Evaluation study of Avahan prevention program shows promising effects for future efforts and highlights the need for building program evaluations into public health interventions.
October 10, 2011 – An ambitious, large-scale HIV/AIDS public health program prevented an estimated 100,000 new infections over five years in the parts of India hardest hit by the AIDS epidemic, indicating that HIV prevention programs that target high-risk groups can reduce HIV rates in the broader population. This is according to a new analysis by the Public Health Foundation of India (PHFI) and the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in collaboration with colleagues at the Ministry of Health and Family Welfare in India.
In three of six states where the Avahan program was implemented, the study found significant reductions in HIV infections, but in the smaller northeastern states, the program appeared to have little or no significant impact. The researchers say the lack of success in some parts of India shows the need to carefully plan programs and to include an ongoing evaluation of the program’s effectiveness from the beginning. The study, “Assessment of population-level effect of Avahan, an HIV-prevention initiative in India,” is published in The Lancet.
“The impact of HIV prevention on high-risk groups such as sex workers and injection drug users has been shown before, but this study shows the broad impact that HIV prevention can have on overall incidence of HIV,” says Dr. Marie Ng, the study’s lead author, who is a former IHME Post-Graduate Fellow and now an Assistant Professor at the University of Hong Kong. “Even though it will take several more years to truly assess the effectiveness of Avahan, we can say that this initial assessment is encouraging.”
India has an estimated 2.4 million people with HIV, making it one of the largest infected populations in the world. Launched in 2003, Avahan targeted the states with the highest HIV rates at the time: four large states in south India — Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu—and two small states in the northeast—Manipur and Nagaland. Together, the states had a total population of 300 million.
Avahan focused on high-risk groups, such as sex workers and their clients, men who have sex with men, and injecting drug users. The program included peer outreach for safe-sex counseling, treatment for sexually transmitted infections, distribution of free condoms, needle and syringe exchanges, and community advocacy activities.
Previous research showed that Avahan has successfully scaled up these interventions. Research also found a subsequent decline in HIV rates among sex workers in some parts of Karnataka, but no previous study has measured the effect of the program on the general population.
This study shows that Avahan had a significant beneficial effect on HIV prevalence in Andhra Pradesh, Karnataka, and Maharashtra, borderline significant effect in Tamil Nadu, and no significant effect in Manipur and Nagaland. Because of Avahan, between 2003 and 2008 the HIV prevalence in the general population fell at the highest by 12.7% in Karnataka and at the lowest by 2.4% in Maharashtra.
The study estimates the cost for each infection averted to be about $2,500, making the program cost-effective compared to the amount of care required to treat a patient with AIDS over his or her lifetime. The first phase of Avahan, from 2003 to 2008, was funded by $258 million from the Bill & Melinda Gates Foundation, which also provides funding to PHFI and IHME. The foundation has continued to fund Avahan while it is being transitioned to control by the Indian government.
“There has been a lull in HIV prevention funding in recent years, with funding shifting to treatment, largely because of increasing evidence on the success of antiretroviral therapies,” says Dr. Lalit Dandona, the study’s senior author, Distinguished Research Professor at PHFI in New Delhi, and Professor of Global Health at IHME. “This study suggests that prevention programs that invest in good planning and management can be effective on a large scale and therefore deserve a balanced infusion of funds.”
Under ideal conditions, a prospective evaluation of the impact of Avahan in the general population would have been rolled out simultaneously with the program, the authors note. This would have allowed researchers to more effectively compare populations that were not covered by Avahan efforts to populations that were covered.
“It’s always hard to thoroughly evaluate a program after the fact,” says Dr. Emmanuela Gakidou, Associate Professor of Global Health at IHME and one of the paper’s co-authors. “Our hope is that as the program is expanded or applied in other countries, the evaluation piece will be built into it from day one. If we don’t know how exactly these programs are working, we won’t know how to maximize their impact.”
The Public Health Foundation of India (PHFI) was launched by the Prime Minister of India in 2006 as a response to redress the limited institutional capacity in India to strengthen training, research, and policy development in public health. It is a public-private partnership that has collaboratively evolved through consultations with multiple constituencies including Indian and international academia, state and central governments, multilateral and bilateral agencies, and civil society groups. PHFI is establishing a network of Indian Institutes of Public Health across the country. The governing board of PHFI includes leading experts in public health and policy internationally and from India.
The Institute for Health Metrics and Evaluation (IHME) is an independent global health research center at the University of Washington that provides rigorous and comparable measurement of the world's most important health problems and evaluates the strategies used to address them. IHME makes this information freely available so that policymakers have the evidence they need to make informed decisions about how to allocate resources to best improve population health.
PHFI in New Delhi:
Ms. Vijayluxmi Bose
Tel: +91 11 4604 6000; Mobile: +91 98114 15443
IHME in Seattle:
Mr. William Heisel
Tel: +1-206-897-2886; Mobile: +1-206-612-0739