Background:

HLFPPT is implementing a condom social marketing (CSM) program among high-risk populations in 33 high prevalence districts in Maharashtra State. HIV prevalence in the state is 0.67% among pregnant women attending antenatal clinics (ANC), a decline from 1.5% in 2003. There are a number of factors that contribute to Maharashtra's vulnerability to the HIV epidemic. It is bordered by other states that have well-established and growing HIV epidemics (Karnataka and Andhra Pradesh). There is extensive migration to and from these states, and there are major transportation routes connecting Maharashtra to them. Maharashtra is a major destination hub for migrants from various states of India. Additionally, Mumbai and several other districts have well recognized places where sex workers operate. The HIV prevalence reported among the most-at-risk-populations (MARPs) is high: 12.8% among female sex workers (FSWs), 16% among men who have sex with men (MSM), 20% among injecting drug users (IDUs) and 10% among STD clinic attendees.

The goal of the condom social marketing program is to ensure availability and accessibility of high quality condoms to most-at-risk-populations (MARPs) such as FSW, MSM, IDU, migrants and people engaged in high-risk behavior. The specific aims of the project are to provide technical assistance (TA) to Maharashtra State AIDS Control Society (MSACS), Mumbai District AIDS Control Society (MDACS), Goa State AIDS Control Society (Goa SACS) and the Avert project in designing, implementing and evaluating condom programming targeted at MARPs and vulnerable populations; to demonstrate CSM models for FSW, MSM, migrants and PLHIV; and provide technical support to the SACS in scaling-up the female condom promotion program.

HLFPPT works closely with the Avert project, MSACS, MDACS, Johns Hopkins University (JHU) and other partners in the implementation of the CSM program. It also collaborates with the Bill and Melinda Gates Foundation (BMGF) and other condom social marketing partners in expanding the program among MARPs while avoiding duplication of efforts.

HLFFPT has supported the state AIDS control society (SACS) in strengthening the logistics and the supply chain systems for male and female condoms including building their capacity in condom social programming. Specifically, HLFPPT is providing TA to the SACS in establishing the various systems including planning, procurement and monitoring of the female condom promotion program. In addition, HLFPPT is also supporting SACS in developing systems for scaling-up the condom vending machines program in high-risk locations of the state.

As part of the female condom promotion program, HLFPPT is training outreach teams including peer educators to promote female condoms among sex workers as an effective device to give them greater control over their own protection, without having to rely on their partners to use a condom.

HLFPPT has established a robust monitoring system to track the outputs and outcomes of the various CSM programs including the technical assistance activities for SACS. The CSM indicators have been integrated into the SACS and Avert management information system (MIS) through which the progress of the activities is monitored. In addition, HLFPPT in consultations with the SACS and Avert project has developed a monitoring checklist for assessing the effectiveness of the field level CSM activities designed for MARPs. HLFPPT has developed a retail sales tracking system that will track condom sales of at retail outlets (13,500) established in high-risk locations. As regards to female condom promotion program, sales and condom usage are tracked routinely by SACS and Avert project.

SUMMARY

The condom social marketing program (CSM) implemented by HLFPPT will come to an end in June 2011. Hence, in FY 2010, HLFPPT will focus on conducting evaluations of the various condom social marketing programs and document best practices and lessons learned. HLFPPT will disseminate the findings of the evaluations at the state and the national level.

ACTIVITY AND EXPECTED RESULTS

ACTIVITY 1: Evaluation of CSM Program for MARPs

HLFPPT has piloted the integration of CSM activities among FSW, MSM and migrant populations. HLFPPT will hire an external agency to evaluate the effectiveness of the CSM programs among MARPs. The key evaluation questions are:

1. How effective were the integration of the CSM strategies in prevention program for brothel based and non-brothel based FSW populations in improving access to condoms?

2. How effective were the CSM strategies for MSM population?

3. How effective were the CSM strategies for the migrant population?

4. How effective were CSM strategies for the trucking population?

5. What were are the lessons learned and challenges in integrating CSM strategies with the prevention programs for MARPs including migrants and truckers?

ACTIVITY 2: Evaluation of the Sahi Condom Outlet Program

In FY10, HLFPPT will hire consultants to evaluate the effectiveness of the Sahi Outlet program in promoting quality condoms. The evaluation question is what proportion of the Sahi outlets are stocking approved condom brands (social marketing and commercial). A post program assessment will be conducted in FY 2010 which would help in measuring outputs and outcomes, analyze strengths and weaknesses and make changes accordingly.

SUMMARY

HLFPPT will provide technical assistance to the MSACS, Goa SACS and District AIDS Prevention and Control Unit (DAPCUs) in developing and operationalizing the CSM plans. Technical assistance will be provided in strengthening various systems, including logistics and inventory management of free condoms and promotion of female condoms. HLFPPT will also provide technical support to NACO in developing national guidelines on various components of the CSM program.

The SACS also need to form strong, ongoing partnerships with social marketing organizations and commercial manufacturers to increase condom sales for HIV prevention. The present capacity of the SACS to scale up and manage CSM programs is not adequate. Hence, it is critical to provide technical support to SACS in strengthening systems to plan, implement and monitor condom social marketing programs.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Technical Assistance to MSACS and Goa SACS

In FY 2009 and continuing in FY 2010, HLFPPT will provide technical assistance to both the SACS in developing condom social marketing plans including operational guidelines and establishing systems to implement and monitor CSM programs. HLFPPT is providing technical assistance in developing demand projections for the supply of free condoms, monitoring condom wastage, logistics and inventory management and retail sales tracking. Technical support will be provided to SACS in developing systems and processes for generic condom promotion, expanding condom retail outlets including training retailers, partnership with social marketing organizations, and assessing condom quality. HLFPPT will also provide ongoing technical support to the SACS in establishing the various systems for planning, implementation and monitoring of the female condom and of the other condom program.

ACTIVITY 2: Technical Assistance at the National Level

HLFPPT will provide technical assistance in developing operational guidelines at the national level on various components of the CSM program including the promotion of female condoms and special condoms for the MSM population. HLFPPT will also provide ongoing technical assistance on specific activities such as the generic condom promotion program, condom retailers' training, partnership with social marketing organizations and condom manufacturers, condom quality testing and monitoring condom sales.

SUMMARY

HLFPPT supports the Maharashtra State's efforts in scaling-up CSM. In addition, HLFPPT provides technical support to Goa State AIDS Control Society (GoaSACS) on CSM initiatives in the state. In Maharashtra State, HLFPPT is demonstrating models of integrating CSM activities into the prevention programs for MARPs. In addition, HLFPPT provides technical support to the National Female Condom Promotion Program implemented throughout the country. HLFPPT is also implementing an innovative program called the "Sahi Outlet" (Sahi meaning "reliable") to promote quality condoms. The key technical strategies are to: enhance access to quality condoms for MARPs through focused distribution initiatives in high-risk areas; increase demand for condoms among MARPs and promote safer sexual behavior among clients of Female Sex Workers (FSWs) such as truckers, migrants and at-risk youth; and to provide technical support to promote female condoms for FSWs in the state of Maharashtra. HLFPPT will form a technical resource group to guide the various innovations in the CSM program.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Integrating CSM in Prevention Programs for FSW Populations

It is estimated that there over 70,250 FSWs in the State of Maharashtra. The FSWs can be classified into two types at a broader level brothel-based which comprises 60-70% of the FSW population, and non-brothel based, which is further sub-divided into street-based, lodge-based and home-based FSWs. The brothel-based and the non-brothel based FSWs are two different sub-cultures and the HIV/AIDS programming is designed to suit to their community structures. Maharashtra State has well defined brothels in certain locations such as Mumbai (5000-7000 FSWs), Nagpur (5000 FSWs), Pune (5000 FSWs), Sangli and Sholapur (2000 FSWs each). Districts such as Thane (7000-10,000), Yawatmal, Kolhapur, Nasik and Ahmednagar (ranging from 2000 to 3000) have large concentration of non-brothel-based FSWs. There are over 70 NGOs working among FSWs in the state.

In FY09, HLFPPT is piloting two models of CSM targeting brothel-based and non-brothel based FSWs. A situational assessment will be carried out to design the integration of CSM into the brothel and non-brothel based FSW prevention programs. In a brothel-based FSW program, the design will include networking between peer educators (supported by outreach workers), brothel madams, other stakeholders as appropriate, condom retail outlets and the HLFPPT sales team. In addition, HLFPPT will also pilot peer-led and madam-led condom retail outlets. In a non-brothel based FSW program, the CSM design will be tailored to the communities in and around the lodge-based, street-based and home-based FSW. In a non-brothel based prevention program, the CSM will be centered on peer educators, pimps and lodge workers. The NGO implementing the prevention programs among FSW will be responsible to manage the CSM program. HLFPPT will develop monitoring tools and indicators in collaboration with state partners and NGOs to monitor progress. The aim of the CSM program is to ensure that over 80% of the FSWs and the clients have access to high-quality condoms. In FY10, HLFFPT will continue the CSM program in collaboration with state partners and NGOs and will evaluate the effectiveness of the CSM strategies.

ACTIVITY 2: Integrating CSM in Prevention Programs for MSM Populations

In FY09, HLFPPT will design a CSM program for over 80,000 MSM populations in the state of Maharashtra. The MSM typologies include Kothis (receptive), Panthis (intertie) and Double-Decker (local terminology for MSMs who are both passive and active). In addition, there are bisexual populations putting both men and women at risk of HIV. The MSMs solicit sex at toilets, cinema halls and public-parks. Unlike the FSW, the MSM populations do not have defined community structures. HLFPPT will implement the peer-based CSM program as this is the most suitable for MSM population. The other approach that is suitable to the MSM community is establishing condom vending machines in NGO offices, toilets and at locations near parks and cinema halls suitable to the MSM community. The NGOs implementing the prevention programs among MSM population will be responsible to manage the CSM program. HLFPPT will develop monitoring tools and indicators to monitor progress. In FY10, HLFFPT will continue to strengthen the CSM program and will evaluate the effectiveness of the CSM strategies.

Activity 3: Piloting a CSM program for Migrant Textile Workers

Bhiwandi in Thane district is the largest exporter of silk and cotton cloth in Maharashtra State. Bhiwandi has 400,000 looms, and over 700,000 single male migrants from Uttar Pradesh, Bihar, Andhra Pradesh, Kerala and Tamil Nadu are engaged in the textile industry. The migrants are vulnerable to HIV due to several factors: being far from home; a lack of social identity, poor work environment and adverse living conditions with little recreation. They live in poorly ventilated and unhygienic clusters with 7-10 workers sharing a single room of 10'x10'. During power cuts and on holidays they spend their time watching movies, marketing, going to bar and visiting a brothel named Hanuman Tekri which is closely located to the textile industry. The brothel has over 993 FSWs. In addition, Bhiwandi has over 882 non-brothel based FSWs and 250 MSM.

The Avert project is piloting a migrant intervention program among the textile workers in Bhiwandi. The key stakeholders in this population are loom owners, mess owners (canteens specifically started for migrant populations) and community leaders. JHU is assisting the Avert project in designing a behavior change communication program for the migrant textile workers. The Avert project has identified and trained over 300 peer educators from among the migrant community. HLFPPT will conduct a situational assessment and design a CSM program tailored to the migrant community structures in Bhiwandi. In FY10, HLFFPT will continue the CSM program and will evaluate the effectiveness of the CSM strategies.

Activity 4: Technical Support to Implement Condom Vending Machine (CVM) Program

One of the key strategies of the National Condom Social Marketing Strategy is the establishment of CVMs in high-risk locations to increase access to quality condoms for MARPs including clients of FSWs. In the states of Maharashtra and Goa, HLFPPT is assisting the SACS in installing and monitoring the effectiveness of the CVM program. In FY08, CVMs have been installed in over 3,250 high-risk sites in Mumbai and Thane districts of Maharashtra State. The CVMs are installed in partnership with a local business partner (lodge owners, chemists, bar owners and shops) to manage the CVM. However, it was observed that this model of partnering with local business partners did not work as the CVMs were not routinely refilled. HLFPPT handed the responsibility of managing the CVM to the condom sales team who regularly ensure that the CVMs are refilled. The CVMs are installed at brothel sites, markets, hospitals, tourist locations and resorts. The sales through the CVMs are tracked. In FY10, HLFPPT will continue providing technical support to manage the CVM program and effectiveness of the program will be evaluated.

Activity 5: Training of Condom Retailers

HLFPPT has trained over 13,500 condom retailers from 22 high prevalence districts using the standard training curriculum and module. In FY10, training of over 6,500 condom retailers from the remaining 11 high prevalence districts (Maharashtra has 33 high prevalence districts) will be conducted. In addition, training for condom retailers from the two districts of Goa State will be conducted. An evaluation of the condom retailers training will be conducted in FY10.

ACTIVITY 6: SAHI Branding

HLFPPT is focused on reducing the availability of poor quality of condoms and will invest in developing non-traditional outlets (NTOs) which will only stock and sell quality condoms conforming to standards required for disease (STI) prevention. Creation of 3R Outlets (Red Ribbon Retail Outlets) within the universe of NTOs mapped in high-risk areas and branded as "Sahi" outlets increase awareness and accessibility of quality condoms at all times. HLFPPT plans to convert most of the NTOs, which were covered in the retailer training program in FY 2009 into SAHI outlets. The outlet would be branded with POP and other merchandise especially keeping in mind the sensitivity of the issue. The outlets will be provided programmatic support as it is important to retain the interest of the NTOs which can obtain higher margin by selling poor quality condoms. The NACO-funded CSM project will be leveraged to maintain the supply chain for the availability of quality condoms. In FY 2009, as a result of sustained efforts by HLFPPT, 2,278 non traditional outlets are stocking and selling quality condoms.

The campaign is further strengthened with messages on quality condoms and their availability for every sexual encounter among the MARPs. By FY 2010, the program aims to reduce the sale of poor quality condoms to less than 10% in the market in partnership with NACO and SACS, Consumer Forum, Excise department, Food and Drug Administration (FDA) and other concerned departments.

ACTIVITY 7: Technical Support to Implement the National Female Condom Promotion Program among FSW Population

As part of the national condom strategy, a female condom promotion program is being implemented among FSWs in selected states of the country. NACO is subsidizing the female condoms (FC). In FY 2007, a pilot assessment was conducted among seven NGOs working with FSW in Maharashtra State. The pilot assessment focused on positioning female condoms as a premium product which empowers the FSWs to have protection at all times. FCs was marketed at a highly subsidized price of Rs.5 per piece. This led to the use of FCs by the FSW with their temporary husbands with whom the condom use was quite low. The perceived pleasure enhancing factor and the premium perception of FC enabled the FSW to negotiate female condom use with their clients. NACO introduced the polynitrile condom FC 2 which is priced at INR 2.00 for NGOs and INR 3.50 for the end user (FSW). In FY 2008, the FC program was scaled up to 65 NGOs supported by SACS, the Avert project and BMGF reaching over 50,000 FSWs in Maharashtra State. In FY 2009 and continuing in FY 2010, HLFPPT will strengthen the FC program to reach 80-90 % of the FSWs. To date, 83,000 FCs have been socially marketed to NGOs.

ACTIVITY 8 Piloting CSM in Prevention with Positives Program

In FY 2009 and continuing in FY 2010, HLFPPT in partnership with Network of Maharashtra Positive People will integrate condom promotion with the positive prevention program in five Avert priority districts of Maharashtra State. The program will promote consistent condom use among sero-discordant couples and unmarried positive people. HLFPPT will also initiate condom promotion activities at counseling and testing centers, ART centers and in care and support programs.

ACTIVITY 9: Safe Zone Project

Maharashtra State has eight national highways with a total of 2564 km. More than 50,000 truckers pass along these highways every day. A workshop conducted in June 2008 with the trucking community (truck association members, Dhaba owners (restaurants at truck points) and members of the Transport Corporation of India) revealed that truckers have very limited access to condoms on highways where they spend most of their time, except at few NGO intervention sites. Once the trucks come out of these intervention points, there is very limited access to condoms along the national highways.

A pilot CSM project covering a km stretch of national highway-four, passing through five Avert priority districts in Maharashtra State will be implemented in FY 2009 and continued in FY 2010. The project will enhance availability, accessibility, and visibility of condoms to truckers along the entire route. A mapping will be conducted to identify the various service providers such as dhabas, small shops telephone booths, tyre repair shops and petrol pumps to develop them into non-traditional outlets for condom sales.