Our Work in India

While India’s HIV prevalence is relatively low at 0.7 percent, the nation’s size places India only second to South Africa in number of AIDS cases, now at 5.1 million infected people. To date, the epidemic has been restricted to high-risk groups, but there is increasing concern that it is spreading to the general population.

Dehydration due to diarrhea kills almost 600,000 children under age five in India every year; most of those deaths could be prevented with the correct use of oral rehydration salts (ORS). WHO and UNICEF now recommend the use of low osmolarity ORS to prevent and treat dehydration as well as the administration of zinc supplements to reduce the recurrence of diarrhea in children.

The public sector has neither the capacity nor funding to meet all these needs. The Abt Associates led-PSP-One project works to expand private sector markets for commercial and subsidized child and reproductive health products and services in urban areas of the least developed states in North India.

Activities include:

• Implementing an injectable contraceptive program through a network of DIMPA clinics to increase access and use in the private sector.
• The United States and India have agreed to establish an innovative HIV/AIDS corporate initiative - the Indo-U.S. Corporate Fund for HIV/AIDS. This fund aims to catalyze private sector engagement and mobilize resources to expand and strengthen India's response to HIV/AIDS.Read more about the Corporate Fund.
• Developing and implementing the Bindas Bol campaign for condoms. The campaign targets the general population in an effort to normalize and encourage condom use for both contraception and the prevention of sexually transmitted infections, including HIV.
• Building on the WHO-ORS marketing campaign launched under the Commercial Market Strategies Project to increase knowledge and use of WHO- approved oral rehydration salts to treat dehydration in infants and children suffering from diarrheal diseases.

Access to High-Quality Affordable Injectable Contraceptives through the DIMPA Network

PSP-One is expanding significantly on the Commercial Market Strategies pilot initiative to introduce injectable contraceptives through a network of DIMPA clinics in Uttar Pradesh, where use of injectables is almost nonexistent. PSP-One continues activities in three pilot cities in Uttar Pradesh (Varanasi, Agra, and Kanpur), focusing on compliance and retention in the three cities and expanding program coverage to six additional cities across Uttar Pradesh.

Specifically PSP-One is working to:

• Deliver evidence-based training to obstetricians/gynecologists and general practitioners to ensure correct use of the method by medical providers and potential users
• Develop a network of trained DIMPA clinics that make injectables available at lower than market prices and that train providers in appropriate screening and counseling as well as in client follow-up plans
• Monitor quality of screening, counseling, and follow-up at all clinics providing DIMPA
• Encourage potential users to seek more information about DIMPA from DIMPA clinics in their city
• Encourage commercial partners to make their products available at reasonable prices
• Advocate at the regional and national levels to improve the acceptance of injectables among the medical community, media, and general public as a high-quality contraceptive method

Results

• The KAP baseline to Midline study shows an increase in number of Providers recommending DMPA as a method form 1% to 20%.
• Mystery client monitoring tracking quality of care at the network clinics shows sustained quality at 80-90 percentiles across all cities.
• Over 1000 providers trained in nine cities
• 308 clinics are now part of the DIMPA network across nine cities.
• The recent Reproductive Health Indicator Survey in UP shows that use of Injectables is at 0.4% in urban areas. This is the first time that injectable use has shown up on any major family health survey in the state.

Operation Lighthouse is a follow-on project to the AIDSMark Project, and specifically targets core at-risk groups, including sex workers and their clients in and around major ports, which also includes truck drivers through 4 mobile and 9 stationary VCT centers.

• Reduce STI/HIV prevalence in 12 intervention sites in India
• Reduce HIV risk through promotion of safer sexual behavior among high-risk groups
• Increase the utilization of VCT, STI, and Helpline services among high-risk groups
• Increase the availability of condoms through non-traditional outlets
• Improve the environment for sustainable programs

Operation Lighthouse uses a behavior change approach, coupled with a monitoring and evaluation component, to implement its program. The behavior change approach centers on educating, raising risk perception, and promoting services, while monitoring and evaluation focuses on behavioral tracking of indicators, counting of sales and services, and where to implement mass media. Operation Lighthouse also provides training and service promotion activities.

Operation Lighthouse has reached 490,000 individuals practicing high-risk behavior over the last quarter. Two media campaigns promoting the Saadhan Voluntary Counseling and Treatment Services (VCT) clinics and the Saadhan helpline are in the cities of Mumbai, Vashi, Chennai, and Vizag. The Helpline is also implemented in Kolkata. The Saadhan VCT clinic campaign strives to provide a confidential personalized risk-reduction plan for clients. The helpline is promoted as a one-stop shop, which provides information, counseling, and referrals on issues related to HIV/AIDS. Additionally, Operation Lighthouse has continued a STI franchise program in Mumbai and Thane and a condom social marketing program.

A Behavior Change Impact Survey in targeted areas found a significant barrier in condom usage due to the perceived inability to put on condoms in the dark. In Vashi, fun month-long events to build skills on using condoms in the dark were promoted. Event participants were blindfolded in branded tents and performed condom demonstrations on a wooden penis. Participants who correctly demonstrated how to put on a condom were given tokens of appreciation. The month long event culminated in a large event, the Saadhan Mela.

Nukkad Natak (Street Theatre) Evaluation

Under the USAID-funded PACT-CRH (Program for the Advancement of Commercial Technology/Child and Reproductive Health) project, the Private Sector Partnerships-One (PSP-One) project carried out interventions to raise awareness of the World Health Organization's oral rehydration solution (WHO-ORS) and its role in home diarrhea management. The interventions were conducted in the urban areas of Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Rajasthan, Uttar Pradesh, Uttarakhand and Delhi.

Building on the WHO-ORS program, the scope of interventions was expanded to include the Complete Home Diarrhea Management (CHDM) program. The key idea behind the CHDM program (2006-07) program is to educate consumers about the severity of diarrhea. It focuses on highlighting the effect of repeated diarrheal episodes, which lead to malnutrition that can have long-term effects on children's overall growth and development. The program focused on the more vulnerable socioeconomic classes D and E (the two lowest quintiles) residing in urban slums across the eight key program states.

The program campaign used a broad mix of communication channels, including community outreach programs like Nukkad Natak (street theatre). This medium is interactive and allows for communication between consumers and those delivering messages. Such activities foster learning and understanding with the aim of adopting positive behaviors. Furthermore, theater-based communication reaches the populations media cannot, crosses the barrier of illiteracy, addresses local factors and myths, and involves all stakeholders.

Since August 2006, the Nukkad Natak has been performed in 27 towns in India. In each town, approximately 20 clusters were identified in which to hold the street theatre activity. To date, there have been approximately 540 Nukkad Natak performances. Each show lasted about 30 minutes.

The points which were communicated through the Nukkad Natak are:

Curative

• Prevent dehydration through early and increased administration of ORS or suitable fluids available at home
• Continue breastfeeding during diarrhea and provide additional food during and after the diarrhea episode
• Recognize critical signs of diarrhea and take the child to a doctor

• Exclusive breastfeeding up to six months
• Wash hands with soap (after defecation, after washing babies’ bottom, before eating/feeding, before preparing/handling food)

An evaluation of the Nukkad Natak initiative was conducted in the states of Uttarakhand, Uttar Pradesh, Jharkhand, Bihar and Rajasthan during January 2007 to understand its impact.

The key objective of the study was to assess if the Nukkad Natak initiative was effective in terms of:

• Reaching a significant proportion of the slum clusters
• Communicating the five key messages to the target group
• Changing knowledge and behavior pertaining to home diarrhea management

The study adopted cross-sectional survey of intervention groups and control groups with ex-post comparison of Nukkad Natak viewers against non-viewers.

The study target group was care-givers of children under five years residing in SEC D and E in urban slums of the Uttarakhand, Uttar Pradesh, Jharkhand, Bihar and Rajasthan. In all, 1,620 care givers were contacted in the intervention slum and 540 care givers were contacted in the control slums.

Almost 34 percent of the target audience (caregivers in the target slum cluster) was reached by the Nukkad Natak.

Across almost all indicators, there were significantly higher knowledge levels about correct steps for diarrhea management among those who had been exposed to the Nukkad Natak, compared to those who had not been exposed.

Amongst caregivers who reported that their child under five years of age had had diarrhea in the past three months, significantly higher proportion of those who were exposed to the Nukkad Natak reported correct diarrhea management practices, especially in terms of administration of ORS and feeding practices during diarrhea, compared to those who were not exposed to the Nukkad Natak campaign.