SUMMARY

Youth interventions are one of the key focus areas of the third National AIDS Control Program (NACP-3)

plan for India. Continuing into the third year of the program, Myrada will continue to target youth, both in

colleges and in the community. The program will focus on abstinence, while certain high risk youth will be

addressed separately through other program areas. The program also works with young couples and adults

in rural communities to focus on the importance of being faithful. Key target groups for these activities are

adolescents and young adults.

BACKGROUND:

Myrada, a 40-year-old field-based non governmental organization (NGO) based in Bangalore, Karnataka,

India, has been directly working in the areas of empowering poor and vulnerable women, natural resource

management, reproductive child health (RCH) and HIV/AIDS in the state of Karnataka, and neighboring

border areas of Tamil Nadu and Andhra Pradesh. All Myrada's work is built on the underlying principles of

sustainability and cost effectiveness through building local people's institutions and capacities, and fostering

effective linkages and networking. These principles have also been incorporated into the Myrada CDC

program.

In the first year of this program (FY 2006), Myrada decided to work in two districts of Northern Karnataka -

Belgaum and Gulbarga. Several reasons led to these decisions including the fact that these were districts

with high HIV prevalence (over 3% in general population); were socio-economically backward districts and

located adjacent to 2 other HIV high prevalence states, Maharashtra and Andhra Pradesh. The initial

strategy was to develop community based models for sustainable HIV prevention activities.

India's epidemic is not generalized. With a prevalence of 0.36% (NFHS and NACO 2007 reports), most of

the focus is on prevention. While all youth may not be sexually active, there is an urgent need to address

their understanding of vulnerabilities to risky behavior situations, more so in the case of young women. In

the UNDP-supported CHARCA project with young women implemented in Bellary, Myrada learnt that

several factors such as early marriage, pre marital sexual abuse, lack of assertiveness skills, local sexual

cultural practices and a very low knowledge of the basics of HIV/AIDS transmission dynamics were

important issues related to increasing young women's risk to HIV/ AIDS. Young men also needed to

understand these vulnerabilities in order to develop positive attitudes towards women as well as reduce

their own risks. Myrada decided to work with youth in college settings as a starting point, as it was easy to

access the youth on a repeated basis to reinforce prevention and life skills messages. In the second year,

the program also targeted youth not in school through community based programs.

ACTIVITIES AND EXPECTED RESULTS

Through CDC's program with Tamil Nadu State AIDS Control Society (TNSACS), Myrada became familiar

with the Red Ribbon Clubs (RRCs) in colleges, and initiated the same concept in 4 taluks of Belgaum and

Gulbarga districts. This field program is currently implemented by two subpartners. There are around 160

RRCs functioning, which are seen as local level institutions that can respond to the needs of peers within

and outside the college setting. Each RRC consists of a group of student members who have joined the

club on a voluntary basis. They select a core group to manage the regular functions of the club, two of

whom are elected as RRC peer leaders. Some of the activities include regular monthly meetings, interactive

competitions (painting, quiz, debates, essays) on the themes of youth, vulnerabilities to HIV and care and

support; support to Orphans and Vulnerable Children and PLHAs, involvement in public functions,

contributing articles to the local press, and conducting awareness programs in local adopted communities.

Together with TNSACS and a resource organization called Insa India, Myrada has developed a 2 part

curriculum for youth. The first part is a 3-hour curriculum addressing large groups of youth aimed at

stimulating their interest in understanding key issues related to adolescence, HIV and related vulnerabilities.

The second part is a 10 hour-curriculum that could either be administered as 10 one-hour capsules, or

covered in a 2 day workshop. This is available to all interested youth and all RRC members. Special faculty

have been identified and trained to handle these sessions. In addition, several issues raised through the

suggestion boxes in all colleges are discussed every month in the RRC.

Myrada will continue this activity in Belgaum and Gulbarga and expand to another 140 colleges in other

districts. Based on the experience of the first 2 years, special attention will be given to the high risk youth in

colleges through one to one and group discussions. This activity has to be addressed tactfully in a state that

has banned sex education in schools and colleges.

ACTIVITY 1: Formation and Strengthening of New Red Ribbon Clubs.

Around 160 red ribbon clubs have already been formed in the Belgaum and Gulbarga field areas. This year,

the whole district will be approached and an additional 40 clubs will be formed. One hundred new clubs will

also be formed in the expanded areas of Chitradurga, Chamrajnagar and Kolar districts, taking the overall

total to 300. All clubs will select 2 peer leaders who will get special training on peer education for HIV

prevention.

ACTIVITY 2: Life Skills Training for Youth in Colleges and Out-of-School Youth

Using the curriculum already developed for youth, all sub grantees and field teams will organize and liaise

with the Red Ribbon Clubs to conduct regular life skills training using both the 3 hour primer and the 10 hour

curriculum.. A total of 25,000 youth will be covered in the project year through this curriculum. The field

teams in all rural working areas will also continue to conduct regular programs at the village level for out-of-

school youth using the same life skills training material, reaching around 15,000 out-of-school youth. The

issues of gender-based violence, cultural sexual practices, early marriage and pre marital sex will also be

addressed. All young persons getting ready to be married will be encouraged to be voluntarily tested for

HIV.

ACTIVITY 3: Training of Selected Youth Leaders

Activity Narrative: The selected RRC peer leaders will be trained on peer counseling, basic care and support issues, advocacy

for youth, reducing stigma and discrimination, and community mobilization. They will also be trained to

identify youth with high risk behaviors and those youth experiencing sexual abuse, and link them to

counseling and the other program area dealing with condoms and other prevention. Around 500 peer youth

will be trained.

ACTIVITY 4: Mainstreaming Youth-Based Prevention Programs

With a view to sustainability, the program team will work with the Department of Education and universities

to mainstream the youth curriculum to all colleges. There will be deliberations with the National Social

Services (NSS) wing of the Ministry of Youth Affairs to leverage financial and administrative support for

mainstreaming this activity. In the corresponding USAID- supported project being implemented by

Karnataka Health Prevention Trust (KHPT), Myrada will collaborate with KHPT to incorporate the Life Skills

Curriculum into their project areas.

ACTIVITY 5: Providing Technical Support to KSACS

Myrada is a highly respected organization in Karnataka and often uses our experiences, technical skills, and

reputation to build the capacity of others in the state. Myrada staff will expand its technical support to the

Karnataka State AIDS Control Society (KSACS) in the areas of HIV prevention, gender issues, rural

outreach, community mobilization, and communication. A full time consultant placed in KSACS under the

guidance of both the KSACS project director and Myrada will be hired in FY08 to provide KSACS with much

needed manpower and expertise. Myrada staff will continue to be active members of a State Advisory

Panel for HIV communication strategies.

SUMMARY

Many HIV/AIDS programs have focused on at-risk populations in urban areas, although women and men in

rural areas are also at risk. Specific groups targeted in this program include adult rural women in Self Help

Groups (some of who may be hidden sex workers), adult men (focus on migrants, unorganized work force),

"devadasi" women and known sex workers. While the level of risk varies in Karnataka, specific factors such

as migration, the devadasi system and hidden sex work in the rural areas are related to risk. The need for

messages on safer sex practices including correct and consistent condom use, reduction of multiple

partners, mutual monogamy is required in addition to "Be faithful" messages for these groups. Issues

related to sexuality and gender violence, need for counseling and testing, early detection and treatment of

STIs and consistent and correct condom use are also addressed in this area. This activity area is well in

line with and a key strategy of the third National AIDS Control Program (NACP-3). It also complements the

prevention programs of the Bill and Melinda Gates Foundation, which are limited to urban locations.

BACKGROUND

Myrada, a 40-year-old field-based non governmental organization (NGO) based in Bangalore, Karnataka,

India, has been directly working in the areas of empowering poor and vulnerable women, natural resource

management, reproductive child health (RCH) and HIV/AIDS in the state of Karnataka, and neighboring

border areas of Tamil Nadu and Andhra Pradesh. All Myrada's work is built on the underlying principles of

sustainability and cost effectiveness through building local people's institutions and capacities, and fostering

effective linkages and networking. These principles have been incorporated into the Myrada CDC program.

In the first year of this program (FY06), Myrada decided to work in two districts of Northern Karnataka:

Belgaum and Gulbarga. Several reasons led to this decision including the fact that these were districts with

high HIV prevalence (over 3% in general population); were socio-economically backward districts and

located adjacent to 2 other HIV high prevalence states, Maharashtra and Andhra Pradesh. The initial

strategy was to develop community based models for sustainable HIV prevention activities.

Based on experience in HIV prevention, Myrada realized that the strategy used in urban areas of designing

targeted interventions with commercial sex workers to reduce HIV transmission would be counterproductive

in rural areas. In the first place, most sex workers resident in the rural area only practiced sex work in the

nearby towns (an exception may be the devadasi community) and were not known in the village as sex

workers. (Devadasi is a system in which an unwanted young girl is "dedicated" to the Goddess Yellamma

by handing her over to an older adult male; while he provides for her, she is also "available" to other men

invited by him, her parents and the temple authorities. He may also pass her off to another person when he

no longer has any use of her. She sometimes ends up becoming a female sex worker (FSW). This practice

is particular to Belgaum, Bagalkot and a few northern Karnataka districts, and is now illegal). Identifying the

two-three "known" resident sex workers and targeting them in the rural areas would not only be cost-

intensive, but could lead to discrimination against her by the general community. Secondly, many rural

women suffer from sexually transmitted infections (STI) and the second largest group of HIV-positive

persons in India are monogamous rural housewives. The program therefore targets all sexually active

women and men to learn the dynamics of HIV transmission, and the importance of safer sex practices.

Myrada has focused on large well-organized populations of adults in high prevalence communities,

including women in self help groups and men in the local workplace. By FY07, around 85,000 persons had

been reached in the high-risk areas of Belgaum and Gulbarga. Myrada also increased outreach to men

outside the organized sector, and to local governance members (gram panchayats) through group

discussions and trainings.

Results from the initial programs show success in building local institutions. Women who have been trained

are now openly talking about issues related to sexuality and HIV within their neighborhood, actively seeking

counseling and testing, and demanding that condom outlets be placed in their villages. The training

modules for women include topics related to gender violence, sexual abuse, infidelity, alcoholism. The men,

both in workplace settings and in the community groups are very keen to learn more about HIV and where

to access treatment for STIs, and wanted condoms to be accessible close to their homes and workplaces.

The workplace managements were very supportive and in some cases sponsored STI health and

counseling and testing camps within their premises.

As a follow-up mechanism to this outreach program, Myrada identified the concept of the Village Health

Committees. This group of representative members from women's groups, gram panchayat, and the local

health department are selected by the general community to take up certain responsibilities in the village

including: organizing regular awareness programs, setting up and maintaining condom outlets, addressing

HIV facilitating co-factors such as alcohol abuse, and providing support and linkages to Most At Risk

Populations and PLHAs. Currently 140 village health committees have been formed.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Training Women in Self-Help Groups (SHG)

In India, the self help group movement has been a great boon to women's empowerment. Started for

purposes of savings and credit management, the groups have become excellent forums to address women

on issues that impact their lives directly. With FY08 funds, all self help groups in the new areas will undergo

a three-module training in HIV/AIDS outreach using an interactive story through flip charts. Once trained,

these women will spread the message to their family and close friends. Around 100,000 women in the new

districts of Chitradurga and Chamrajnagar will go through this Phase 1 training in FY08.

ACTIVITY 2: Formation and Strengthening of Sub Health Committees (Phase 2)

This follow-up activity will take place in the areas where Phase 1 has been completed (Belgaum and

Gulbarga). Two hundred gram panchayat areas will be covered. Each Sub Health Committee will undergo

a standard training and have regular monthly meetings. The activity will be linked with the activity with the

Rural Development and Panchayat Raj ministry to influence policy decisions for the formation of these sub

committees (see the Policy and Systems Strengthening narrative)

ACTIVITY 3: Reaching Men in the Organized and Unorganized Sectors

Existing HIV/AIDS prevention programs in the workplace will continue. Myrada will focus on getting

managements to develop a workplace policy, thereby integrating HIV/AIDS prevention and care into their

Activity Narrative: personnel policies. The workplace programs, together with supportive programs such as STI health camps,

VCT camps and condom promotion, will reach around 20,000 adult men.

Men in the unorganized sector, who are perceived to be most at risk, are difficult to reach on a regular basis

outside their villages. Many migrate to other areas in search of work. Myrada will use an "origin and

destination" approach to reach this vulnerable population. To reach these adult men in their villages,

Myrada will support a series of ongoing group discussions covering topics such as basic facts on HIV and

STIs, risk perception, and prevention and testing services. 400 villages will be reached in FY08. In addition,

regular field-based training programs will be conducted to train outreach workers from Myrada's sub-

partners and staff from selected NGOs working in neighboring Goa (a large number of MARPs migrate from

northern Karnataka into Goa) in strategic community mobilization and outreach planning for vulnerable

populations, FSW, and men who have sex with men.

ACTIVITY 6: Technical Support to Karnataka State AIDS Prevention Society (KSAPS)

Myrada is a highly respected organization in Karnataka and often uses its experiences, technical skills, and

reputation to build the capacity of others in the state. Myrada staff will expand its technical support to

KSAPS in the areas of HIV prevention, gender issues, rural outreach, community mobilization, and

communication. A full-time consultant placed in KSAPS under the guidance of both the KSAPS project

director and Myrada will be hired in FY08 to provide KSAPS with much needed manpower and expertise in

these areas. Myrada staff will continue to be active members of a state advisory panel for HIV

communication strategies.

SUMMARY

This program area will continue to address palliative care from a community perspective: that is, what the

community can provide and access, and how to link with existing services for long term sustainability. The

focus will be on training, providing nutrition support and encouraging the community leaders to respond

proactively to care and support of their positive community members. All identified PLHAs the targeted

areas of Belgaum and Gulbarga districts will be followed up. This includes community-level follow-up for 18

months after delivery of mother-baby pairs to support the PMTCT services provided by the Government of

India (GOI).

BACKGROUND

Myrada, a 40 year old field based non governmental organization (NGO) based in Bangalore, India, has

been directly working in the focus areas of empowering poor and vulnerable women, natural resource

management, reproductive child health (RCH) and HIV/AIDS in the state of Karnataka, and neighboring

border areas of Tamil Nadu and Andhra Pradesh. All Myrada's work is built on the underlying principles of

sustainability and cost effectiveness through building local people's institutions and capacities, and fostering

effective linkages and networking. These principles have also been incorporated into the Myrada CDC

program.

In the first year of this program (FY06), Myrada decided to work in two districts of Northern Karnataka:

Belgaum and Gulbarga. Several reasons led to this decision including the fact that these were districts with

high HIV prevalence (over 3% in general population); were socio-economically backward districts and

located adjacent to 2 other HIV high prevalence states, Maharashtra and Andhra Pradesh. The initial

strategy was to develop community based models for sustainable HIV prevention activities.

ACTIVITIES AND EXPECTED RESULTS

Palliative care involves all aspects of care and support of People Living with HIV/AIDS (PLHA) outside of

ART or TB medication. Several facets of palliative care have however been neglected due to a combination

of factors. While health care providers tend to equate care to medical treatment, PLHA have no clear idea of

the other components of care, and therefore cannot demand these services. In addition, most district PLHA

networks focus on advocacy issues and the importance of "positive speaking". Very few have been

convinced that they need to look after their own as much or even more than focusing on advocacy issues.

They have typically expected others to "provide" them the services.

Myrada initiated the palliative care program due to the felt needs of PLHA in Myrada's focus areas. While

some PLHA were affiliated to the district positive network, none of them were aware that there were

components of care besides ART. So far around 205 PLHA have been identified in the working areas of

Belgaum and Gulbarga. All of them are followed up on a monthly basis and receive regular counseling,

home based care, nutrition advice and referrals for medical check up and ART work up. Those who are on

ART are followed up in the field.

This year there will be a focus on ensuring that women get equal access to care and support services. The

local Self Help Groups will be encouraged to support their PLHA members through livelihood options, food

security, ensuring education of their children and the like. Village sub health committees (representative

members from women's groups, gram panchayat, and the local health department who are selected by the

general community to take up certain responsibilities in the village) will also propagate zero tolerance

messages towards discrimination and violence against infected women, handle property rights issues and

other HIV-related issues.

This program is being implemented in collaboration with the local district positive networks. This will

continue until Myrada is confident that these PLHA clients can be transferred to the USAID- supported

Samastha project.

ACTIVITY 1: Provision and Training in Basic Community-Based Palliative Care

This will be implemented through the district PLHA network by a team of PLHA community resource

persons (CRPs). These CRPs will identify and register all PLHA into the program. Regular palliative care

will include the following elements: regular medical check up, home based care, family counseling, nutrition

support, referral for opportunistic infection (OI) management, CD4 testing and ART work up, ART follow up,

and linkages to livelihoods and other social schemes. In the project year, it is expected that around 200

persons in Belgaum, Chitradurga and Kolar districts will be receiving palliative care. In the other two

districts, PLHA will be linked to the USAID-supported Samastha project care program. Around 100

persons, both male and female caregivers, will be trained in the basics of home-based care and nutritional

supplementation.

ACTIVITY 2: Follow-up and Care Post-Delivery

While the GOI PMTCT Centers will provide PMTCT services and drugs, Myrada will provide referrals and

will follow-up mother-baby pairs at the community level for 18 months after delivery. Community resource

persons trained by Myrada will conduct follow-up visits, focusing on infant feeding practices, the health of

the mother and baby, and referring the baby for HIV testing at 18 months. It is expected that at least 30% of

those pregnant women tested positive under Myrada's CT intervention will be followed up for the 18 month

period.

ACTIVITY 3: Sensitization of Community Leaders to Reduce Stigma and Discrimination

In all 400 villages, sensitization programs will be held with community leaders regarding stigma and

discrimination. This is an important component of palliative care. With the existing stigma, it is difficult for

PLHA to be "open" about their status. Unless they are willing to accept their status, they do not come

forward to access any other services. Community leaders can play an important role in influencing access

to services, community norms and the attitudes of health providers.

ACTIVITY 5: Translation and Adaptation of Follow-up Counseling Toolkit

This newly developed toolkit consisting of flip books and trigger videos has had a positive impact in getting

PLHAs to understand issues related to acceptance, need for regular care and support, stigma and

discrimination, and the importance of healthy positive living. The modules will be translated into Kannada

and used in care and support settings. Myrada will encourage KSAPS and other agencies to include these

modules as part of their care and support package of services.

Activity Narrative:

ACTIVITY 6: Capacity Building of PLHA District Network Staff

Special training programs will be held for the staff of the district positive networks on palliative care

programming, and how to plan and manage such a program in their network area. Included in the package

will be trainings on follow-up counseling using the USG-developed toolkit.

ACTIVITY 7: Building Linkages with Other Program Activities and Service Providers

The community based care program is implemented in the same areas where the prevention outreach and

outreach counseling and testing programs are being implemented. Active linkages are already present in

the field area in Belgaum and Gulbarga using the CRPs and the newly established village health

committees that focus on HIV/AIDS. These mechanisms will be used to identify clients and strengthen

linkages among clients and services. .

Both the palliative care program area and OVC area will be managed by the district PLHA network with

extensive support from the Myrada team. It is hope that this support will enable them to strengthen their

capacities to sustain the services to their members over time. All medical services will continue to be

provided through the government program.

SUMMARY

Published estimates of the number of HIV-infected children in India vary from 50,000 to 300,000 and there

may be 2-10 million children in India with an HIV-positive parent. The National AIDS Control Program has

only recently taken cognizance of children as People Living with HIV/AIDS (PLHAs) and, in collaboration

with international agencies such as the Clinton Foundation, infected children are now getting pediatric ART.

However, other aspects of care and support for OVC, such as nutrition, education and counseling have not

been systematically addressed by either the HIV-positive networks or the government. This intervention will

address comprehensive care and support for OVCs through a community-based approach. This is not a

stand-alone activity and is a natural follow up to the prevention outreach program.

BACKGROUND

Myrada, a 40 year old field based non governmental organization (NGO) based in Bangalore, India, has

been directly working in the focus areas of empowering poor and vulnerable women, natural resource

management, reproductive child health (RCH) and HIV/AIDS in the state of Karnataka, and neighboring

border areas of Tamil Nadu and Andhra Pradesh. In addition, Myrada provides regular technical assistance

to various government and non government projects in India, Central and South Asia, and Africa. All

Myrada's work is built on the underlying principles of sustainability and cost effectiveness through building

local people's institutions and capacities, and fostering effective linkages and networking. These principles

have also been incorporated into the Myrada CDC program.

In the first year of this program (FY 2006), Myrada decided to work in two districts of Northern Karnataka:

Belgaum and Gulbarga. Several reasons led to these decisions including the fact that these were districts

with high HIV prevalence (over 3% in general population); were socio-economically backward districts and

located adjacent to two other HIV high-prevalence states, Maharashtra and Andhra Pradesh. The initial

strategy was to develop community-based models for sustainable HIV prevention activities.

The past two years have taught us that focusing only on prevention in high prevalence districts is not

enough. In the course of the program, several OVCs were identified. Since there were no interventions in

place, Myrada initiated a community-based OVC program in Belgaum and Gulbarga, working with the

district-level positive networks as sub grantees. The six components of primary care mandated by WHO

and the Government of India (GOI) for OVC have been introduced, including testing for HIV, CD4 testing for

those found HIV positive, regular medical check ups, referrals for minor illnesses, nutrition support, support

for education and family counseling. In addition, the teams have been working with the village health

committees and other leaders to advocate for a reduction in stigma and discrimination towards these

children and their families. Special focus has been on ensuring that both boys and girls get equal access to

care and support. The children are identified through the community based palliative care program and the

voluntary counseling and testing program.

Now that USAID is working in Karnataka with care and support as a major focus area, Myrada will explore

the possibility of transferring the 970 identified OVCs to the USAID program. Until then, the program will

continue services for this group of children.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Basic Care and Support for Registered OVCs

All identified orphans/vulnerable children of PLHA families will be registered with the Myrada program, and

encouraged to undergo HIV testing to determine their individual status. All registered OVCs will receive the

WHO/GOI six components of care regularly. OBC are also tracked for all six OGAC categories of OVC

services, with Myrada directly providing four of the six OGAC components. It is expected that around 300

OVCs in the implementation area will receive the total package of community-based care and support. The

others will receive certain components and will be linked to the USAID-supported Samastha project by

FY08 for the total package.

ACTIVITY 2: Regular Referrals for CD4 Testing and OI Management

All registered children will be sent for CD4 screening to determine whether or not they require ART. Those

found eligible will be referred to the pediatric ART centre. A few doctors trained to provide OI care will be

identified to provide regular medical check ups and treatment of OIs for these children. All these children will

also be followed up to see that they receive routine immunizations and vitamin supplements.

ACTIVITY 3: Families Livelihood Options and Social Entitlements

Many families are already socio-economically vulnerable following the illness/death of an adult member. It is

important to address this issue to help families identify their needs so that the remaining family members

can cope with their debt issues and future expenses. Women in the families will be linked to existing self

help groups, while all efforts will be made to link family members to available social entitlement schemes of

the government.

ACTIVITY 4: Training Family Care Givers

At least one adult family member will be specifically trained on how to manage the child at home, and how

to make a balanced diet plan for their children. This will include how to provide home-based care and

nutritious foods, as well as to know when to refer for medical care.

SUMMARY

The purpose of this activity is to make counseling and testing (CT) easily accessible to the rural remote

communities. Started in June 2006, this activity will continue in Belgaum and Gulbarga districts and expand

to 3 other areas in Chamrajnagar, Chitradurga and Kolar districts. The activity sends outreach CT teams to

remote rural government primary health centers to conduct CT of at-risk community members, including

Most at Risk Populations (MARPs), Sexually Transmitted Infections (STI) patients, TB patients, and

pregnant women. In FY08 there will be a strong emphasis on motivating pregnant women to access CT,

links with PMTCT Centers and follow-up after delivery.

BACKGROUND

Myrada, a 40 year old field based non governmental organization (NGO) based in Bangalore, Karnataka,

India, has been directly working in the focus areas of empowering poor and vulnerable women, natural

resource management, reproductive child health (RCH) and HIV/AIDS in the state of Karnataka, and

neighboring border areas of Tamil Nadu and Andhra Pradesh. All Myrada's work is built on the underlying

principles of sustainability and cost effectiveness through building local people's institutions and capacities,

and fostering effective linkages and networking. These principles have been incorporated into the Myrada

CDC program.

In the first year of this program (FY06), Myrada decided to work in two districts of Northern Karnataka:

Belgaum and Gulbarga. Several reasons led to these decisions including the fact that these were districts

with high HIV prevalence (over 3% in general population); were socio-economically backward districts and

located adjacent to 2 other HIV high prevalence states, Maharashtra and Andhra Pradesh. The initial

strategy was to develop community-based models for sustainable HIV prevention activities.

When this program was initiated in June 2006, only 30% of around 75 Government of India (GOI)

Counseling and Testing Centers (CTCs) were functional. Therefore Myrada used two approaches: a static

clinic-based CTC and outreach CT through sub-grantee partners in two high HIV- prevalence districts of

northern Karnataka: Belgaum and Gulbarga. Demand for testing is generated during the outreach

prevention programs in the neighboring rural communities and workplace sites. The outreach CT team

consists of a counselor and lab technician who travel by local public transport to a remote government

primary health centre (PHC) on a fixed schedule twice a month. A HIV-positive person was included in the

team as a peer counselor. His/ her role is to assist in post-test follow-up counseling and offer peer-based

counseling options. From last year's experience, this model has strengthened the link to care and support

for those who were detected positive. The teams also respond to invitations to conduct programs at

workplaces and large villages where the local governance teams (gram panchayats) provide space and the

local communities organize the people.

The outreach CT teams have been well received in the PHCs. Over 9000 persons were tested and

received their test results in a span of 9 months. Out of the 9,000 tested, the positive rate has been around

3.9%. Each team has tested around 2,000 persons. The approach is cost effective since it is integrated into

the GOI's PHC system, and is replicable and sustainable. The average cost per team is around $4,500 per

year (excluding the costs of the first-line testing kits). Testing kits have been and will continue to be

leveraged from Karnataka State AIDS Prevention Society (KSAPS).

Another interesting feature is that the majority tested were rural women (68%). This is an encouraging

statistic for health-seeking behavior and gender equity and may be the result of the intensive sexual health

interventions for self-help group women conducted by Myrada in these communities.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Counseling and Testing through Mobile Teams

In FY08, since KSAPS has recently expanded their testing centers to over 500 across the state, Myrada will

end the static CT model. Using seven mobile teams, outreach CT will continue in Belgaum, Gulbarga, and

expand to Chamrajnagar, Kolar and Chitradurga districts. Counseling and testing will follow NACO

guidelines. It is planned to reach 10,000 at-risk persons in remote government PHCs, workplace sites, and

community hot spots (the purpose of supporting testing at the PHCs is the goal of mainstreaming CT into

the regular functions of the PHC, for sustainability). Clients for the mobile CT will include adult men and

women from high risk villages, patients referred at the PHC, persons with TB, families of identified PLHAs,

and those referred by local health practitioners.

ACTIVITY 2: Community Outreach to Pregnant Women and Demand Creation for CT Services

Myrada will train community resources persons (CRPs) in the five target districts to expand their outreach to

pregnant women to motivate them to access CT services. Approaches will included one-to-one and groups

discussions in their communities. The CRPs will also work with Self-Help Groups and the Village Health

Committees (VHCs) to link the committees to the existing PMTCT centers and to strengthen VHC support

for CT testing for pregnant women and subsequent attendance at PMTCT if the woman is HIV positive.

VHC members and community level workers will be trained in the basics of PMTCT. It is expected that

through this activity and that the current average PMTCT uptake of around 4% in these areas will increase

to at least 50% if not more. By FY2008, the goal is that all pregnant women in 700 villages of 5 districts will

be motivated to undergo HIV testing and at least 50 % of those tested postive will be followed up till 18

months after delivery.

.

ACTIVITY 3: Linking Positive Persons to Care and Support

All those identified as positive by the CT team will receive follow-up counseling and be linked to care and

support services available in the district. These include basic opportunistic infection management, nutrition

support, counseling services and referral to ART centers for CD4 testing and HIV staging. In the Belgaum,

Chitradurga and Kolar areas, community based palliative care (details in the Palliative Care narrative) will

be provided through community resource persons (CRP), while in the other two districts, the teams will link

with the USAID-supported Integrated Positive Prevention and Care Centers (IPPCC) set up in these

districts.

ACTIVITY 4: Translation and Adaptation of Follow-up Counseling Toolkit

This newly developed toolkit consisting of flip books and trigger videos has had a positive impact in getting

Activity Narrative: people living with HIV/AIDS to understand issues related to acceptance, need for regular care and support,

stigma and discrimination, and the importance of healthy positive living. The modules will be translated into

Kannada and used by the program CT teams. Myrada will encourage KSAPS and other agencies to include

these modules as part of their counseling services

ACTIVITY 5: Training of Counselors and Technicians

By the end of FY08, all counselors and technicians will have undergone refresher training in CT skills, as

well as training in follow up counseling. Myrada, in collaboration with district health authorities, will also

train existing technicians and outreach staff in the PHCs visited by the outreach team in CT, so PHCs can

take on this function routinely.

ACTIVITY 6: Expanding the Outreach Testing Model

Under the National AIDS Control Program Phase 3 (NACP-3), mobile testing in high risk and remote

communities will be promoted and scaled up by State AIDS Control Societies with funding from NACO.

First, cost-efficient Indian models for mobile testing need to be piloted and documented. Myrada will

document the processes, cost effectiveness and experiences of the outreach testing module and share it

with other partners in the State, including KSAPS, as a basis for scaling up this approach. This model will

also be used in Gulbarga and Bellary districts under the USAID-supported Samastha project to which

Myrada is a sub partner.

SUMMARY

In order to improve access to HIV/AIDS prevention and care services, there is a critical need to strengthen

health systems at all levels, to introduce innovative field models that are cost effective and sustainable and

to influence policies to adopt successful models. Myrada will support the Karnataka State AIDS Prevention

Society (KSAPS) for systems strengthening, and will also strengthen the response of the local governance

to community needs for HIV prevention, care and support.

BACKGROUND

Myrada, a 40 year old field based non governmental organization (NGO) based in Bangalore, India, has

been working in the areas of empowerment for poor and vulnerable women, natural resource management,

reproductive child health (RCH) and HIV/AIDS mostly in the state of Karnataka. All Myrada's work is built on

the underlying principles of sustainability and cost effectiveness through building local people's institutions

and capacities, and fostering effective linkages and networking. These principles have been incorporated

into the Myrada CDC program, which has developed several models of effective interventions that can be

replicated and scaled up.

Myrada has developed an excellent working relationship with KSAPS. Myrada has supported various

KSAPS programs as well as implementing targeted intervention, and community mobilization programs with

KSAPS support and is a member of the KSAPS Technical Resource Group for Communications. At the

local level, Myrada has strengthened the capacity of local institutions to create long-term village structures

to facilitate follow up for behavior change communication programs and create strong linkages between

prevention, testing, and care. As a result, village health committees that work with gram panchayats (local

governance units) have been piloted in over 100 villages.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Technical Support to KSAPS

In collaboration with KSAPS and CDC, the program will focus on providing technical assistance to

strengthen the operations management and monitoring and evaluation systems of KSAPS. This will be

done at all three levels: state, district and field. Activities will include placing full-time consultants in KSAPS,

organizing capacity-building programs and developing operational guidelines. Myrada will continue to

support the IEC program component of KSAPS. At the field level, active support will be given to the local

Integrated Counseling and Testing Centers (ICTCs); at the district level Myrada will provide technical

support to the district support team and nodal office. This program will directly support at least two district

management teams in Chitradurga and Chamrajnagar districts, as models for the state to build upon.

ACTIVITY 2: Working with Rural Development and Panchayat Raj Institutions

At the village level, Myrada has worked to support the development of village health committees and

conducted trainings for gram panchayat (local sub-division organizations) members. These community

members and local leaders have agreed to support a subcommittee at the gram panchayat level dedicated

to address the health needs of their constituency including HIV/AIDS. This subcommittee would have

representation from the local health department and one or two representatives from each village. The

subcommittee will be merged with the village health committee to ensure that there are regular meetings

and that the subcommittee is accountable to the local administration. Also, linkages to social entitlements

and services will be enhanced through the direct involvement of the local administration responsible for

these areas.

Myrada will continue to engage Panchayat Raj institutions (which manage the decentralized governance

system of India) and develop their capacity to address major public health and social issues such as HIV.

Myrada will offer technical assistance in the formation and training of these institutions on HIV/AIDS. This

plan will be further discussed with Panchayat Raj institutions with regard to expanding it to all districts in the

State.

ACTIVITY 3: Supporting KSAPS in Mainstreaming

Through its active linkage with the department of Women and Child Development in the state, Myrada has

worked with KSAPS to develop a program to train representatives of the women's Self-Help Groups (SHG)

in Karnataka through a combination of a satellite-based and field-based interactive approach. Myrada will

continue to advocate for statewide expansion of mainstreaming HIV/AIDS education into SHGs, which

reach large numbers of rural women, and will provide technical assistance in how to accomplish this. Other

mainstreaming approaches will include efforts to expand the youth Red Ribbon Club (RRC) initiative (see

the AB narrative) through the Department of Higher Education and Ministry of Youth Affairs; and working

with the USAID-supported Connect project to support workplace interventions. This technical support will be

expanded to other geographical areas where Myrada works in order to encourage mainstreaming of HIV

prevention issues in other sectors such as natural resource management and rural development activities.

ACTIVITY 4: Training in Strengthening Referral Systems and Procedures.

The team strongly believes that all HIV/AIDS-related services need to be integrated into the government

health system down to the grassroots level. Therefore, technical assistance will be given to strengthen

referral and tracking systems within local government health systems as well as to develop strong networks

between the government, NGOs and community-level institutions. Technical support will be provided to all

subgrantee partners to foster this linkage.

ACTIVITY 5:Technical Support to USG Partners and Other Agencies/NGOs.

Myrada will provide USG partners and other agencies training and guidance in human resource

management, community mobilization, monitoring and evaluation, linkages and referral systems, and

resource mapping. Specific focus will be on providing such support to the NGOs funded by the Avert

Society in southern Maharashtra and the CDC-funded NGOs in AP and Jharkhand.