmission had more than doubled the odds of having “fear related to HIV transmission through casual contact, right knowledge about transmission did not act as a protective factor against judgmental thoughts – it is the other way around.
Intervention planned Even though the legal framework is still absent, the Centre plans to expand the scope of stigma-reduction interventions in the fourth edition of National AIDS Control Programme (NACP-IV), which will be launched in 2012.
My experiments while working in the field of Developmental sector in the community show that creating a space for communication, which would encourage people to ask questions, discuss, think and change for a supportive environment in small groups such as youth club members or political party office bearers, is critical. Properly-designed intervention programmes keeping all the three aspects of stigma in mind can help mainstream PLHIVs.
Report is submitted for information, consideration and taking necessary steps enumerated in the report.
Dr. Avnish Jolly