Orchid Assessment REPORT

DesignsByMary&Chris

Dr. Sundar Sundararam, Dr. Mariam Claeson (The World Bank), Dr. Swarup Sarkar (UNAIDS) Dr Shariha Khalid and the SCOPE Consulting Team from Kuala Lumpur, Malaysia

CONTENTS EXECUTIVE SUMMARY

3-14

BACKGROUND

15-22

Injecting drug use and HIV The Avahan programme in Manipur and Nagaland

16 19

ASSESSMENT - CONTEXT & OBJECTIVES

22-24

METHODS

25-29

KEY FINDINGS

Objective A: Analysis of programme output and outcome data Objective B: Adoption of recommendations from Phase I review Objective C: Challenges faced by the programme Objectives D and Objectives E

32 45 50

RECOMMENDATIONS

50-51

Objective A: Innovation developed by Project ORCHID to effectively implement a comprehensive harm reduction package in India Objective B: Documentation and dissemination of Project ORCHID model to date Objective C: Challenges and recommendations

61 61

ANNEX

ANNEX 1: Summary of Project ORCHID Outputs and Outcomes and Achievement Against These ANNEX 2: Project ORCHID Phase II â&#x20AC;&#x201C; Avahan Milestones. ANNEX 3: Case Studies ANNEX 4: Methodology for Project ORCHID Assessment in Manipur and Nagaland ANNEX 5: Terms of Reference and Scope of Work for External Evaluation of Project ORCHID ANNEX 6: Relevant Data Sources for Project ORCHID

EXECUTIVE SUMMARY

64 66 70 71 75 79

ABBREVIATIONS

REFERENCES

3 | Assessment of Project ORCHID, September 2011

1. CONTEXT An assessment of the Bill & Melinda Gates Foundation Avahan Project, ORCHID, in Manipur and Nagaland of Northeast India, was conducted in September 2011,i to determine whether the project is on track to achieve intended programme outputs and outcomes and to assess its implementation principles and unique approaches to enhance efficiency and effectiveness of a universal harm reduction package. Specifically, the assessment team measured the achievement of project milestones, the challenges faced and innovative approaches to address them, and progress on key recommendations of the Phase 1 review.

The geographically dispersed nature of the populations in Manipur and Nagaland presents challenges in outreach, testing, and continuity of care and support. The insurgency and bandhs (general strikes) in Manipur state disrupt programme operations, including provision of commodities, although the problem is now less serious than in the past. Although the environment is changing in the positive direction, discrimination by families, police, and religious leaders and violence faced by the drug users, pose additional challenges. Heroin is readily available across the porous borders as well as other injectable pharmaceutical drugs, such as spasmo proxyvon (SP), which contribute to the injecting drug use driven HIV epidemic. Changes in drug availability and drug use patterns are also being observed, but have not been fully documented or studied well enough. Given the high unemployment and other social and structural amplifiers such as the stigma and discrimination faced by health services providers and the drug users themselves, especially female drug users, the challenges are immense, and creative and context-specific innovative solutions are required. Manipur and Nagaland are home to several innovations by communitybased organisations (CBOs) and the first ever region in Asia to initiate a government-endorsed programme providing both clean needle and syringes and Opioid Substitution Therapy (OST) -- 2 pillars of the national comprehensive harm reduction services for the states. Although major progress has been made, neither of the two states has yet reached full-scale with these comprehensive programmes. The State AIDS Control Societies (SACS) of Manipur and Nagaland have the overall responsibility for the prevention and control of HIV, and fund a large number of targeted interventions for People Who Inject Drugs (PWID). The goals of the SACS are to achieve changes in programme outputs and outcomes (i.e., risk behaviours and STIs) leading to a reduction in HIV among high-risk groups (HRGs) throughout the states. The specific goal of the Avahan project is to contribute to these national and state goals, by developing a model programme that would achieve results among the HRGs covered by the project.

i The Assessment was carried out by SCOPE with a team of external experts from the Avahan Technical Panel.

4 | Assessment of Project ORCHID, September 2011

5 | Assessment of Project ORCHID, September 2011

2. GOALS AND TARGETS

3. ACHIEVEMENTS:

The goals of the Avahan supported Project ORCHID and the focus of this assessment are to:

Below is a summary of some of the main achievements and remaining challenges of Project ORCHID, identified by the assessment team for each of the project goals I - IV.

1. Develop a “model” harm reduction programme for people who inject drugs (PWID) 2. Achieve impact on the epidemic among HRGs in the project geographies

Project Goal

3. Disseminate the model and lessons learned in India and globally, and 4. Transfer the targeted interventions ii (TIs) to the government to sustain the project achievements

The Avahan programme operates through 24 implementing partners (12 in Manipur and 12 in Nagaland) with 46 drop-in centres (DICs) and 38 clinics (23 in Manipur and 15 in Nagaland), across 13 districts (7 in Manipur and 6 in Nagaland). The Project ORCHID targets are to reach 10,800 PWIDs, of whom 1,520 are on OST, 3,250 female sex workers (FSW), and 1,450 men who have sex with men (MSM), with an intervention package that includes: outreach services; needle and syringe exchange programme; abscess treatment; condoms and lubricant distribution; STI diagnosis and treatment; counselling services; creating an enabling environment and local advocacy, including crisis response; focus on community strengthening and mobilisation; and referral to integrated counselling and testing centres (ICTC), antiretroviral treatment (ART) and tuberculosis (TB) treatment. In addition, management of overdose through readily accessible naloxone services -- to reduce the high case fatality due to overdosing -- was added to the programme by one of the implementers (Social Awareness Service Organisation or SASO, Imphal). This is an example of a clinical innovation introduced by the project. Overall the project covered 28% to 54% of the overall estimated PWIDs in the states, complementing other state run programmes in most districts, or as the only programme in some of the districts.

To develop a “model” harm reduction program for PWIDs a. The business model of AVAHAN works for harm reduction also in challenging geographies and for PWID: Avahan has shown that a harm reduction package can be scaled up in the Northeast of India in the same way as targeted interventions has been scaled up in the south for sex workers and MSM. The AVAHAN innovative approach to scaling up works in injecting drug use (IDU) settings and in difficult geographic zones of hilly areas and in socially difficult contexts where strong political, security and religious undercurrents pose additional barriers to uptake of services. Participatory planning at project sites (micro-planning) and flexibility in implementation plans are two cornerstones of Project ORCHID's management that have been key to these current achievements. b. Tailoring TIs to address neglected issues and beneficiaries have succeeded in reaching the hard-to-reach population groups: Avahan, in collaboration with the Government and NGOs, has successfully demonstrated and implemented delivery models with ‘additional elements’ of necessary but often neglected components of harm reduction programmes in order to reach female injectors, young injectors and female partners of PWIDs. In addition, combating overdose to reduce deaths has been a key strategy to mobilise PWIDs to seek safer health. c. Increasing the efficiency of the state model TI by task shifting, matching supply and demand, and increasing accessibility and availability of services: Examples of activities that increased efficiency of TIs include: nurse-led STI clinics, use of quality controlled secondary distributors for needles and syringes, optimisation of the OST human resources plan, and integrating mobile services with existing outreach services to increase uptake of VCT.

ii "Targeted interventions" is a terminology that is used in India to refer to HIV focused preven-

tion programmes with high-risk groups.

6 | Assessment of Project ORCHID, September 2011

7 | Assessment of Project ORCHID, September 2011

The table below summarises the components and innovations developed by Project ORCHID to effectively implement a comprehensive harm reduction package in India:

Even in the absence of sufficient data on impact at this stage, it is also recommended that these additional components and delivery approaches for effective coverage of TIs among PWIDs be considered and incorporated in the design of NACP IV.

The “What” – additions to the standard harm reduction package currently implemented in India

The “How” – the approaches used for effective scaling up of harm reduction

1. Focus on new injectors (those who have been injecting for less than three months)

1. Strong programme management and execution approach for ensuring scaled delivery

2. Customised intervention with female injecting drug users (FIDUs)

2. Use of data for local decision-making – e.g., use of micro-planning through peer-based outreach

3. Provision of naloxone and other critical components of the commodity package

3. Enhanced local and state advocacy with key structural players (e.g., religious leaders, police, power structures)

4. Specialised services for female sexual partners (spouses) of PWIDs

4. Strong focus on community mobilisation including active involvement in programme design and delivery

5. Customised interventions for geographically hard-to-reach PWIDs (pilot)

5. Capacity building among the institutions involved in service delivery – the NGOs

The three landmarks of the model for effective programming for PWIDs: Three factors help explain the potential of Project ORCHID to serve as a model for HIV prevention among injecting drug users: (i) the combined effect of community mobilisation, (ii) the government’s stewardship and supportive role, and (iii) the Project ORCHID/Avahan model of scaling up of the evidence-based comprehensive harm reduction package. The impressive progress to date, and the likelihood of the project achieving its objectives to develop an effective and replicable model, achieve impact in the areas covered, and disseminate the knowledge and lessons learned, can be viewed against these three landmarks of the Indian response to HIV: a. Community and local innovations setting the stage: India was the first developing country to initiate peer led outreach programmes among PWIDs (Manipur) and the first to introduce a buprenorphine substitution programme in a community setting (Delhi). Manipur was also the first site in Asia to implement a harm reduction policy encompassing both clean needle and syringe and opioid substitution programmes. Community organisations played a pivotal role in: shaping this response; conducting “snow balling size estimation” led by PWIDs (Manipur 1990); and introducing the concept of an enabling environment. Community innovations ranged from tailoring the response to the demands of the community, such as providing primary health care services and addressing violence, to the formation of self-help groups.

6. Flexibly responding to local barriers through innovative service models, such as: a. b. c. d.

b. Government stewardship: NACO adopted and scaled up these community innovations early in the National AIDS Control Programme (NACP), and boldly supported targeted interventions for the prevention of HIV among high-risk groups by rolling out and scaling them up during the second and third programme phases. In addition, NACO supported community-based organisations (CBOs) and NGOs as the main front line organisations for service delivery for marginalised groups, by funding them and creating space also for direct donor funding of NGOs. It will be important over the next phase (NACP-IV) to expand further the space for flexible delivery locally and adaptation to different local contexts, in order to reach the most marginalised populations at highest risk.

Enhanced staffing of the NGO delivered OST programme Secondary distributors to ensure adequate and uninterrupted commodity supply in remote locations Mobile clinics used extensively to bring services to work places, hot spots, and other locations where key populations are located Nurse-delivered STI services to address the unavailability of doctors in the region

c. Project ORCHID/Avahan showing how to go to scale: Avahan demonstrated “how” community led organisations can scale up services rapidly to achieve results. Project ORCHID -- in Manipur and Nagaland -is showing that the Avahan business model of scaling up can be effectively applied in a setting where HIV is driven primarily by injecting drug use, and that it can be replicated in a challenging setting, especially in the context of difficult geographic terrain and overall poor governance.

Some of these innovative concepts have been introduced recently and are either not practiced at scale or not for sufficient duration yet to show population level impact. Therefore, it is recommended that the project be continued until these practices are implemented at full scale and that the population impact of these interventions and delivery strategies be carefully evaluated. The necessary resources and collaboration with the Government should be ensured to continue the scaling up of the model.

8 | Assessment of Project ORCHID, September 2011

9 | Assessment of Project ORCHID, September 2011

To achieve Impact on the HIV epidemic among the HRGs in the project geographies a. Evidence of programme Scale-up: In a short time frame of 3-4 years, the programme has been able to steadily scale up its services across 13 districts in Manipur and Nagaland so that by 2010 more than 391 peer educators were working on the ground to deliver the services, 15,750 PWIDs were contacted, over 250,000 needles and syringes distributed, 2,716 PWIDs has attended clinics, and 1,621 were tested for HIV (see panel below).

Project Goal

b. Coverage and impact (outputs and outcomes) (for details see Annex 1): Project ORCHID has achieved its target of reaching at least 80% of PWIDs with services. Accessibility to needles and syringes through the programme is high. The programme has also made progress in reaching out to the highest risk PWIDs including female PWIDs, and new and young injectors. The percentage of PWIDs <25 years registered has increased from 25% (2009-10) to 33% (2010-11); the percentage of female PWIDs registered has increased from 2.7% (2009-10) to 7% (2010-11); the % of PWIDs who have been injecting drugs for <1 year registered has increased from 4% (2009-10) to 21.5% (2010-11). Progress has been made in reaching most milestones and following up on critical recommendations of the evaluation of Phase 1. OST coverage is still less than the 20% national target; however, this is due to the limited number of slots for OST provided by the National AIDS Control Organisation (NACO) to date. More than 40% of the PWIDs in the programme have been tested for HIV at least once, but repeat testing needs to be increased.

Notes: The data shown graphically are for IDUs only in Project ORCHID (i.e. two north-eastern states). The data are for March of each year except for 2012, which is for February 2012. Data are provisional. Source: Project ORCHID CMIS

Notes: Dotted horizontal lines represent targets. Data is shown as annual avaerages. Source: Project ORCHID CMIS

Note: all indicators and targets above are average monthly indicators and targets (e.g. average monthly contact, average monthly clinic attendance, average monthly tested for HIV at ICTC).

10 | Assessment of Project ORCHID, September 2011

11 | Assessment of Project ORCHID, September 2011

Dissemination of learning:

While condom use among paid partners is increasing, condom use among regular partners is lagging behind. In the districts (two in Nagaland and two in Manipur) where trend data are available (IBBAiii ), there are positive trends in needle sharing behaviour. While HIV prevalence among PWIDs in Nagaland is stable, the picture is mixed in Manipur: in Bishnupur clean needle use is high and there is a significant decline in HIV prevalence (from 23% in 2003 to 16% in 2008); while in Churachandpur clean needle use is also high but HIV prevalence has increased among PWIDs (from 32% in 2003 to 40% in 2008). There is an overall decline in HIV among the general population (using ANC as proxy) in Manipur, from 1.06 (2003) to 0.39 (2008)iv among women 15–24 years old, and a levelling off overall in Nagaland (1.99 in 2003 to 1.91 in 2008). The result is quite encouraging in Bishnupur district of Manipur – a district where Project ORCHID/Avahan is the only implementing agency. Further analyses of injecting and condom behaviours and trend data from more districts (Avahan and non-Avahan) are needed to explain the variation in biological outcomes and to evaluate the effectiveness of the programme.

To disseminate the model and lessons learned in India and globally Relevance of the lessons learned from Project ORCHID for the South Asia region:

The assessment team recommends that the unique scaling up principles of Project ORCHID, which build on the Avahan work in South India, be shared widely within India --especially with NACO in light of NACP-IV design -- and beyond. The targeted intervention site managed by the Dedicated People’s Union (DPU) in Kumbi has served as a successful regional learning site. Through presentations, discussions, field visits and interactions with community members, visitors learn about the programme’s outreach, community mobilisation, and service delivery programmes, with a focus on good practices contributing to programme effectiveness. Because the DPU is currently without funding and dedicated staff for this function, the number of visitors has decreased sharply, with only 2-3 visitors thus far in 2011, compared to 200 over a short period in 2007. This learning site should continue to build capacity and disseminate the lessons from Project ORCHID; efforts need to be made to find funding to support its dedicated staff and core functions.

Project Goal

a. Scaling up harm reduction: Most countries in Asia have serious HIV epidemics among PWID that can escalate especially where IDU and sex work intersect. Therefore, an early successful response to a PWID epidemic can nip a generalised epidemic in the bud. Unfortunately, most countries in the region do not have a satisfactory coverage of needle and syringe programmes (NSP) and OST of more than 10 to 20%. In addition, most countries in the region do not have specific outreach for young injectors, or female PWIDs -- which are well within the scope of harm reduction. Most countries also do not have any programme to reduce the high mortality from overdosing. Harm reduction at scale and implementation of key innovations, as demonstrated by Project ORCHID, with the stewardship of the Indian Government, can serve as a model for many other countries that need to scale-up effectively and rapidly.

To transfer TIs for the prevention of HIV among PWID to the Government to sustain project achievements Building on the strong local experience, impressive results to date, and the presence of comprehensive harm reduction in the two states of Manipur and Nagaland, Project ORCHID could work with NACO to ensure that the innovations are scaled up in the rest of the Northeast and beyond, in other emerging injecting drug use areas in India. The Government could also consider retaining select areas of Project ORCHID management capacity even after the handover of Avahan supported interventions to NACO/SACS in order to assist the SACS in managing targeted interventions in these states. The assessment team recommend that: a.

The transition the programme to the Government of India is completed in a phased manner over the next one to two years. The rationale for this suggestion is two-fold: 1) a phased approach was adopted in the four southern states so that the Government and Avahan could learn lessons on transition during each phase and the SACS would not to be overloaded if all sites were transitioned at the same time (Project ORCHID has not had the advantage of going through this process other than transitioning <5% of its interventions in Manipur); and 2) several innovations are still maturing and it would be wise to provide adequate time for them to demonstrate their effectiveness and share lessons with the Government.

Project ORCHID explore with NACO ways to continue the management model post-transition; Project ORCHID has provided a “management supervision” model that should be continued in these states, especially in light of the lack of statespecific technical support units (TSUs).

b. Increase the knowledge of spasmo proxyvon and how to manage it: Northeast India is facing an increase in the use of spasmo proxyvon which has not been observed or not documented anywhere else globally. The lessons learnt for how to tackle this problem could contribute to the advancement of global knowledge, and it is therefore recommended that this is specifically documented.

iii Integrated Behavioural and Biological Assessments are conducted in select districts

where Avahan operates with PWIDs. IBBA was conducted in Phek and Wokha in Nagaland and Bishnupur and Churachandpur in Manipur. ivNACO HSS- ANC (2003-08).

12 | Assessment of Project ORCHID, September 2011

13 | Assessment of Project ORCHID, September 2011

4. MAIN RECOMMENDATIONS The main recommendations for the remaining duration of the Project ORCHID/Avahan project are to: a. Programme • Extend coverage, continue to increase quality, intensity and coverage (post-2008 effort), paying attention to paraphernalia control and sharing, and further enhance the role of PWIDs. • Strengthen the behavioural communication skills and human resources to improve coverage and on-course correction, extending the use of participatory micro-planning tools (e.g., colour coding, mapping, etc.). • Consider how to mainstream micro-planning. Many peer educators find the micro-planning process time-consuming and difficult to implement. Micro-planning is a pillar of the project, so this problem needs to be addressed before the transition of project sites to the SACS, which has fewer resources. b. OST • Consider a feasibility study of introducing methadone maintenance therapy (MMT) as an OST option where heroin use dominates; and ensure uninterrupted drug distribution with the involvement of community centres. • Explore with NACO: the role of the naloxone and buprenorphine combination as take home drugs in difficult to reach areas; rolling out a naloxone programme to combat overdose; setting a target of 40% reach of OST to ensure impact in districts that are yet to achieve declines (e.g., Churachandpur); and providing assistance to NACO and SACS to immediately expand the Project ORCHID model to Mizoram and Meghalaya.

BACKGROUND

c. Transition • Transition the programme to the Government of India in a phased manner over the next one to two years, as discussed above. d. Dissemination • Support the learning site as a regional, national and potential international learning site for community driven “comprehensive harm reduction” programmes while finding partners to sustain it under NACP-IV. e. M&E • Fast-track the evaluation of the programme. • Link M&E activities with mainstream academia and research groups in the country to better assist with the evaluation and monitoring components of the programme. To evaluate project impact in areas covered by Project ORCHID in the Northeast, it is recommended that Project ORCHID/Avahan conduct further data triangulation and analysis of available (and additional) data. Also, to draw overall lessons from the response to the injecting drug use epidemic in the Northeast and guide future response, conduct a synthetic study, including: (a) other Northeast states, and (b) similar emerging.

14 | Assessment of Project ORCHID, September 2011

15 | Assessment of Project ORCHID, September 2011

Injecting drug use and HIV

while Thailand provides OST through government-run clinics7. To date more than 5,500 have been reached by OST services in India nationwide. Buprenorphine is the drug of choice for OST in India currently. Finally, HIV and HCV prevention targeted to PWIDs is limited throughout the region and it is estimated that only 1,700 people who inject drugs receive anti-retroviral therapy (ART).

The International Harm Reduction Association (IHRA) estimates that there are nearly 16 million people who inject drugs (PWID) around the world. The vast majority of PWIDs (up to 80%) live in low- and middle-income countries, with the largest numbers living in Asia and Eastern Europe1. The Asia region accounts for approximately one-third of PWIDs worldwide, and adult HIV prevalence is highly concentrated in PWID populations throughout much of the region. With nearly 5 million PWIDs estimated in the region, India and China alone report more than 1 million PWIDs2. Up to 10% of HIV cases are attributed to injecting drug use3. The estimates of adult HIV infection among PWIDs in Asia range from a low 0.20 – 2.25% in Bangladesh, to a high of 89.4% in Vietnam. Adult hepatitis C virus (HCV) infection is even higher among PWIDs in Asia, with estimates ranging from 25% in Bangladesh to 98% in Indonesia4.

The epidemic in India is a concentrated one driven by high-risk behaviour among sex workers, men who have sex with men (MSM) and PWIDs. The two states assessed in this report, Manipur and Nagaland, are particularly affected by drug use epidemics. The third National AIDS Control Programme (NACP-III) of India has considerably scaled up prevention programmes, including harm reduction programmes (including clean needle and syringe coverage as well as OST) with PWIDs. In addition to programmes funded by the Government of India and implemented by the National AIDS Control Organisation (NACO), prevention programmes in the six high priority states have been implemented by the Avahan programme funded by the Bill & Melinda Gates Foundation. Emerging evidence suggests that the interventions among sex workers is having an impact and has been cost-effective8. However, impact among PWIDs remains to be assessed.

Harm reduction programmes such as needle and syringe programmes (NSPs) and opioid substitution therapies (OSTs), including buprenorphine and methadone, are recognised best practices for preventing the transmission of HIV and are recommended by the World Health Organisation (WHO), UNAIDS and the UN Office on Drugs and Crime (UNODC) as essential components of a comprehensive response to HIV prevention. While there has been an increase in government policies to include harm reduction in HIV prevention programmes, the overall response has been inadequate, with only 82 of 158 countries reporting having either harm reduction policies or programmes in place.

The HIV/AIDS epidemic among PWIDs in Manipur and Nagaland According to the annual HIV sentinel surveillance data (HSS-PWID) conducted by NACO, the prevalence of HIV among PWIDs is several fold higher in Manipur as compared to Nagaland. In the 2008 data, the state average of HIV prevalence among PWIDs in Manipur is 27.8% and Nagaland is 3.9%. Variations are also seen between districts. In Nagaland HIV prevalence among PWIDs ranges between 0.9% (Phek district) and 10.6% (Dimapur district); in Manipur between 17.9% (Imphal West) and 34.4% (Bishnupur). However, large variations between years within the same district are also seen which points to the limitations of using the HSS conducted among HRGs to analyse trends. The limitation is largely due to the lack appropriate sampling, which is being resolved in the 2010 HSS to some degree.

Lack of attention to HIV among PWIDs is fuelled by the criminalisation of drug use, laws, police behaviour that discourages PWID from carrying clean needles and syringes, stigma and discrimination towards drug users, and objections to programmes on the ‘moral’ ground that access to NSP and OST will enable or increase the prevalence of drug use. Drug treatment often is provided in custodial facilities that offer unsupported withdrawal and hard labour as their only ‘treatment’ options. The lack of programmes is especially notable in prison settings, with only eight countries offering NSP and 33 offering OST5. The International Harm Reduction Association notes that progress has been observed during recent years in the acceptability of NSP and OST programmes in Asia6. Among the 23 Asian countries that report PWIDs within their population, 13 (57%) offer NSP, with nearly a quarter of these described as ‘limited’. While the number of NSP sites has increased in several countries, including China, India, Malaysia, Myanmar, Taiwan and Nepal, access to NSP remains low: at 3% in Southeast Asia and 8% in East Asia. While China has rapidly scaled up its NSP since 2000, 7% of PWIDs had access to these services. In India it is estimated almost 80% of PWIDs have access to services, although the actual coverage rate of PWIDs who use clean needle and syringes needs to be ascertained better through behavioural surveys. OST remains unavailable in many Asian countries. Hong Kong has the most well-established programme, with 7,000 clients receiving OST – nearly 25% of the PWID population. Taiwan has achieved rapid scale-up with demonstrated impact on HIV prevention among PWIDs. China and India are working to scale up their programmes,

16 | Assessment of Project ORCHID, September 2011

17 | Assessment of Project ORCHID, September 2011

The Avahan programme in Manipur & Nagaland

HIV prevalence among PWIDs (HSS-PWID) in Manipur

In 2003, the Bill & Melinda Gates Foundation launched the Avahan programme, the foundationâ&#x20AC;&#x2122;s India AIDS Initiative focused on scaling up prevention among high-risk groups in six priority states (Karnataka, Maharashtra, Tamil Nadu, Andhra Pradesh, Manipur and Nagaland)9.

34.3 31.1

19.7 17.1

16.3

17.9 15.5

12.6

11.5 9.9

7.99

12.9

Bishnupur Churachandpur

8.2

7.1

6.6

5.7

In 2003, these six states accounted for 83% of HIV infections in India10. As an assessment of Avahanâ&#x20AC;&#x2122;s PWID programme in the two North-eastern states of Manipur and Nagaland, this study will describe and elaborate only those components of the Avahan programme relevant to PWIDs.

Imphal West

HIV prevalence among PWIDs (HSS-PWID) in Nagaland

13.4

10.6

5.7

5.5 4.6

4.4 1.01 0.2

2.3

5.6

2.7

1.6

1.4

0.2

2003

0.9 0.6 0.4 0.2 0.4 0.2

2004

2005

2.04 2.04

3.1 1.01

2006

1.4

2.5 1.5

2007

0.6 0.5

3.2

0.5

0.45 0.9 0.9 0.4

0.5

2008

18 | Assessment of Project ORCHID, September 2011

19 | Assessment of Project ORCHID, September 2011

The prevention package for PWIDs

Project ORCHID (Organised Response for Comprehensive HIV Interventions in selected high-prevalence Districts of Manipur and Nagaland) was initiated in May 2004 as collaboration between EHA and AIHI, now Nossal Institute for Global Health, University of Melbourne. The project received funding from the Bill & Melinda Gates Foundation through the Avahan programme. Project ORCHID has been working to reduce transmission of HIV and STI among people who inject drugs (including female PWIDs), female sex workers (FSWs), men who have sex with men (MSM) and their sexual partners through a response of increased scale and coverage in selected high-prevalence districts and townships of Manipur and Nagaland in Northeast (NE) India. Project ORCHID completed Phase I in March 2009 (2004 – 09) and is now in Phase 2 (2009-13). The goal of this Phase II grant is to: (1) consolidate HIV/AIDS prevention services among PWIDs, female sex workers and men who have sex with men, (2) transfer the programme to the community and government, and (3) disseminate learnings within and beyond India.

Avahan provides an enhanced package of harm reduction services to the PWID community, whose components include: Standard components of the harm reduction package in India: • • • • •

The primary goals of Avahan in the Northeast with IDUs: Mon Longleng

Tuensang

Wokha

Nagaland

• • •

1. Build a “model” DU program 2. Transfer the program to natural owners: the community and government 3. Foster and disseminate learnings within India and globally

The Project ORCHID programme also added several components to the delivery of the standard harm reduction package in India:

Zunheboto Dimapur

In 2011-12, the program is targeting 10,800 PWIDs; 1,520 OST clients; 3,250 FSWs; and, 1,450 MSM (based on 2010 mapping numbers).

Senapati

Tamenglong Ukhrul Imphal West Bishnupur

Churachandpur

Imphal East

Manipur

Thoubal

Chandel

• • •

Project ORCHID tagets:

Phek

Avahan Districts District Headquarters

•

Special focus on new injectors Focus on spouses of PWIDs Special programmes for  Female PWIDs  Hard to reach populations Provision of naloxone and other key commodities

At the time that the project was initiated (2003), OST was not part of the national guidelines. Thus, the project did not include OST in the initial five years of implementation. However, during the first five years, Project ORCHID received support from DfID (February 2006 - December 2007) and then NACO (January 2008 - June 2008)v for OST delivery for 1,800 PWIDs. OST was then added to the Project ORCHID second phase proposal to scale up this service in both states. However, delivery of additional OST (through foundation funds intended to scale coverage of PWIDs with OST beyond what is funded by NACO) was withheld by the foundation given the fact that NACO policy at the time (2009-11) was to ‘freeze’ scale-up of OST in NGO settings, awaiting the roll-out results from the government setting model. Given that the Avahan programme planned to transition to the government, the decision was made to not provide additional OST through Avahan NGOs, given the potential lack of ‘takeover’ by the government in the near future. However, Avahan funding supplemented existing OST sites by funding additional staff positions to make the delivery more effectivevi. Since 2009, Project ORCHID has played a significant role in advocating for NGO-delivered OST in Manipur and Nagaland based on their experience.

Avahan provides services through 24 implementing partners (12 in Manipur and 12 in Nagaland) and operates 46 drop-incentres and 38 project clinics ithin the DICs, across 13 districts (7 in Manipur and 6 in Nagaland).

It is worth noting that the foundation’s investment in the Northeast was done with the key objective of building and disseminating a “model” PWID programme. The original purpose of the HIV prevention programme among PWIDs was not to achieve state level impact on HIV (as with states in the south where Avahan intervened). Rather, it was to build capacity, scale up interventions in select geographies (covering 28%-54% of the PWID population in both states), and demonstrate a model. There are three contextual factors underlying this approach. First, integrated and comprehensive PWID programmes in India were nascent at the time, and a good model needed to be created and thereafter disseminated within India and beyond. Second, given the challenging socio-political-geographic environment of the Northeast, a large scale presence of the foundation was not optimal and feasible. Third, with limited, rather than scaled programmatic engagement, aiming for state level epidemic impact was unrealistic.

20 | Assessment of Project ORCHID, September 2011

Provision of safe spaces to the community through drop-in centres (DIC) Diagnosis and treatment of abscesses and sexually transmitted infections (STIs) through programme-supported clinical services Needle and syringe exchange programme (NESP) -- provision of clean needles and syringes and collection of used ones Provision of condoms and lubricants Referrals and linkages to government-delivered treatment/testing services (ICTC, ART, TB) Opioid substitution therapy using buprenorphine Overdose management Community mobilisation (including participatory mapping and service planning, capacity building, legal literacy and advocacy)11

v During this period, NACO took on most of the full staffing and structure of the DFID OST program. From July 2008 onwards it is integrated with TIs. vi In July 2008, NACO integrated OST with TIs. Where OST staff and budgets were cut, TI staff covered OST services. 21 | Assessment of Project ORCHID, September 2011

Avahan’s focused HIV prevention programme features a set of basic implementation standards relating to aspects of technical and managerial programme guidance. These basic implementation standards are referred to as the Common Minimum Programme (CMP). The CMP aims to build a common vision and define a set of operating standards including: • • • •

Well-documented guidelines for programmatic and technical standards and approaches Key project milestones (i.e., time-bound measurable targets) A common management framework A common set of indicators against which the programme can be monitored

The CMP is flexible enough to allow for customisation based upon local needs. Local level innovations are able to be channelled back to the broader Avahan programme level and, in fact, the CMP has been thrice revised within five years12.

ASSESSMENT

22 | Assessment of Project ORCHID, September 2011

23 | Assessment of Project ORCHID, September 2011

Context and objectives of the assessment External experts (see Annex 5 for TOR of evaluators) and a Scope Group was invited by Avahan to assess Project ORCHID. The assessment aims to contextualise the Project ORCHID harm reduction model within the global context, highlighting the innovations, challenges faced and lessons learnt throughout the implementation of the programme, in order to prepare for a smooth transition/handover of the programme to the Indian Government and assist in disseminating the most relevant learnings. The Project ORCHID Phase II Avahan milestones are presented in Annex 2. Specifically, the goals and objectives of the assessment and learning project are (see Annex 4 for methodology): Goal 1: Determine whether Project ORCHID is on track to achieve intended programme outputs and outcomes (programme coverage and quality versus milestones/intended coverage) Goal specific objectives: A. Are the monitoring and evaluation indicators and methods used by the programme appropriate? What has been adapted so far and what can be done differently? B.

Determine if programme milestones of Phase II ORCHID project are on track

Find out if all the key recommendations suggested were adopted and implemented from Phase I Project ORCHID review

Identify challenges faced by Project ORCHID in implementing these key recommendations suggested from the Phase I review

Goal 2: Determine whether Project ORCHID developed unique implementation principles (a ‘model’)vii to enhance implementation efficiency and effectiveness of a universal harm reduction package and capture these. Goal specific objectives: A.

Identify key principles of the Project ORCHID ‘model’ which advance harm reduction delivery strategies

Determine if there has been any effort to document and disseminate, and identify the mechanisms for dissemination within and outside of India – whether this has been adequate

Make key recommendations to Project ORCHID on how to better disseminate the ‘model’ (key principles)

Asssessment Goal

METHODS

Asssessment Goa

vii Project ORCHID is implementing a universal harm reduction package. “Model” refers to innovations in delivery, management and data to make the provision of services more effective and efficient. 24 | Assessment of Project ORCHID, September 2011

25 | Assessment of Project ORCHID, September 2011

Types of assessment

•

Two primary types of assessment were conducted: on-site and off-site assessment including collection of primary and secondary data (quantitative and qualitative data). The off-site method allowed the team to interview the programme managers and chief functionaries of some of the NGOs in Imphal (in Manipur) and Dimapur (in Nagaland). Group discussions were held to obtain feedback and to better understand the implementation of Project ORCHID’s key principles.

•

The on-site method involved the assessment team physically visiting the respective project sites. The limited time and uncertain political climate and bandhviii in several districts also made it difficult for the assessment team to travel to some of the project sites. Therefore, selection criteria were used to select sample districts.

•

Site and sample selection criteria There were no specific sampling techniques used to select the site and sample for the field visit. The assessment team used several guidelines to ensure they were able to answer most of the objectives of the assessment. The assessment team was guided by these criteria for site representation: •

• •

•

Availability of good behavioural data (e.g., BTS, PBS).  Availability of data (outcome/impact and behavioural) will be useful as the sites will allow the team to obtain data especially those to fill the gaps from the secondary data analysis conducted before the assessment. Mixture of sites seen in the previous review and ones not yet seen.  This mixture will ensure that additional sites that have not been assessed previously will be visited. This will complement the previous assessment and also reduce bias of data being derived from the same sites visited in Phase I. Demonstration of linkages to testing and treatment.  Visiting these sites will provide an understanding to the assessment team of the link between drug users and testing and treatment. Understanding the operational issues involved linking these services for drug users will be important. Distance and time to reach.

Based on the above criteria, the final selected sites/districts for the assessment were the following: In Manipur, the assessment team visited the following organisations/programmes: 1. SHALOM (male and female PWID programme), Churachandpur 2. Humanitarian Organisation for Progress and Empowerment (HOPE), Churachandpur 3. Dedicated People’s Union (DPU), Kumbi 4. SASO Imphal East and West (including an overdose management site) 5. A Muslim youth-based organisation, Imphal

Urban intervention.  Urban sites will provide an understanding of interventions being implemented in urban settings. For example, most of the OST programmes are implemented in urban settings. Dispersed population intervention. Sites found to be weakest in the mid-term evaluation, to which strong recommendations for follow-up were given.  Visiting weaker sites will also allow the assessment team to gauge if improvements have been made from the first phase and to also understand the reasons why these sites are weak. It will also provide a basis for comparison with the stronger sites. Female PWID intervention or women-friendly services for PWIDs.  Visiting a female PWID intervention site will give the team insights on the type of services that has been rolled out for female PWIDs. Demonstration of community building activities (e.g., a strong community-based organisation, CBO).  The team will be able see and document activities that have been implemented and also understand the operational issues involved in CBOs. High prevalence district.  It is important to assess high prevalence districts as the team will be able to assess the effectiveness of interventions being implemented by Project ORCHID. Availability of good data sources to assess outcome/impact (e.g., sites with integrated biological and behavioural assessment [IBBA] data).

A visit was also made to the project director of SACS Manipur and a stakeholders’ meeting was also held. In Nagaland, the assessment team visited the Rukizumi Welfare Society, Pfutsero. Data collection Primary and secondary data were collected during the assessment. Secondary data were obtained from the Project ORCHID monitoring and evaluation (M&E) team and from Avahan. These data were primarily quantitative and have been collected routinely by Project ORCHID through the various Avahan surveys (IBBA, BTS, PBS and mapping/size estimation data) as part of their M&E agenda and government data on the HIV/AIDS epidemic (HSS, PPTCT). See Annex 6 for all the relevant data sources on Project ORCHID. Primary data were collected during the assessment. This was qualitative data and was collected using in-depth individual interviews and group discussion. The details of the interviews are given below:

viii Bandh is a form of protest by political activists.

26 | Assessment of Project ORCHID, September 2011

27 | Assessment of Project ORCHID, September 2011

Duration of assessment

Institution

Programme

Type of data

SHALOM, Churachandpur

Male PWID

Group discussion with outreach workers (ORW)

Female PWID

Group discussion with outreach workers (ORW) Observation (at sex worker hot spot)

HOPE, Churachandpur

Male PWID (including OST programme)

Presentation by and discussion with the management of HOPE

DPU, Kumbi

Male PWID (including OST programme)

In-depth interviews: • Nurse • Project manager • ORW Group discussions: • Peer educators (PEs) • OST clients

SACS, Manipur

Project Director

In-depth interview

SASO Imphal East and West

Male PWID

Observations: • Overdose management • OST clinic

The field visit was carried out from the 26th to the 30th of September 2011. The first three days (26 – 28 September 2011) of the field visit was in Manipur and the remaining two days (29 – 30 September 2011) in Nagaland. A pre-assessment visit was carried out by the SCOPE consultancy team to plan for the actual assessment. Protection of human subjects Several measures were taken to ensure that human subjects are protected. All data were provided on a voluntary basis and no personal identifiers were obtained from these subjects. The quantitative data analysis will be conducted to obtain aggregate data that cannot be linked back to any particular individual. All qualitative interviews conducted with drug users were confidential and no personal data were referred to in the report that will allow it to be linked to any particular individual. Limitations The conduct of this assessment involved people separated by distance and countries. This limited the coordination and communication between the team members. The uncertain political climate made it difficult for the assessment to select the sites. The selection of sites could only be determined at the last moment and the assessment team had to rely on the advice of Project ORCHID’s management team. However, the guidelines provided by the assessment team ensured there was some variation in the sites assessed.

Group discussions: • OST clients • Peer educators Muslim Youth Group, Imphal

Male PWID

Group discussion: • Board members

Project ORCHID

Key management staff

Group discussions Individual interview: • Transition manager

Stakeholders

Key stakeholders in Manipur

Group discussion

Rukizumi Welfare Society, Pfutsero

Male PWID

Group discussions: • ORW • Peer educators • Church leader, women’s NGO leader, local community leader and parent of drug user • OST clients

Daily de-briefing The objective of the daily de-briefing was to assess the progress made for the day and also to review and summarise the type of information or data that has been collected. This allowed the team to monitor closely the type of data being collected and to collate all the data that will be used to analyse and write the final report.

28 | Assessment of Project ORCHID, September 2011

29 | Assessment of Project ORCHID, September 2011

The duration of the assessment was only one week and the team had to cover two states. Considerable time was spent travelling given the geographical spread of the project locations. The assessment team tried to minimise this impact by doing off-site assessments. One member of the mid-term review team (Dr. Sundar Sundararaman) was also part of the current assessment team, and Dr. Mariam Claeson and Dr. Swarup Sarkar participated in the Manipur and Nagaland parts of the field visit, respectively. A financial audit was not conducted, as it was not in the scope of this assessment, which focused on programmatic progress, and is conducted through three other mechanisms: 1) costing analysis that is being conducted by an external evaluation of the Avahan programme, 2) financial audit review to be conducted as part of the NACO evaluation that will take place before handover of the programmes, and 3) external Project ORCHID audit through KPMG. Two Avahan staff were also part of the assessment team, and were present at each site visit and at interviews conducted at the site. Because of the possibility that their presence may influence the feedback and responses during the meetings and interviews, it was made clear that the Avahan staff were not directly involved in the process of the assessment, but merely to assist with the coordination. In addition, the Avahan team also provided required inputs in the preparation of this report.

KEY FINDINGS

Property rights of the data The data shared here cannot be distributed, used or published for any other purpose than the Project ORCHID evaluation report.

30 | Assessment of Project ORCHID, September 2011

31 | Assessment of Project ORCHID, September 2011

The team reviewed the indicators and methods used for monitoring and evaluation and had the following findings: 1) Robust MIS 2) Indicators and methods were sufficient and appropriate for project monitoring (M) 3) However, more focus needed to be given to ensure appropriate evaluation (E) of the impact of the Project ORCHID programme. 4) The team had several recommendations on what needed to be done next in terms of evaluation. These included: a) conducting community led surveys at the intervention level to monitor levels of HIV (e.g., through saliva tests), b) implementation of a 3rd round of the IBBA survey among PWIDs to obtain up-to-date and end of program results on changes in biological and behavioural indicators, and c) fasttracking the evaluation agenda to include statistical and modelling methods to conclusively ascertain the impact of the programme on PWIDs in the geographies where it operates.

Assessment Goal

•

Accessibility to needles and syringes from the programme: Outreach services provided by NGOs in Manipur, indicated by the measure of PWIDs who obtained their needles from NGOs in Manipur and PWIDs receiving condoms, in general have increased when compared to data from 2006 and 2009 based on the population-based surveys IBBA and BTS. All districts, except for Chandel, show an increase in the percentage of PWIDs who obtained needles from NGOs. The district of Chandel shows a decrease from 87% in 2006 to 68% of PWIDs who acquired their needles from NGOs in 2009. Ukhrul shows the highest increase, from 29% to 71%, whereas Bishnupur and Churachandpur both show an increase of about 20%.

Objective

Percentage PWID who normally get needles from NGO (IBBA & BTS), Manipur

Below we present the findings for all the other objectives of goal 1.

Programme output data A comprehensive analysis of programme output data (using the Project ORCHID CMISix) was done to understand whether the programme is on track in terms of provision of services and scale-up in the geographies where Project ORCHID operates. A summary of our findings is the following: •

• •

Objective

Percentage (%)

Analysis of programme output and outcome data (Objective B)

Regular contacts: Almost 80% of the PWIDs are contacted each month at the Project ORCHID level, with levels slightly lower in Nagaland and slightly higher in Manipur. In Nagaland 8,170 PWIDs and 13,501 PWIDs in Manipur have been contacted at least once by the programme till date. Clinic visits: Monthly clinic visits have exceeded the monthly (15% achieved compared to 5% monthly target). Needle/syringe distribution: On average, 20 needles/syringes were distributed per month per key population (KP) at the Project ORCHID level (12 in Nagaland and 22 in Manipur). The higher rates in Manipur reflect the different drug use patterns between the two states. The exchange rate of needles/syringes (NS) is >65%.

District

Based on reported NGO programmatic data, accessibility to needles and syringes for PWIDs was quite high in Manipur. Bishnupur with 95% showed the highest percentage of PWIDs who had access to needles and syringes when needed. Imphal-East with 56.3% and Imphal-West with 62.8% showed a lower access compared to the other districts. This corresponds to the measure of PWIDs who practice unsafe injecting in the district of Bishnupur (21.9%).

ix The period analysed is from November 2009 to July 2011.

32 | Assessment of Project ORCHID, September 2011

33 | Assessment of Project ORCHID, September 2011

Percentage PWID who can access new needles/syringes when needed, Manipur

All NGOs in the districts in Nagaland reported high accessibility of PWIDs to needles and syringes. Zunheboto and Kiphire reported that all PWIDs were able to access needles and syringes when needed, while Phek also showed a very high access rate at 98%. However, there are large discrepancies between IBBA/BTS findings and the percentages of PWIDs who can access new needles as reported by the NGOs in the districts. While all the NGOs reported over 90% access, population-based surveys found the percentages to range from as low as 13% in Wokha, to 79% in Phek.

Percentage (%)

Percentage PWID who can access new needles/syringes when needed, Nagaland

District

* Percentages presented in this graph are based on weighted averages of data obtained from various NGOs within each district. In Nagaland, the districts of Phek and Kiphire both show an increase of PWIDs who obtain needles from NGOs, with Phek showing the strongest increase from 11% in 2006 to 79% in 2009, followed by Kiphire with an increase from 36% to 75%. Wokha and Zunheboto continue to have low levels of access to needles, at 11% and 35%, respectively.

District

â&#x20AC;˘ Condom distribution: Approximately 10 condoms per PWID per month are distributed. This low level possible reflects low levels of sexual activity among PWIDs.

Percentage PWID who normally get needles from NGO (IBBA & BTS), Nagaland

â&#x20AC;˘ Accessibility to condoms: From data reported by NGOs, most districts in Manipur showed a measure of over 80% of PWIDs who can access condoms when they need them, except for Imphal-East and Imphal- West with measures of 41% and 72%, respectively. Percentage PWID who can access condoms when they need them, Manipur

Percentage (%)

* Percentages presented in this group are based on weighted averages of data obtained from various NGOs within each district

District District

34 | Assessment of Project ORCHID, September 2011

35 | Assessment of Project ORCHID, September 2011

However, demand and distribution of condoms increased substantially in August. The average monthly demand for condoms among PWIDs in Bishnupur is 6,200 and the average monthly distribution of condoms is 6,164, where 470 PWIDs are receiving these condoms per month. Bishnupur:

The district Kiphire showed all PWIDs having access to condoms when they need them. Phek also showed a very high accessibility for PWIDs to obtain condoms, with 96%. The lowest accessibility rate was in Tuensang at 64%. Percentage PWID who can access condoms when they need them, Nagaland

Condom Promotion (data from Jan 2011 to Aug 2011)

Percentage (%)

6600

6400

Demand

6200

Distribution 6000

5800

HIV testing:x Over 40% of the PWIDs in the programme have been tested at least once for HIV. Among those tested for HIV at least once in each year, the percentage positive have shown a decreasing trend. Against the target of 50%, only 10% of PWIDs are tested twice in a year at the Project ORCHID level. However, this has been increasing steadily since 2009 as new approaches are being used (e.g., extensive use of mobile ICTC in coordination with the SACS).

â&#x20AC;˘ In Nagaland, the accessibility to condoms through NGOs ranges between 74% and 83% in 2009, except for the district of Wokha which showed just 43%, although this was still an increase from 32% in 2006. Percentage PWID who normally get condoms from NGO (IBBA & BTS), Nagaland

% of IDU contacted in the month 140

2006/2007 2009

Target (Avahan) Nagaland Manipur ORCHID

Percentage (%)

120 100 80 60 40 20 0

Nov -09

Feb -10

May-10

Aug -10

District

x HIV testing data for 2011 is only until the month of July.

* Data not available for Zunheboto and Kiphire in 2006.

36 | Assessment of Project ORCHID, September 2011

37 | Assessment of Project ORCHID, September 2011

Nov-10

Feb -11

May-11

NSP per month per IDU

Reaching out to priority populations:

A priority for the programme was to reach out to priority populations including female PWIDs, young PWIDs (less than 25 years old), and PWIDs who have been injecting less than one year. The programme has made progress in reaching out to all of these highest-risk populations: the percentage of PWIDs <25 years registered has increased from 25% (2009-10) to 33% (2010-11); the percentage of female PWIDs registered has increased from 2.7% (2009-10) to 7% (2010-11); the % of PWIDs who have been injecting drugs for <1 year registered has increased from 4% (2009-10) to 21.5% (2010-11).

Nagaland Manipur

ORCHID

0 Nov-09

Feb-10

May-10

Aug-10

Nov-11

Feb-11

The team also conducted an analysis of the Avahan milestones. A summary of a sub-sample is the following:

May-11

NSP Exchange rate (ORCHID)

400000

70%

350000

60%

300000

50%

250000

40%

200000

30%

150000

20%

100000

10%

50000

Apr-09

Aug-09

Dec-10

Apr-10

Aug-11

Dec-10

Distributed Returned Exchange rate

Apr-11

Milestone

Status

Average monthly contact at 80%

Achieved (94% at ORCHID level; 96% Manipur, 90% Nagaland)

Average monthly outreach through peer educator at 50%

Achieved (87% ORCHID; 99% Manipur, 80% Nagaland)

50% of PWIDs access clinical services at least once a year

Achieved (81% ORCHID; 93% Manipur, 62% Nagaland).

50% of PWIDs tested for syphilis at least once a year

Achieved (48% ORCHID; 53% Manipur, Nagaland pending (41%)

Avahan milestone: % of IDUs who visited clinic for any reason at least once in the year for Nagaland and Manipur states (April 2009-July 2011)

% Tested for HIV (ORCHID) 12.0

8.0 # tested at least once

4.0

% positive

0.0 Manipur

38 | Assessment of Project ORCHID, September 2011

39 | Assessment of Project ORCHID, September 2011

Nagaland

Programme outcome data

Percentage of PWID who ‘sometimes’ shared injecting equipment in the previous month, Nagaland

Percentage (%)

To better understand whether the programme is having impact, it is critical to analyse outcomes on both behavioural (needle/syringe sharing and condom use) and biological indicators (levels of HIV and STIs). Several data sources exist (see Annex 6) and include the Integrated Behavioural and Biological Assessment (IBBA),xi the Behavioural Tracking Survey (BTS) and the Polling Booth Survey (PBS).xii A summary of the analysis is below: 1. Needle sharing: As per the IBBA, safe injection patterns are showing increasing trends in both Bishnupur and Churachandpur districts of Manipur, and both Phek and Wokha districts of Nagaland (although further improvements are needed). In Nagaland and Manipur, the percentage of PWIDs who did not share a needle with a stranger in the last month increased (from 44% to 82% in Wokha; 42% to 86% in Phek; 21% to 76% in Bishnupur; 53% to 95% in Churachandpur). Not injecting with NS previously used by others in the last injection has reached high levels in all districts (96% in Bishnupur and Churachandpur, 83% in Wokha and 80% in Phek). There is an increasing proportion of PWIDs never sharing with anyone between the two rounds of IBBA: percentage of PWIDs not having an injection partner increased from 43% to 65% in Wokha, 51% to 61% in Phek, 72% to 87% in Bishnupur, and 41% to 79% in Churachandpur.

2. Condom use: As per the IBBA, the programme is seeing increasing levels of sexual activity among PWIDs. In Manipur, PWIDs who ever had sex with a female partner increased from 65% to 79% in Bishnupur and 76% to 90% in Churachandpur; in Nagaland 89% to 91% in Wokha and 78% to 92% in Phek. Last time condom use with non-paid regular female partner has increased in Manipur (29% to 49% in Bishnupur, 32% to 42% in Churachandpur), with mixed results in Nagaland (declined from 40% to 30% in Wokha, increased from 32% to 57% in Phek). Condom use in last sex with FSW is high in all districts. Although there is an overall improvement in condom use, these results underscore the need to pay attention to sexual risk among this population (especially with non-paid female partners).

The Project ORCHID Phase II milestone on needle sharing is “<30% of PWIDs sharing needles and syringes in the last month”. As per the PBS data, the milestone is achieved or close to being achieved in 4 of the 7 districts in Manipur and 3 of the 5 districts in Nagaland. Percentage of PWID who ‘sometimes’ shared injecting equipment in the previous month, Manipur

The target of 40% consistent condom use with non-regular partners (Project ORCHID milestone) is achieved in all districts in Nagaland, but not in Manipur. Percentage of PWID reporting ‘always’ using condoms with non-regular partner in the previous month, Manipur Project ORCHID milestone: <30% IDU sharing needles and syringes in the last month

Percentage (%)

Project ORCHID milestone: <30% PWID sharing needles and syringes in the last month

xi IBBA wad conducted in select districts: Bishnupur and Churachandpur in manipur, and Wokha and Phek in Nagaland

xi PBS is conducted at the intervention level.

40 | Assessment of Project ORCHID, September 2011

41 | Assessment of Project ORCHID, September 2011

Project ORCHID milestone: <40% PWID consistently use condoms with non-regular partners

Percentage of PWID reporting ‘always’ using condoms with regular partner in the previous month, Nagaland

Percentage (%)

Project ORCHID milestone: <40% PWID consistently use condoms with non-regular partners

Project ORCHID milestone: <40% PWID consistently use condoms with regular partners

Percentage (%)

Percentage of PWID reporting ‘always’ using condoms with non-regular partner in the previous month, Nagaland

4. HIV levels: Changes in HIV levels among PWIDs can be ascertained from the IBBA-Round I conducted in 2006 and Round II conducted in 2009. It should be noted that in Manipur, Churachandpur district is shared between the SACS and Project ORCHID and therefore results reflect the cumulative impact of these two programmes as all PWIDs in the district were sampled regardless of which programme they accessed for services. Between the two rounds of the IBBA, there has been a significant decline in HIV in Bishnupur district (23.1% to 16.2%). HCV levels have also significantly declined (55.9% to 45.7%). Whereas there has been a significant increase in Churachandpur (from 32.2% to 39.9%) and in HCV levels (77.6% to 92.2%). In Nagaland, in both Phek (~1%) and Wokha (~2%) levels remain low and stable. It should be noted however that the Project ORCHID programme does not have an integrated HCV prevention programme (which is one recommendation from this assessment).

Project ORCHID milestone: <40% PWID consistently use condoms with regular partners

5. STI levels: Trends in both the districts of Manipur have remained stable and low. In Nagaland, we see significant declines in STIs in Wokha, but increases in Phek district. IBBA Result Levels of consistent condom use with regular partner are lower than the target milestone of >40% of PWIDs consistently using condoms with their regular partners as per the PBS/BTS. In Manipur, the milestone has been achieved only in Bishnupur district, and in Nagaland in Wokha and Zunheboto districts.

55.9 45.7

3. HIV testing: As per the IBBA, there has been improvement in levels of HIV testing, but still remains low. Those who have ever taken an HIV test are 9% in Wokha, 36% in Phek, 42% in Bishnupur and 54% in Churachandpur. It should be noted that these are results as of 2009 and the programme has placed significant emphasis since then on scaling up HIV testing.

Bishnupur R-1

R-2

23.1 16.2

14.9 5.7

42 | Assessment of Project ORCHID, September 2011

43 | Assessment of Project ORCHID, September 2011

4.1

6.3

9.7 2

1.7 1

0.3 0

Assessment Objective 92.2 77.6

32.2

39.9

Churachandpur

0.9 2.7

5.8

21.6 17.8

11.6

R-1 2.1 1.9

R-2

0 0.7

Adoption of recommendations from Phase I review (Objective C)

Recommendation

Strive to attain the goal that every person belonging to the key population has access to care and ongoing prevention services.

Qualitative data from the site review provides evidence that some to significant progress has been made on 13 of the 14 recommendations from the Phase I review. The following discussion highlights the recommendations on key areas of progress and the adoption and implementation of key recommendations from the Phase I Project ORCHID review.

• • • •

• • Phek

13.9 11.4 7.5

7.4 4.8

12.5 R-1

8.7

R-2

0.6

Recommendation

5.4

1.1 1.0

2.0

Focus outreach and prevention activities to a greater extent on the rural communities, border areas, and inaccessible regions. • • • •

20.8

19.5

6.8 1.8 2

9.0

Mobile clinics, especially where ICTC is integrated, improve reach. Secondary distribution networks improve consistent commodity supplies, especially in rural and inaccessible regions. Peer outreach workers are effective at motivating PWIDs to visit clinics. Project ORCHID/Dimapur is initiating a pilot test to collaborate with other organisations to collect blood samples from inaccessible areas and batch them for testing, mitigating the need for clients to visit an ICTC site.

Wokha

21.1

16.7

16.5

A TI programme for female PWIDs is cited as preventing new HIV infections by the Shalom female PWID programme. The Shalom male PWID programme reports success in ARV treatment adherence among OST clients. Shalom and DPU accompany 90% or more of referrals, contributing to continuity of services. Mobile clinics bring services to work places, hot spots and other locations where PWIDs are located, as reported by Shalom and Project ORCHID/Dimapur. RWS integrates ICTC with mobile units on a quarterly basis, using rapid test kits to provide preliminary results on the spot. The presence of community volunteers at the DPU clinic leads to increased service uptake by PWIDs. Secondary distribution networks help ensure consistent availability of commodities when and where they are needed.

R-1

R-2

11.1 5.6 2.8

1.6

0.4

44 | Assessment of Project ORCHID, September 2011

Recommendation

45 | Assessment of Project ORCHID, September 2011

Expand activities to deliver targeted sustained and evidencebased prevention interventions to high-risk priority populations. • •

Shalom, RWS, and Project ORCHID/Dimapur have developed specialised services for female PWIDs, many of whom are FSWs, and report increased service uptake through this model. It is unclear, however, whether these are evidence-based approaches.

Recommendation 4: Incorporate need-based services like hepatitis C prevention and overdose prevention and management. • DPU operates a peer led hepatitis C prevention programme. • Abscess and ulcer cases are becoming increasingly rare at Shalom, and the majority of those presenting are caught at an early stage. • Naloxone interventions have decreased overdose deaths. Recommendation 5: Place greater emphasis on women-centric services. • Project ORCHID has established a process for identifying female PWIDs through peddlers and male PWIDs. If numbers in a district are small, they are encouraged to join a male group. If there is a critical mass, a specialised service is established, as at Shalom, RWS and Project ORCHID/Manipur. Recommendation 6: Integrate OST services into existing harm reduction interventions. • Integration of OST with harm reduction package was observed at the DPU programme site. Recommendation 7: Find new ways to support HIV/AIDS workers in the field and to draw on their experience in establishing networks for sharing best practices. • DPU has obtained ID cards for outreach workers from the police; other programmes issue their own ID cards. • Hope has a “community first” policy in structures and processes to build capacity of community members for most organisation positions. They report a focus on community empowerment and peer progression. • Supportive supervision by chief functionaries and capacity enabling management has been put into place by all programmes. • Networking among local organisations is taking place and provides for mutual support and capacity building. Recommendation 8: Enhance collaboration with drug demand reduction organisations to ensure that those requiring drug counselling and treatment are provided with these services. • No evidence was observed of this activity during the site visits. Recommendation 9: Work with medical institutions and hospitals to ensure that PWIDs receive adequate medical services. • HIV infected community members are referred to organisations for treatment, care and support services. • DPU has established MOUs with health centres to improve quality and access to services.

Recommendation

11 12

Recommendation

46 | Assessment of Project ORCHID, September 2011

• •

•

Recommendation

47 | Assessment of Project ORCHID, September 2011

DPU operates a peer led hepatitis C prevention programme.

Recommendation 12: Create opportunities to interface with law enforcement, paramilitary, custodial settings, and religious groups. •

•

All programmes report referrals to ICTC and track clients who require pre-ART or ART services. (See quantitative data for numerical evidence.) Project ORCHID/Manipur provides care, support and impact mitigation.

Recommendation 11: Take steps to ensure that an appropriate treatment regime is offered to PWIDs co-infected with HIV and hepatitis C.

•

Recommendation

Recommendation 10: Increase the number of HIV infected PWIDs in ART clinical care.

DPU has carried out advocacy with police, women’s leaders, local authorities, church leaders, social workers and army majors to sensitise them to the needs of PWIDs and explain project aims. As a result, stakeholders have visited the programme and invited staff to participate in events and serve as resource persons. Project ORCHID/Dimapur has developed media messages and videos that they present to village elders, elected officials and religious and social groups, followed by discussion and interactions with PWIDs. Relationship building by RWS with the Mothers’ Association and religious groups has led to better cooperation with the police and leadership by the Baptist Theology College reduces stigma and discrimination.

Recommendation 13: Facilitate community mobilisation by providing adequate support/training for them to ensure that they become owners of interventions. • •

Programmes have carried out exposure visits, leadership identification processes, and skills development. Programmes are moving from inclusion to participation and engagement.

Recommendation 14: Include SACS officials in project discussions at the state level and develop transition plans. •

Project ORCHID has negotiated a transition strategy with NACO that includes establishing a state transition committee, identifying areas of overlap between geographic areas and KPs, implementing a NACO/Avahan transition tool, fixing a date for transition and verifying assets and documents, and final induction.

Based on our review, we created a qualitative score card to highlight the current progress against each recommendation. 2009 REVIEW RECOMMENDATIONS

PROJECT ORCHID RESPONSE (as of September 2011)

R1: Maximise reach to every person needing service

• Direct revised size estimation • Increased contact: 71% to 91% • Innovative approaches -- female injectors, link OST facility & community, mobile clinics

Communication to MARP

R2: Rural communities, border areas and inaccessible regions

R3: Expand HR to high-risk population population (e.g., sex workers)

STATUS

• Local materials: PWID flipbook produced by the community • Retraining of ORWs/PEs in peer education • “First ever Hard to Reach programme” in Ukhrul & Wokha; results to be available in 12 months • Mobile clinics & ICTC link • Female PWID registration as % of all registration increased 7 times • Special focus and strategy to reach 0-3 and 4-12 month injectors • Seven-fold increase in percentage of new injectors Churachandpur, Bishnupur, Imphal • Spouse programme

R4A: Overdose prevention

• Overdose prevention management (naloxone, training in use, crisis response teams training) introduced early 2010

R4B: Hep C

• IEC materials in liver care and Hep C developed and launched in 2010

R5: Women-centric services.

• Female PWID TI introduced in Churachandpur; new programme results awaited

R6: Integrate OST services into existing interventions

• Completed except for MNP+ Imphal, Care Foundation Imphal and GA Dimapur

R7: Sharing best practices

• Sharing best practices in NGO reviews • Visits from other state SACS/TSUs

R8: Ensure drug counselling and treatment in detox programmes

• Regular link and monitor these services

48 | Assessment of Project ORCHID, September 2011

2009 REVIEW RECOMMENDATIONS

PROJECT ORCHID RESPONSE (as of September 2011)

R9: Work with medical institutions and hospitals to ensure that PWIDs receive adequate medical services

• SACS training for PHC staff in Nagaland • MoU signed between most NGOs and and local PHC and ICTC • Advocacy through DAPCU • Inclusion of PWIDs in DAPCC

R10: Increase ART coverage for PWIDs though ART centres

• HIV testing increased fivefold in PWIDs • Increased advocacy with ART centres and SACS regarding opening hours and follow-up

R11: Appropriate treatment offered to PWIDs co-infected with HIV and hepatitis C

• HCV testing and treatment not funded & without guidelines • HCV testing and treatment not funded & without guidelines • IEC/liver care leaflet

R12: Approach enforcement, paramilitary, custodial settings and religious groups

• Key stakeholders involved • Project ORCHID staff engaged in this advocacy

R13: Facilitate community ownership of interventions

• Extensive training and evaluations to facilitate community mobilisation • 28 community-based groups & 55 community committees over both states

R14: Include SACS officials & develop transition plan

• Joint state steering committees chaired by PD SACS formed to coordinate state activities and oversee transition • Joint visits to potential transition sites • Joint transition training of NGOs

Activity accomplished

49 | Assessment of Project ORCHID, September 2011

Positive results, activity ongoing

STATUS

Activity not accomplished

Objective

Challenges faced by the programme (Objectives D and E) Key informants referred to numerous challenges faced by Project ORCHID both in achieving or not achieving Phase II milestones and in implementing Phase I recommendations. Challenges that were cited thematically across sites include: 1. The geographically dispersed nature of the populations presents challenges in outreach, testing, and continuity of care and support. Travel costs to testing and treatment sites are barriers to service uptake. 2. PWIDs are, by nature, hidden populations. This is particularly true for women outside of cities, who are also highly mobile, and for PWIDs in Nagaland, who inject at home, rather than in hot spots. In addition, hot spots relocate on a regular basis.

D E &

3. The insurgency creates disruptions in programme operations, including provision of commodities; however, this is currently viewed as a less serious problem than in the past. 4. Despite knowledge of the harm associated with heroin use, heroin remains a drug of choice, resulting in low acceptance of OST.

Phase I recommendations

Phase II follow-up recommendations

Place greater emphasis on providing womencentric services.

• Link with hot spots covered by other organisations to better track mobile female PWIDs (Shalom female PWID programme) • Provide child care for working women, including FSWs (Shalom female PWID programme) • Provide shelter services to reduce female vulner ability (Shalom female PWID programme) • Link women with other women in their neighbour hoods for psychosocial support (Shalom female PWID programme) • Provide special facilities for childbirth (Shalom female PWID programme) • Provide for sexual reproductive health needs of female PWIDs (Shalom female PWID programme)

Find new ways to support HIV/AIDS workers in the field and to draw on their experience in establishing networks for sharing best practices.

• Continue to invest in capacity building; specific requests include additional training in interpersonal skills, communications, and counselling for PEs • Review PE salary and allowances to determine if they are appropriate (Project ORCHID team, RSW); consider incentives for high performing PEs (RSW) • Simplify micro-planning process (DPU, stakeholders meeting) • PEs are physically weak and need more health support (DPU)

Work with medical institutions and hospitals to ensure that PWIDs receive adequate medical services.

• HIV and PWIDs should be viewed in broader health context; health providers should be prepared to counsel and provide referrals to necessary health services (stakeholders meeting) • Advocate for the reduction of stigma and discrimi nation in health care settings (NGO leaders, Shalom female PWID programme, DPU)

Create opportunities to interface with the law enforcement, paramilitary, custodial settings, and religious groups.

• Discrimination in health care needs to be prioritised as it makes it difficult for PWIDs to access services (NGO leaders) • Continue to invest in advocacy and tell the stories of PWIDs to give a face to the issues (RWS)

Facilitate community mobilisation by providing adequate support/training for them to ensure that they become owners of interventions.

• Increase community knowledge of HIV, Hep C, safer injecting and safer sex (DPU) • Strengthen focus on community mobilisation in the next national plan (SACS) • Provide training in community mobilisation to staff of state TIs (SACS) • Continue to invest in community involvement and ownership building

5. Data on injecting and sexual behaviour submitted by PEs is some times incorrect. This problem is solved by cross-checking data. 6. Stigma and discrimination from the health sector, religious groups, and communities serve as barriers to service uptake. Recommendations Phase I recommendations

Phase II follow-up recommendations

Strive to attain the goal that every person belonging to the key population has access to care and ongoing prevention services.

• • • • • •

Integrate ART services in Project ORCHID programmes (DPU) Work with youth to prevent blood-related diseases (DPU) Advocate to increase continuity of government response (SACS) Expand HCV prevention and treatment Establish data reliability checks for micro-planning and OST target data (Project ORCHID team) Extend continuum of prevention and care to include social protection and impact mitigation, especially employment programmes and nutritional support for people on ART (Project ORCHID team, DPU, SACS, stakeholders meeting)

50 | Assessment of Project ORCHID, September 2011

51 | Assessment of Project ORCHID, September 2011

OBJECTIVE A: Innovations developed by Project ORCHID to effectively implement a comprehensive harm reduction package in India The Avahan/ORCHID developed two sets of innovations: improvements/additions to the existing package of harm reduction services in India; and innovations in the approach to delivering the package – in other words, innovations in the ‘what’ and ‘how’ of harm reduction delivery.

The Avahan/Project ORCHID Harm Reduction PLUS Model

Assessment Goal

Objective

A summary of the ‘PLUS’ components is listed below, with details to follow: The “What” – additions to the harm reduction package

The “How” – the approaches used for the delivery system

1. Focus on new injectors (those who have been injecting for less than three months)

1. Strong programme management and execution approach for ensuring scaled delivery

2. Customised intervention with female PWIDs

2. Use of data for local decision-making – e.g., use of micro-planning through peer based outreach

3. Provision of naloxone and other critical components of the commodity package

3. Enhanced local and state advocacy with key structural players (e.g., religious leaders, police, power structures)

4. Specialised services for female sexual partners (spouses) of PWIDs

4. Strong focus on community mobilisation including active involvement in programme design and delivery

5. Customised intervention for geographically hardto-reach PWIDs (pilot)

5. Capacity building among the institutions involved in service delivery – the NGOs 6. Flexibly responding to local barriers through innovating service models – e.g.,: a. Enhanced staffing of the NGO delivered OST programme b. Secondary distributors to ensure adequate and uninterrupted commodity supply in remote locations c. Mobile clinics are used extensively to bring services to work places, hot spots, and other locations where key populations are located d. Nurse-delivered STI services to address the unavailability of doctors in the region

Core

PLUS Components

PLUS delivery approach

Core harm reduction package (as per WHO guidelines) Innovations in the pacakage: FIDU, hard to reach, new injectors, naloxene, spouses of injectors Innovations in the delivery system: peer led microplanning, strong community mobilisation focus, local advocacy, execution focus and capacity building, flexibility in execution (e.g. mobile clinics, secondary distributors, nurse-led STI, additional OST staffing).

52 | Assessment of Project ORCHID, September 2011

53 | Assessment of Project ORCHID, September 2011

The “What” component of the innovations

The following chart reviews Avahan programmes against these approaches, notes whether services are provided directly by the implementing partners or indirectly through referrals and tracking, and highlights Avahan good practices related to these approaches.

Avahan (through Project ORCHID) has added innovations to the ‘what’ of the Indian harm reduction package to enhance services in Manipur and Nagaland: 1. Focus on new injectors (those who have been injecting for less than three months) – Because evidence had shown the high risk of these new entrants, the programme refocused on this group to influence needle sharing norms for safe injecting. 2. Introduction of female friendly harm reduction services (female PWID TI) that takes into consideration the specific needs of female PWIDs such as injection and sex work, linkages to night shelters for women, support for tackling domestic violence and sexual harassments frequently faced by female drug users. The coverage of female PWIDs increased by 76% from August 2010 to December 2011 with STI-related visits increasing two-fold during the same period (from 22.7% to 48.7%) along with other significant service uptakes in other TI service components. 3. Naloxone and other key commodities have also been added to the package of the PWID programme in Project ORCHID and these are being delivered through the community. 4. Intervention for spouses of PWIDs has been incorporated into Project ORCHID PWID TIs with the aim of generating awareness on HIV/AIDS/STI, safer practices, sexual and reproductive health, transfer of negotiation skills, and linking them to primary health care services, ICTCs, diagnosis and treatment of STIs in spouses through outreach clinics for those who are unable to visit the centres. Other women oriented services include the formation of support groups for spouses, which is expected to increase the power and control over the issues and problems faced by spouses. Coverage of spouses by the programme has increased substantially especially in Manipur (n=545), with roughly 15% of them visiting the clinic in one quarter. 5. A distinct set of services are delivered in hard-to-reach settings, such as Ukhrul in Manipur, where injectors are spread out across distant geographic areas. The pilot has been initiated via CARE in Ukhrul, and via Renth Youth Mission in Wokha. The key aspect of the intervention, which is distinct from a standard TI, involves service delivery through existing social networks of the PWIDs where they are mobilised to change their group norms and increase their service uptake from the TI. The operations of the TI such as management and service delivery are all designed as mobile units to cover PE/ORW operational areas and to ensure equity in service distribution. The pilot has been operational for about five months and has shown a considerable increase in coverage of the remote locations.

54 | Assessment of Project ORCHID, September 2011

Evidence-based Approach

Direct or Indirect

Avahan Good Practices

Community-based Outreach

Direct

• Peer educators and outreach workers • Involving KP leaders and peddlers to locate potential clients • Health camps at hot spots • Micro-planning • Outreach through social events

NSP

Direct

• Mobile clinics • Secondary distribution of commodities

OST

Direct

• Integration with TI • Family-centred interventions

HIV Counselling & Testing

Direct & Indirect

• Integration of ICTC with mobile clinics using rapid testing • Field collection of blood samples from inaccessible areas for testing at clinics

ART

Indirect

• Peer education and motivation for testing • Tracking of OST clients from testing to pre-ART to ART

STI Prevention & Treatment

Direct

• Nurse-led services • Use of community volunteers as clinic staff

Condoms Distribution

Direct

• Secondary distribution networks

Targeted IEC

Direct

• Integration of harm reduction, STI and HIV prevention messages

Vaccine, Diagnosis & Treatment for Viral Hepatitis

N/A

• Viral hepatitis is not a stated concern; however hepatitis C is a significant concern and one implementing partner has developed a peer-led hepatitis C prevention programme

Prevention, Diagnosis, Treatment of TB

Direct

• Integrated with clinic services at Shalom

Enabling Environment (Advocacy)

Direct

Attention to Needs of Female PWIDs

Direct

55 | Assessment of Project ORCHID, September 2011

• Mapping exercise with primary and secondary stakeholders as an advocacy tool • Advocacy with health to improve quality and access to care • Advocacy with social groups (Mothers’ Association, church groups) to mobilise their influence with police, policy-makers, and communities • Clear process for planning specialised services for female PWIDs

The “How “ of delivering a harm reduction package at scale in India Avahan has developed a model that is unique in “how” it plans, monitors and implements the programme:

1. As in other projects that Avahan operates, Project ORCHID applies sound business principles, micro-planning, on-course correction based on data generated by the project, and emphasis on management and intensive supervision to scale up the programme. According to key informants, implementing partners have maintained relatively flat structures that support flexibility, efficient decision-making, and inclusion of community members. There is concern that these attributes will be lost as programmes are transitioned to NACO.

2. Data use for decision-making is another aspect of this programme – based on data collected from females who inject drugs (FIDU), a separate intervention has been set up for this community. The IBBA conducted under Avahan also highlighted the gap in services and increased vulnerability of new injectors. Based on this data, innovations for new injectors have been initiated. Micro-planning is used for management, outreach planning, implementation and reporting; however, it has received mixed reviews. It is viewed as an important tool for customising services and tracking clients to ensure continuity. It has been reported to empower PEs in their work. Several informants shared concerns that, as programmes are transitioned to the state, there will be a loss of M&E resources that might negatively impact micro-planning and other data gathering. Shalom and DPU provide accompanied referrals to testing and other services. DPU maintains a detailed tracking system of clients, which is enabled by the micro-planning process. Together, these strategies help to ensure continuity of care and provide the means to identify and follow up with clients who become “lost” in the system.

Enhanced staffing of the NGO-delivered OST programme has also helped ensure quality of services to OST clients – this is in line with the government model for public health delivered OST (e.g., dedicated nurse, outreach worker, counsellor for OST, separate from the TI). This has proved to be effective in ensuring high uptake of and adherence to OST. Ensuring that clean needles and syringes reach PWIDs in the most dispersed and hard-to-reach locations through strategies such as the use of secondary distributors to improve delivery. Secondary distribution of commodities by market vendors and KP leaders helps ensure that clean needles and syringes, and condoms, are available when and where they are needed. These networks are particularly valuable in remote and dispersed regions. Placement of secondary distributors such as ex-PWIDs, petty shop keepers, etc. is used to cater to PWIDs' requirements for condoms, needle and syringes in hard-to-reach and rural areas monitored by the NGO outreach teams. During March 2010--April 2011, secondary distribution of commodities in Nagaland accounted for 10% of total needles/syringes and 14% of condoms distributed in Manipur and Nagaland. Nurse-led STI services- given the challenge of working in a resource constraint setting with scarce trained medical resources (medical doctors), the project has developed a model where trained nurses could be effectively employed to deliver the required medical services of a harm reduction services. The role of doctors is limited to supervision and those instances when a highly trained personal is needed.

4. Community mobilisation and involvement of people who inject drugs: the use of networks in all aspects of programme implementation is a central feature, resulting in improved quality, adherence and increased client uptake of services, for example, by engaging members of the community as outreach workers who are best able to motivate peers to visit clinics. The “community first” policy helps build capacity of community members to hold organisational positions. The clinic volunteer programme provides opportunities for volunteers to learn new skills and create a system of “peer progression”. a. The use of community members as service providers (peer educators, outreach workers, clinic volunteers, and secondary distribution networks) not only encourages service uptake, but also provides an environmental scanning tool to anticipate changes in risk behaviour and relocation of hot spots. b. Peer progression is considered to be well thought-out with significant numbers of peer educators ascending to the level of outreach workers.

3. Flexibility in execution, especially in light of several structural barriers to the programme a. Mobile clinics are used extensively to bring services to work places, hot spots, and other locations where key populations are located. For clients in areas far from static facilities, the mobile clinics may represent their only opportunity to receive services. The mobile clinics also serve as an outreach tool to encourage clients to attend regular clinics. RWS integrates ICTC with mobile units on a quarterly basis and offers rapid HIV testing to provide preliminary counselling, education and results on the spot. There appears to be a delay in follow-up testing, which may create anxiety for clients and enable risk-taking behaviours in the case of false negatives. DPU holds health camps at hot spots, which they credit as a useful tool for outreach and building trust with community members. Outreach/field-based clinics have substantially improved clinic attendance and referral services, such as a 50% or more rise in STI consultations; 2-3 fold increase in syphilis testing rates; and a fourfold increase in successful ICTC referrals from clinics. Timing and location of nurse-led mobile clinics are planned with the outreach team and government ICTC mobile units (where available) to maximise attendance.

A focus group of NGO leaders notes that the Project ORCHID programme has moved from community inclusion to community participation and engagement, important steps towards community ownership of the PWID and PLHIV response.

56 | Assessment of Project ORCHID, September 2011

57 | Assessment of Project ORCHID, September 2011

5.Informed dialogue with opinion leaders has reduced stigma and created a more enabling environment for effective programming. Stigma and discrimination, and the criminalisation of PWIDs, are cross-cutting issues that negatively impact access to prevention, testing, care, treatment, and social protection. In the context of Manipur and Naga land, religion and culture have contributed to deep rooted stigma and discrimination, especially influencing the attitudes and perceptions and engagement of the church and other societal and opinion leaders. Other local authorities, including the police and government health care providers, have served as barriers to prevention, treatment, and care, especially for HIV+ PWIDs. • Having received capacity building support from Avahan, several of its implementing partners report success in creating a more enabling environment for service delivery and social protection. • DPU in Manipur has carried out advocacy with stakeholders, including police, women’s leaders, local authorities, church leaders, social workers and army majors. Their approach is to sensitise stakeholders to the needs of PWIDs and explain the aims of the project. Indicators of success are that these stake holders have visited the programme and asked staff to participate in events and serve as resource persons on issues related to PWIDs and PLHIV. DPU reports that this has reduced police harassment. Furthermore, DPU OST clients have perceived a reduction in stigma over time. They report that the community now increasingly interacts with OST clients. • RWS, another implementing partner in Nagaland, has built positive relationships with the Mother’s Association and church leaders. As a result, rather than serve as barriers to programme implementation, these groups have become champions of the programme. RWS reports that the Mother’s Association has played a pivotal role in working with the police to enable distribution of needles, syringes and condoms, and reduce instances of police harassment. • RWS also has worked closely with the Baptist Theological College to sensitise its leaders to the challenges faced by PWIDs and PLHIV. As a result, the college has developed a course, and conducts community workshops, on HIV and drug use, with the expressed aim of reducing stigma and discrimination among its students and church members. The college’s key message is that PWIDs and PLHIV are precious souls that are loved by God and that the church also should love them. Whereas it was previously common for churches to excommunicate PWID and PLHIV members, they no longer engage in this practice in Naga land. It can be assumed that this reduction in stigma and discrimination increases the self-esteem of PWIDs and PLHIV, and opens them to social support, which are both important to treatment outcomes. • Project ORCHID/Dimapur has developed media messages and a series of videos (with previous funding from BBC World Service) that they have presented to village elders, elected officials and religious and social groups. Video presentations are followed by discussion and interaction with PWIDs. They report that these interventions have led to a reduction in stigma and discrimination.

DPU in Manipur has mobilised the community through numerous interventions. They utilise community volunteers at their health clinic, which leads to increased attendance by PWIDs and also increases the self-esteem of the volunteers. They have mobilised KP leaders in outreach to locate potential clinic clients. Community members participate in secondary distribution networks in geographically remote locations, ensuring consistent supplies of commodities, including clean needles and condoms. DPU also operates a peer led hepatitis C prevention programme in a geographic area where HCV infection among PWIDs is estimated at 92%. ORCHID/Manipur has established a HIV positive network to provide mutual support and promote self-help. DPU has suggested the need for improved community literacy on subjects that include HIV, hepatitis C, safer injecting and safer sex. Such a network can be utilised to do this, as well to expand community involvement in programme planning, implementation, monitoring, evaluation, and advocacy. The existing PLHIV network, MNP+, needs to be strengthened, since many informants said that it is not effective. Consideration should be given to the relative merits in achieving programme objectives through investment in capacity building and organisation development for the current network, with a sub-network focused on HIV+ PWIDs and those at risk, or in creating a new network that coordinates and partners with the existing network. Project ORCHID/Manipur reports that community involvement in programme implementation has improved quality and increased client uptake of services. They also report that outreach workers who are members of the community are effective at motivating PWIDs to visit clinics. SACS has called for a greater focus on community mobilisation in the next national plan and would like assistance from Project ORCHID to provide training in community mobilisation to the staff of state TIs.

Roadmap of Project ORCHID partners

58 | Assessment of Project ORCHID, September 2011

59 | Assessment of Project ORCHID, September 2011

Assessment Objective

•

These outcomes came about through transparent dialogue with opinion leaders and interactions between these opinion leaders and PWIDs that give a human face to the issues PWIDs confront. Dialogue, when it is grounded in mutual respect and trust, is a powerful tool to change individual values, leading to social change. The effectiveness of these dialogue interventions suggests a sophisticated approach to advocacy on the part of staff. • Discrimination by government health care providers continues to be reported, which reduces access to testing and treatment. This dynamic also is related to self-stigma among PWIDs and PLHIV; however, self-stigma can only exist in an environment marked by actual stigma and discrimination. Key informants have suggested the need to increase efforts to educate physicians about PWIDs and PLHIV in a broader health context.

6. Capacity-building is inextricably linked with community mobilisation and ownership. Project ORCHID has committed significant energy to building capacity throughout the delivery system. The focus group of NGO leaders reports high returns on this investment, with staff moving from no knowledge of harm reduction to a high degree of sophistication in the roll-out of services. Specific areas of knowledge that have been critical to achieving programme indicators include: planned outreach, abscess management, NSP, STI diagnosis and treatment, and enabling strategies. They observe a distinct difference from the SACS capacity development process of training only to an integrated system of training, skills building and reinforcement. District support teams have been critical in assessment, input to capacity development, addressing ongoing and emerging needs, and linking capacity with service delivery. • Project ORCHID’s implementing partner, Hope, has a “community first” policy to build capacity of community members to hold organisational positions. The clinic volunteer programme at DPU provides opportunities for volunteers to learn new skills, which may result in FSW volunteers becoming qualified for less risky employment and to create a system of “peer progression”. DPU reports that 70% of its employees come from the community. A focus group of stakeholders notes that networking among local organisations has provided for mutual capacity building and support. • Project ORCHID’s previous capacity building activities focused primarily on classroom-type training. In response to the mid-term evaluation, the model has transitioned towards a greater focus on workplace-based training combined with on-the-job consultation and supportive supervision. FHI provides support for centralised training. While the evaluation team did not have the opportunity to observe training and supervision during site visits, Project ORCHID/Dimapur described the process to include lectures and exercises followed by on-the-job observation and coaching. Theoretically, this represents a process appropriate for adult learners in which new knowledge is put to immediate application through exercises and skills are reinforced over time.

Assessment Objective

60 | Assessment of Project ORCHID, September 2011

61 | Assessment of Project ORCHID, September 2011

OBJECTIVE B: Documentation and Dissemination of Project ORCHID Model to Date • DPU (an implementing NGO funded by Project ORCHID) in Bishnupur has served as a regional learning site. At the height of funding in 2007, and with dedicated staff, it hosted as many as 200 visitors for periods of one to four days. Through presentations, discussions, field visits and interaction with community members, visitors learned about the programme’s outreach, community mobilisation, and service delivery programmes, with a focus on good practices contributing to programme effectiveness. Currently without funding and dedicated staff for this function, the number of visitors has decreased sharply, with only 2-3 visitors thus far in 2011. •

Project ORCHID/Manipur has developed materials including: o Guidelines on Primary Health Care Services for PWIDs and their Sexual Partners (in collaboration with FHI) o A flip chart for outreach workers and peer educators o Video: Turning the Tide: Inspiring Stories of Women Fighting the Stigma of HIV/AIDS o Video: Strumming for Freedom: Key Advocacy Material for Oral Substitution Therapy o Video: Dreams United: A Community-led Event

•

In addition, Project ORCHID has participated in local forums for dissemination in India and globally: o As part of the PWID Technical Resource Group (TRG) of NACO, Project ORCHID shared lessons which were incorporated into NACP-III guidelines, including training modules for PWIDs. o Project ORCHID received a GFATM Round 9 grant for capacity building of PWID interventions in the rest of India. o Project ORCHID is also the State Training and Resource Centre or STRC for additional states (Manipur, Nagaland, Meghalaya and Tripura and Assam)

Objective C: Challenges and Recommendations • PEs have made specific requests for additional capacity building in the areas of interpersonal communication and counselling skills. • Mr. Ashok Kumar of SACS notes that services standards need to be developed. It is not evident whether performance standards have been developed for categories of staff in the Avahan-supported programmes. In the absence of standards, it is difficult to plan, measure and justify investments in capacity building. In addition, establishment of clear performance expectations against standards is a key factor to ensure good performance. • Consideration should be given to whether micro-planning can be streamlined without detriment to achieving programme objectives. • Key populations are scattered over large geographical areas that have difficult to navigate terrain and poor communications infrastructure. This is especially the case in Nagaland, where travel distances and costs make it difficult for clients to access OST, testing, and if HIV+, OI/ART services.

• Key populations represent “hard-to-reach” populations; many are hidden. • Effects of the insurgency on programme operations (more so in Manipur than Nagaland) • Policy barriers (e.g., legal status of PWIDs) • From the perspective of PEs, micro-planning is time consuming and has limited benefit (useful for estimating demand for commodities only). From the perspective of programme managers, PEs may respond to the time consuming nature of this task by falsifying data. • PEs feel their compensation is not commensurate with their work load. • Hepatitis C is a significant, and growing, concern. • Commodity stock-outs (although both programmes in Manipur and Nagaland have found innovative ways to deal with this problem – sharing commodities between sites in Manipur, airlifts of supplies by travelling staff, early telephone notification by secondary distributors in Nagaland). • Shalom’s male PWID programme needs to focus more on reaching out to populations who do not visit the DICs. • Government rehabilitation centres do not inform PWIDs about the availability of OST. • General health services are not sufficient for the needs of PWIDs. • Limited OST hours of operation. • Employment, social activities and vocational training for youth are too limited and are risk factors for drug use (LRRC). • Some heroin users are not interested in OST. Some OST clients miss injecting activities and behaviour and find it tempting to be in the presence of current users at the centres. • Community mobilisation is not given sufficient priority under the current national plan. • Project officers have insufficient time in the field. • Fear of stigma from ICTC providers. • In Nagaland, PWIDs inject at home, making them more difficult to reach.

ANNEXURES

62 | Assessment of Project ORCHID, September 2011

63 Project ORCHID, September 2011 63 || Assessment Assessment of of Project ORCHID

ANNEX 1: Summary of Project ORCHID Outputs and Outcomes and Achievement Against These Category

Project ORCHID key target indicators

Achievements to date

Source

OUTPUT

Average monthly contact at 80%

Achieved (94% at ORCHID level; 96% Manipur, 90% Nagaland)

CMIS

Average monthly outreach through peer educator at 50% 50% of PWIDs access clinical services at least once a year

Achieved (87% ORCHID; 99% Manipur, 80% Nagaland)

CMIS

NSP exchange

Achieved (81% ORCHID; 93% Manipur, 62% Nagaland)

CMIS

50% of PWIDs, FSWs and MSM referred to ICTC 6 monthly

Achieved (ORCHID 59%; Manipur 64% and Nagaland 48%)

CMIS

50% of PWIDs tested for syphilis at least once a year

26% for ORCHID , 27% for Manipur and 24% in Nagaland

CMIS

95% of PWIDs screened for syphilis receive treatment

Achieved (48% ORCHID; 53% Manipur, Nagaland CMIS pending (41%)

Minimum of 70% of new abscess or ulcer cases identified and treated at grade 1 and 2

Not achieved (70% ORCHID; 57% Manipur, 75% Nagaland)

CMIS

90% of NGOs implementing safe disposal and disinfection guidelines

100% are identified and treated at grade 1 and 2 Nagaland= 92.25% Manipur= 87.3%

CMIS

95% of people diagnosed with STI syndromes completed appropriate treatment

Achieved (96% for ORCHID; 91% for Nagaland and 97% for Manipur)

CMIS

The number of partners of PWIDs attending the clinic for treatment to be 30% of the number of PWIDs treated for STI syndromes

ORCHID 18%; Nagaland 22%, Manipur 16%

CMIS

% of regular clients on OST

ORCHID 88.6%; Manipur 89.6%, Nagaland 83.25%

PBS, IBBA

64 | Assessment of Project ORCHID, September 2011

Category

Project ORCHID key target indicators

Achievements to date

Source

OUTCOMEBehavioural

<30% of PWIDs sharing needles/syringes in the last month

As per the PBS data, the milestone is achieved or close to being achieved in 4 of the 7 districts in Manipur and 3 of the 5 districts in Nagaland

PBS, IBBA

As per the IBBA conducted in 4 districts results (% of PWIDs sharing in last month) are: 18% in Wokha, 14% in Phek, 24% in Bishnupur and 5% in Churachandpur)

OUTCOMEBiological

>40% of PWIDs consist ently (always) use condoms with non-regular partners in previous month

Largely achieved: In all districts of Nagaland (>50%), but not in Manipur (<40%)(PBS)

>40% of PWIDs consistently (always) use condoms with regular partners in previous month

Not achieved. In Manipur, the milestone has been achieved only in Bishnupur district and in Nagaland in Wokha and Zunheboto districts

PBS, IBBA

70% of PWIDs consistently use condoms with commercial partners in previous month

Partially achieved. IBBA: Manipur - 66% in Bishnupur; 9.2% in Churachandpur. Nagaland - 100% in Phek

IBBA

High titer syphilis reduced by at least 50% in IBBA2 compared to IBBA1

Not achieved.

IBBA

NG and CT less than 5% in at least 80% of the districts among FSWs and PWIDs in IBBA2 and IBBA 3

Achieved. Trends in both the districts of Manipur have remained stable and low (Bishnupur CT is 1% and NG 0%; CCP CT is 1.9% and NG 0.7%). In Nagaland, we see significant declines in STIs in Wokha (CT from 5.6% to 2.8%; NG from 1.6% to 0.4%), but increases in Phek district (CT from 11.4% to 12.5%; NG from 0.6% to 2.0%)

IBBA

Significant declines in HIV among PWIDs between IBBA R1, R2 and R3

Mixed results: In Manipur, significant decline in HIV in Bishnupur district (23.1% to 16.2%), but increase in Churachandpur (from 32.2% to 39.9%). In Nagaland, in both Phek (~1%) and Wokha (~2%) levels remain low and stable.

IBBA (Round 3 is pending and will be conducted in mid2012)

65 | Assessment of Project ORCHID, September 2011

PBS, IBBA

IBBA: Increased in Manipur (29% to 49% in Bishnupur, 32% to 42% in Churachandpur), with mixed results in Nagaland (declined from 40% to 30% in Wokha, increased from 32% to 57% in Phek)

ANNEX 2: Project ORCHID Phase II - Avahan Milestones

ANNEX 2: Project ORCHID Phase II - Avahan Milestones No. Milestone

Definition

At least 80% of registered FSWs, MSM and PWIDs contacted through DIC, outreach or clinic every month.

Over 50% of outreach contacts made through peer educators.

Numerator

Denominator

Source

No. Milestone

This is the number of Total number of individuals (a head count), individual KPs not the number of episodes. contacted through DIC, outreach and This means that every month clinic in a given at least 80% of active month. registered key population (KPs) should be reached/contacted by at least one kind of service.

Total number of active KP registrations in that same given month.

ORW/PE logbooks

Out of the total number of individuals contacted through outreach, more than 50% should be contacted by PEs.

Total number of ORW/PE individuals contacted logbooks through outreach by ORWs and PEs combined.

Total number of individuals contacted through outreach by PEs.

Individuals tracking

At least 60% of MSM Syphilis/VDRL test. and FSWs (including PWID/SW) get tested for syphilis 6-monthly.

Number of individual MSM and FSWs (including PWID/SW) tested for syphilis in a 6-month period (using ICST rapid test).

Total number of Syphilis testing active individual MSM register and FSWs, PWID/SW registrations in the same 6-month period.

At least 50% of PWIDs get tested for syphilis annually.

Syphilis/VDRL test.

Number of individual PWIDs tested for syphilis annually (using ICST rapid test).

Total number of active individual PWID registrations in the same 12-month period.

At least 30% of MSM receive an internal examination quarterly.

‘Internal examination’ means a speculum examination. Only receptive and ‘double decker’ partners require an internal examination.

Number of receptive and ‘double decker’ partners receiving an internal examination.

Total number of MSM Daily clinic registered. register

At least 50% of ‘Internal examination’ means Number of FSWs FSWs (and a speculum examination. receiving an internal PWID/SW) receive an examination. internal examination quarterly.

Total number of active individual FSW registrations in the same quarter.

Syphilis register Daily clinic register

At least 95% of those Tested positive for syphilis who tested positive complete treatment. for syphilis complete treatment.

Number of KPs who tested positive for syphilis and completed treatment.

Total number of KPs who tested positive for syphilis.

Syphilis register Daily clinic register

Minimum of 50% of Only new abscess or ulcer new abscess or ulcer cases. cases identified and treated at grade 1 and 2.

Number of new PWID abscesses treated at grade 1 and 2.

Total number of new abscess cases.

Abscess register

Individuals tracking

At least 80% of KPs receiving 1-1 HIV/STI female sex workers, prevention communication PWIDs and MSM given by ORW or PE. receiving 1-1 HIV/STI prevention communication monthly.

Total number of individuals receiving 1-1 HIV/STI prevention communication in a given month.

Total number of active KP registrations in that same given month.

At least 50% of PWIDs access clinical services at least once a year.

This means that 50% of PWIDs access any clinical service at least once in a year (any clinical service, not just STI services).

Number of PWIDs attending clinical services at the centre or receiving clinical services in the field.

Total number of Daily clinic active individual register PWID registrations in the year.

At least 70% of MSM and female sex workers and PWID/SW access sexual health related services quarterly.

‘Access’ means a consultation, which may or may not result in treatment.

Number of individual MSM and FSWs (and PWID/SW) who accessed sexual health services in the quarter.

Total number of active individual MSM, FSWs, PWID/SW registrations in the quarter.

A sexual health consultation includes any STI check-up, asymptomatic treatment, regular monthly check-up, follow-up visits, etc.

Denominator

Clinic register

For example, if the total number of individuals contacted through outreach (by ORWs and PEs) is 500 in a month, over 250 of these individuals should have been contacted by PEs. 3

Numerator

DIC register

Definition

ORW/PE logbooks Individuals tracking

Daily clinic register

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Source

Syphilis testing register

ANNEX 2: Project ORCHID Phase II - Avahan Milestones

ANNEX 2: Project ORCHID Phase II - Avahan Milestones No. Milestone

Definition

Numerator

12 80% of NGOs implementing safe disposal and disinfection guidelines.

Using the developed assessment tool, each NGO to be allocated a score. A score of 80% or above means they are successfully implementing the guidelines. The milestone is actually that at least 80% of NGOs will score at least 80% on the standardised assessment. The score is at the NGO level not at the clinic level (bearing in mind that some NGOs have more than one clinic) – all clinics should score 80% or above for the NGO to score 80% or above.

Number of NGOs Total number of implementing safe NGOs. disposal and disinfection guidelines (i.e., number scoring 80% or above on the assessment).

13 95% of people diagnosed with STI syndromes completed appropriate treatment.

This is interpreted as ‘completed appropriate treatment’ in the case of clinic-administered injections, but can be interpreted as ‘received appropriate treatment’ in the case of ongoing oral therapy that is taken away from clinic. ‘Appropriate treatment’ is as per clinic treatment guidelines.

Number of KPs diagnosed with an STI syndrome who complete treatment.

Total number of KPs diagnosed with an STI syndrome.

Daily clinic register

14 100% of MSM and FSWs (and PWID/SW) attending the clinic for the first time receiving asymptomatic treatment.

Only the first time receiving asymptomatic treatment.

Number of MSM and FSWs (and PWID/SW) visiting the clinic for the first time who received asymptomatic treatment.

Total number MSM and FSWs (and PWID/SW) visiting the clinic for the first time.

Daily clinic register

15 The number of clients of FSWs attending the clinic for treatment to be 60% of the number of FSWs treated for STI syndromes.

‘Clients’ are defined as all sexual partners (i.e., regular/non-regular and commercial/noncommercial).

Number of clients of FSWs treated for STI syndromes (regular/non-regular and commercial/ non-commercial).

Total number of FSWs treated for STI syndromes.

Daily clinic register

Denominator

Source Project ORCHID assessment to be done annually

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No. Milestone

Definition

Numerator

Denominator

Source

The number of partners of PWIDs attending the clinic for treatment to be 60% of the number of PWIDs treated for STI syndromes.

‘Partner’ is defined as all regular/non-regular.

Number of PWID partners treated for STI syndrome (regular/ non-regular and commercial/noncommercial.

Total number of PWIDs treated for STI syndromes.

Daily clinic register

50% of PWIDs, FSWs, and MSM referred to ICTC monthly.

‘Referred’ means the person Number of individuals Total number of active individual KPs attended for testing and was KPs referred to ICTCs and actually registered. tested. tested.

At least 95% of suspected TB cases (on the basis of TB screening at the clinic) have been successfully referred to the Revised National Tuberculosis Control Programme (RNTCP).

‘Successfully referred’ means that the person attended the RNTCP clinic, regardless of the outcome of the consultation.

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Number of individuals Total number of suspected TB cases. KPs referred to RNTCP who actually attend.

Referral register

Avahan TB record Referral register

ANNEX 3: Case Studies

ANNEX 4: Methodology for Project ORCHID Assessment in Manipur and Nagaland Project ORCHID background: Project ORCHID (Organised Response for Comprehensive HIV Interventions in selected high-prevalence Districts of Manipur and Nagaland) was initiated in May 2004 as collaboration between EHA and AIHI, now Nossal Institute for Global Health, University of Melbourne. The project received funding from Avahan, Bill & Melinda Gates Global Health Foundation. Project ORCHID has been working to reduce transmission of HIV and STI among people who inject drugs (PWID), female sex workers (FSWs), men who have sex with men (MSM) and their sexual partners through a response of increased scale and coverage in selected high-prevalence districts and townships of Manipur and Nagaland in Northeast (NE) India. Project ORCHID completed Phase I in March 2009 (2004-09) and is now in Phase 2 (2009-13). The goal of this Phase II grant is to: (1) consolidate HIV/AIDS prevention services among PWIDs, FSWs and MSM, (2) transfer the programme to the community and government, and (3) disseminate learnings within and beyond India. It is worth noting the foundation’s investment in the Northeast was done with the key objective of building and disseminating a “model” PWID programme rather than scaling up services to ensure coverage of more than 80% of all HRGs and thereafter achieving epidemic impact at the state level. The reasons for this paradigm were several. First, comprehensive PWID programmes in India were nascent and a good model needed to be created and thereafter disseminated within India and beyond. Second, given the challenging sociopolitical-geographic environment of the Northeast, a large-scale presence of the foundation was not optimal and feasible. Third, with limited, rather than scaled programmatic engagement, aiming for state level epidemic impact was unrealistic.

Benefits of OST to Clients’ Families OST is a treatment that not only saves the lives of people who inject drugs and reduces their vulnerability to HIV and other illnesses; it also provides the means to improve the lives of families and communities that are affected by injecting drug use. At DPU in Manipur, we heard the stories of male OST clients and their families. Before OST, the clients spent each day focused on where they would get their next fix. Not only were they unable to do productive work, most drained family resources that should have been used to support basic needs and their children’s educations. Some turned to crime to support their habits and family life became a round of crises and conflicts. They were shunned by their communities. At DPU, the clients received not only treatment, but counseling and peer support. And their families were encouraged to become part of the treatment process. With the help of DPU, clients are now able to be responsible and productive family members. Their wives report that their husbands are more dependable and contribute to family income. Domestic conflicts have sharply reduced. The wives support their husbands by reminding them to keep scheduled appointments, and extended family members have paid travel costs to attend the clinic. Whereas once the families knew only problems, now they have opportunities for happiness.

Giving Back to the Community

Profile Target population: 10,800 PWIDs, 1,520 OST clients, 3,250 FSWs, 1,450 MSM during 2011-12. The Project ORCHID intervention covers 13 districts (7 Manipur, 6 Nagaland) and there are 30 intervention sites with 24 implementing partners (23 in Manipur, 23 in Nagaland). The number of drop-in centres is 46 (30 in Manipur, 35 in Nagaland) and the number of project clinics is 38 (all are within the DICs).

The DPU clinic utilises volunteers from the community to provide services. As members of the community, their presence encourages others to obtain clinic services, knowing that they will be served by people who understand their lives and will not discriminate against them. The volunteers, who have experienced stigma because of drug use and sex work, are eager to give back to the community, even when it interferes with opportunities to generate income. At the clinic, they are appreciated and valued, and they are learning new skills they can apply in the future. One of the volunteers offered, “When I come here, I know that I am doing something of value; I am contributing something important to the community, and then I value and respect myself.”

Of the total mapped PWID population, Project ORCHID covers 54% in Manipur and 28% in Nagaland (MACS target 2011-12= 18,700; Project ORCHID Manipur=6,400; NSACS target 2011-12=14,135, Project ORCHID Nagaland= 4,400). HIV services provided to the PWID community The services provided to the community through the Avahan programme include a broad spectrum of harm reduction services including: clean needles and syringes and safe disposal (NSEP); counselling and outreach services; abscess treatment; STI diagnosis, counselling and treatment; free condoms; referrals and linkages to government-delivered treatment/testing services (ICTC, ART, TB), safe space in project DICs, and overdose management.

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At the time that the project was initiated (2003), OST was not part of the national guidelines. Thus, the project did not include this in the initial five years of implementation. However, during the first five years, Project ORCHID received support from DfID and then NACO for OST delivery for 1,800 PWIDs. OST was then added to the Project ORCHID second phase proposal to scale up this service in both states. However, delivery of this OST was withheld by the foundation given the fact that NACO policy at the time (2009-11) was to ‘freeze’ scale-up of OST in NGO settings, awaiting the roll-out results from the Government Setting model. Given the Avahan programme was to transition to the Government, the decision was made to not provide additional OST through Avahan NGOs, given the potential lack of ‘takeover’ by the government in the future. Since 2009, Project ORCHID has played a significant role in advocating for NGO-delivered OST in Manipur and Nagaland based on their experience.

Objectives of the Assessment Goal

Objectives

1. Determine whether Project ORCHID is on track to achieve intended programme outputs, and outcomes of Phase II.xiv

A. Are the monitoring and evaluation indicators and methods used by the programme appropriate? What has been adapted so far and what can be done differently? B. To measure if programme milestones of Phase II Project ORCHID project are on track C. To find out if all the key recommendations suggested were adopted and implemented from Phase I Project ORCHID review D. To identify challenges faced by Project ORCHID in implementing these key recommendations suggested from the Phase I review E. To document the challenges faced by Project ORCHID in achieving or not achieving Phase II milestones

2. Determine whether Project ORCHID developed unique implementation principles (a ‘model’) that enhances implementation efficiency and effectiveness of a universal harm reduction package and capture these.xv

A. Identify key principles of the Project ORCHID ‘model’ that advance harm reduction delivery strategies a. What delivery strategies (for NSP, condoms and clinic services) did it use to ensure that it would effectively reach its target population (in urban and dispersed areas)? How do these strategies compare to other harm reductions programmes (within and outside India)? b. What advocacy strategies did Project ORCHID employ to pave the way for delivery of harm reduction services? Related to this--how were stakeholders engaged and partnerships perceived/formed? c. How did the programme engage community to ensure uptake of services? d. What programme management and capacity building approaches did they use to increase efficiency and effectiveness of programmes? B. Determine if there has been any effort to document, and disseminate and identify the mechanisms for dissemination within and outside of India – whether this has been adequate. C. Make key recommendations to Project ORCHID on how to better disseminatexvi the ‘model’ (key principles) and what domain if any.

Target population for assessment The assessment will focus on people who inject drugs (male and female) in the ORCHID project. Documents to be provided to reviewers 1. Background reading a. Avahan ORCHID monograph b. Mid-term Project ORCHID assessment report – evaluation conducted by Drs. Suresh Kumar, Sundararaman and Sushena Reza Paul c. All peer reviewed and non-peer reviewed publications from Project ORCHID 2. Programme data and epidemic data a. Programme indicators for Project ORCHID (Avahan’s P2 format) b. Programme indicator analysis (output) c. HIV epidemic analysis for Manipur and Nagaland d. Programme outcome analysis e. Integrated Biological and Behavioural Surveys for select Avahan districts in Manipur and Nagaland 3. Logistics for the visit a. TOR b. Agenda for the evaluation c. District profiles (districts to be visited in Manipur and Nagaland)

Goal

Goals of Assessment Goal 1 Determine whether Project ORCHID is on track to achieve intended programme outputs and outcomes (programme coverage and quality vs. milestones/intended coverage). Goal 2 Determine whether Project ORCHID developed unique implementation principles (a ‘model’)xiii that enhance implementation efficiency and effectiveness of a universal harm reduction package and capture these.

xiv We are currently two years into Avahan Phase II (2009-13). Therefore, this goal is ongoing and we are assessing progress against this goal. xv The Project ORCHID model should have been achieved by now and dissemination should be in progress. xvi For example, within and outside India.

xiii Project ORCHID is implementing a universa harm reduction package. “Model” refers to innovations in delivery, management and data to make the provision of services more effective and efficient.

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ANNEX 5: Terms of Reference and Scope of Work for External Evaluation of Project ORCHID

Expected recommendations from the evaluators: 1. What lessons of Project ORCHID are immediately generalisable and should be offered to NACP-IV, World Bank, UNAIDS (among others) and what could it do better to be generalisable in the future? 2. Whether the approach is generalisable or not, what should Project ORCHID do to increase the effectiveness and impact of its programme?

Nature of Work: Conducting field visits in Manipur and Nagaland and desk review Timelines: Approximately 10 days in the months of September and October, 2011 Background of Project ORCHID: Project ORCHID (Organised Response for Comprehensive HIV Interventions in selected highprevalence Districts of Manipur and Nagaland) was initiated in May 2004 as collaboration between EHA and AIHI, now Nossal Institute for Global Health, University of Melbourne. The project received funding from Avahan, Bill & Melinda Gates Global Health Foundation. Project ORCHID has been working to building capacity of local implementers and to reduce transmission of HIV and STI among people who inject drugs (PWIDs), Female Sex Workers (FSWs), men who have sex with men (MSM) and their sexual partners through a response of increased scale and coverage in selected high -prevalence districts and townships of Manipur and Nagaland in Northeast (NE) India. Project ORCHID completed Phase 1 in March 2009 (2004-09) and is now in Phase II for another five years. Goal of the Assignment: To conduct an external assessment of Project ORCHID for the period 2008 to 2011 with special focus on people who inject drugs (PWIDs) and make observations and recommendations in two key areas: 1. Determine whether Project ORCHID is on track to achieve intended programme outputs and outcomes (programme coverage and quality vs. milestones/intended coverage). 2. Determine whether Project ORCHID developed unique implementation principles (a ‘model’)xvii that enhance implementation efficiency and effectiveness of a universal harm reduction package and capture these. Overall Scope of Work for Evaluators: The evaluation of Project ORCHID will be facilitated by SCOPE consultants, with the involvement of four technical experts: Drs. Suresh Kumar, Swarup Sarkar, Mariam Claeson, and Sundar Sundararaman. While the evaluators will reflect on all the major objectives of the evaluation, each of the technical experts will be responsible for ‘leading’ select aspects of the overall effort. SCOPE consultants will compile daily notes, debriefing notes, and draft the report based on inputs from the technical experts during their visit. The team leader for the evaluation will be Dr. Sundar Sundararaman.

xvii Project ORCHID is implementing a universal harm reduction package. “Model” refers to innovations in delivery, management and data to make the provision of services more effective and efficient.

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The objectives of the evaluation and the activities expected of the evaluators are outlined below. Lead responsible

Goal

Evaluation objective

Goal 1

a. Review of data sources and A. Are the monitoring and monitoring/evaluation tools and evaluation indicators and methods used till date and determine methods used by the programme whether they are the most appropriate appropriate? What has been adapted so far and what can be done differently?

Goal 2

Specific evaluator role

Dr. Suresh Kumar/ Swarup Sarkar

B. To find out if all the key recommendations suggested were adopted and implemented from Phase I Project ORCHID review

b. Epidemiological review of Manipur/Nagaland and review of HIV outcomes in key Project ORCHID intervention areas (IBBA review, ANC analysis)

C. To identify challenges faced by Project ORCHID in implementing these key recommendations suggested from the Phase I review

c. Assessment of programme achievements against intended objectives

D. To measure if programme milestones of Phase II Project ORCHID are on track

d. Programme coverage and quality in intervention areas – progress and challenges

d. Dr. SureshKumar

E. To document the challenges faced by Project ORCHID in achieving or not achieving Phase II milestones

e. Programme management by Project ORCHID – principles and practice

e. Dr. Mariam Claeson

A. Identify key principles of Project ORCHID ‘model’ which advance harm reduction delivery strategies

Project ORCHID ‘model’ description (if any) and extrapolation of lessons worth disseminating to other settings/programmes

Drs. Sundar, Mariam and Swarup

b. Dr. Swarup Sarkar

c. Dr. Swarup Sarkar

B. Determine if there has been any effort to document and dissemnate, and identify the mechanisms for dissemination within and outside of India – whether this has been adequate

A description of the specific areas of inquiry (evaluator roles) is outlined below: a. Project ORCHID ‘model’ description (if any) and extrapolation of lessons worth disseminating to other settings/programmes  Describe the Project ORCHID ‘model’ if any, how it is unique, if at all  Describe individual components of this ‘model’ if any  Document lessons for other programmes/geographies b. Review of data sources and monitoring/evaluation tools and methods used till date and determine whether they are the most appropriate  Review monitoring tools used (e.g., CMIS) and understand uses and challenges  Review surveys used by the project to collect behavioural and biological data  Summarise lessons from these tools and make recommendations based on findings c. Epidemiological review of Manipur/Nagaland and review of HIV outcomes in key Project ORCHID intervention areas (IBBA review, ANC analysis)  Review trends and levels of epidemic in Manipur and Nagaland  Review trends and levels of the epidemic in general population and PWIDs in Project ORCHID intervention geographies d. Assessment of programme achievements against intended objectives  Review Project ORCHID grant objectives  Summarise progress against these key objectives (could include findings from areas c, d, e below, in addition to additional findings) e. Programme coverage and quality in intervention areas – progress and challenges  Review programme reach and coverage  Review programme quality indicators  Identify areas which are strengths of the project (including innovations)  Identify challenges in the project, steps taken to address them if any, pending issues to address f. Programme management by Project ORCHID – principles and practice  Review and assess the role Project ORCHID has played as a programme manager  Identify key areas of strength of the programme management  Identify key challenges/weakness in the programme management and provide recommendations to strengthen further

C. Make key recommendations to Project ORCHID on how to better disseminatexviii the ‘model’ (key principles) what domain if any xviii For example, within and outside India.

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Annex 6: Relevant Data Sources for Project ORCHID

Description of Work: 1. Assist in analysis of project data against key indicators to assess progress and outcome of the original objectivesxix.

Data type

Data sources

Description

Districts available for

Time periods available for

2. Visit field sites in both Manipur and Nagaland and assess the quality of service delivery mechanism â&#x20AC;&#x201C; DIC, STI services, commodity distribution, OST, referrals and advocacy initiatives, etc.

HIV prevalence data

HSS-ANC

HIV prevalence data collected from pregnant women attending antenatal clinics as part of the annual sentinel surveillance (~400 samples/site/year)

All

2003-2008

HSS-HRG

HIV prevalence data collected from HRGs as part of the annual sentinel surveillance (~250 samples/site/year)

Select districts: HSS-PWID districts in Manipur = Bishnupur, Churachandpur and Imphal West ; HSSPWID districts in Nagaland= Wokha, Mokokchung, Phek, Dimapur, Kohima, Mon, Tuensang and Zunheboto

2003-2008

PPTCT

HIV prevalence data collected from all women attending government antenatal clinics (much larger and more comprehensive sample set than HSS-ANC)

All

2007 - 2010

VCTC

HIV prevalence from men and women attending VCTC sites

All

IBBA (integrated behavioural and biological assessment)

HIV prevalence HCV prevalence Syphilis prevalence

2007 (IBBA round I) and 2009 (IBBA round II) in select districts of Avahan states. Data on PWIDs from two districts of Manipur (Churachandpur, Bishnupur) and two districts of Nagaland (Wokha, Phek) â&#x20AC;&#x201C; but only males

3. Synthesise findings against goals and objectives in a final evaluation report.

Biological data

xix Much of the analysis will be conducted by the external support team (SCOPE and other external consultants).

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2007 - 2010

2007 (IBBA-R1); 2009 (IBBA- R2)

Data type

Data sources

HBehavioural PBS (polling booth data on survey) PWIDs

BTS (behavioural tracking survey)

Programme output indicators

PWID mapping data

Project ORCHID/Avahan CMIS

Several

Description

Districts available for

Time periods available for

Collects behavioural data All TIs/districts at the level of intervention using the polling booth method. Even though this is a convenience sample, the responses from PBS tend to be more valid/honest compared with other methods as there is no social desirability bias seen in F2F interviews.

Round 1 data not valid. Data from round II available for all districts

Behavioural survey collected from F2F interviews. Looks at sexual behaviour and injection patterns among PWIDs.

2007 and 2009 for PWID

PWID data (only males) was collected in Kiphire and Zunheboto in Nagaland, and Ukhrul and Chandel in Manipur

Routinely collected All programme data from all TIs (data collected by doctors/nurses at clinics on uptake of clinical services, by PEs on outreach, etc.). Data are entered at the TI level into the Project ORCHID CMIS by the M&E officer from the clinic registries and outreach forms. Data quality checks are conducted by Project ORCHID routinely. Data are uploaded into the Avahan and NACO CMIS on a monthly basis.

2008 onwards (CMIS issues were there in Phase I, reliable data are available only from last year of Phase I onwards)

Size estimation and All mapping were conducted to understand the denominator of PWIDs in each district and structure of networks to enable effective programme planning and outreach.

Details found in the Project ORCHID report (PWID validation)

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ABBREVIATIONS AIDS

Acquired immune deficiency syndrome

ART

Antiretroviral therapy

CBO

Community-based organisation

CMP

Common Minimum Programme

DfID

Department for International Development

DIC

Drop-in centre

EHA

Emmanuel Hospital Association

FIDU

Female injecting drug user

FSW

Female sex worker

FWID

Females who inject drugs

HCV

Hepatitis C virus

HIV

Human immunodeficiency virus

HRG

High-risk group

HRP

Harm reduction programme

ICAAP

International Congress on AIDS in Asia and the Pacific

ICTC

Integrated counselling and testing centre

IDU

Injecting drug user

IHRA

International Harm Reduction Association

Implementing partner

KAP

Key affected populations

Key population

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M&E

Monitoring and evaluation

MSM

Men who have sex with men

NACO

National AIDS Control Organisation

NGO

Non-governmental organisation

NSEP

Needle and syringe exchange programme

Opportunistic infection

ORW

Outreach worker

OST

Opioid substitution therapy

Peer educator

PLHIV

People living with HIV

PWID

People who inject drugs

SACS

State AIDS Control Society

SHALOM

Society for HIV/AIDS and Lifeline Operation in Manipur

Spasmo proxyvon

SRH

Sexual and reproductive health

STD

Sexually transmitted disease

STI

Sexually transmitted infection

Sex worker

UNAIDS

Joint United Nations Programme on HIV/AIDS

UNODC

United Nations Office of Drugs and Crime

VCCT

Voluntary confidential counselling and treatment

WHO

World Health Organisation

REFERENCES

82 | Assessment of Project ORCHID, September 2011

Harm Reduction and Human Rights: The Global Response to Injection-Driven HIV Epidemics. Submission to the Office of the High Commissioner for Human Rights for the biennial report on HIV/AIDS requested by the Commission on Human Rights Resolution E/CN.4/RES/2005/84. 17 November 2008.

Regional overview of HIV, HIV and AIDS Data hub, Asia and Pacific. http://www.aidsdatahub.org

Kumar R, Mehendale SM, Panda S, et al. 2011. Impact of targeted interventions on heterosexual transmission of HIV in India. BMC Public Health. 2011 Jul 11;11:549.

Avahan. Avahan â&#x20AC;&#x201C; The India AIDS Initiative: The business of HIV prevention at scale. Bill & Melinda Gates Foundation: New Delhi, 2008.

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10 Avahan. From Hills to Valleys: Avahan’s HIV prevention program

among injecting drug users in Northeast India. Bill & Melinda Gates Foundation: New Delhi, 2009.

11 Avahan. Avahan – The India AIDS Initiative: The business of HIV prevention at scale. Bill & Melinda Gates Foundation: New Delhi, 2008. 12 Avahan. Avahan – The India AIDS Initiative: The business of HIV prevention at scale. Bill & Melinda Gates Foundation: New Delhi, 2008.

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