Large-scale delivery of targeted HIV prevention for high risk, vulnerable populations: Lessons from the Avahan India AIDS Initiative

Issue: HIV concentrates in Asia among some of the most marginalized populations—sex workers (SW), men who have sex with men (MSM), and injection drug users (IDU). Community-based targeted intervention is a core best practice in HIV prevention for these hard-to-reach groups, yet there is little understanding of how to sustain large-scale delivery of this practice across diverse cultural, political, and geographic areas. Description: We focus on lessons learned from the Gates Foundation's Avahan India AIDS Initiative, a community-oriented HIV prevention program for high risk SW, MSM, IDU, and bridge populations that operates at scale across India's six highest prevalence states. Lessons Learned: The following are core components of a reinforcing activity system to enable local, community-appropriate variability while operating at scale: 1) investment in target communities' self-identified needs beyond HIV, generating demand for services and enabling care seeking behavior; 2) a structure of accountability partnered with experienced management staff who enforce program standards; 3) data management systems enabling illiterate community member participation and frequent evidence-based course correction at every level of planning; 4) donor relationships encouraging grantee innovation to achieve improved results. Recommendations: Large-scale, high-quality interventions ensure that known solutions reach populations most in need. Philanthropic and policy sectors can support this by formalizing structures to 1) encourage collaboration with existing large-scale systems and 2) provide incentive to attempt scale.