India HIV/AIDS Resource Centre
National AIDS Control Organisation
Ministry of Health & Family Welfare, Government of India

It is estimated that more than 90% of HIV transmission in India is related to unprotected sexual intercourse or sharing of injecting equipment between an infected and an uninfected individual. The most effective means of controlling the spread of the HIV epidemic in India is through the implementation of Targeted Interventions (TIs) amongst persons most vulnerable to HIV/AIDS, people belonging to High Risk Groups (HRGs) such as Female Sex Workers (FSWs), Men who have Sex with Men (MSM) and Transgenders (TGs) and Injecting Drug Users (IDUs). In addition, the Bridge Populations of truckers and migrants also require focused interventions as broader transmission of HIV occurs through these sexual partners of HRGs, who also have lower-risk sexual partners in the general population. They are known as 'Bridge Population', because they form a transmission bridge from the HRG to the general population.

Targeted Interventions (TIs) with specific strategies and deliverables have been designed to focus on five major components to reach the goals of controlling and reversing HIV/AIDS:

  - Behaviour Change Communication (BCC)

   - Treatment for Sexually Transmitted Infections (STI )

   - Distribution of condoms and other risk reduction materials

   - Ownership building

   - Creating an enabling environment

   - Needle syringe exchange programme

   - Opioid Substitution Therapy (OST)

   - Employer Led Model (ELM) of intervention amongst migrants

Key Components
I. Target Groups:

A. Core High Risk Groups (HRGs): Groups or networks of individuals who have a higher number of sexual partners or share injection equipment have higher levels of risk of contracting as well as spreading HIV infection to other population groups and are designated as “High Risk Groups” (HRG).There are three core HRGs — Female Sex Workers  (FSWs), high risk Men who have Sex with Men and Transgenders (MSM and TGs), and Injecting Drug Users (IDUs).

 

       

Female Sex Workers (FSW)
For the purpose of Targeted Interventions (TIs), a Female Sex Worker (FSW) is an adult woman, who engages in consensual sex  for money or payment in kind, as her principal  means of livelihood. The relative importance of FSWs as an HRG is consequential to their  having many sexual partners concurrently. The numbers of clients leads to a  substantially higher prevalence of HIV among them than  in the general population.

Men who have Sex with Men (MSM)
MSM is used to denote all Men who have Sex with other Men as a matter of preference,regardless of their sexual identity or orientation and irrespective of whether they also have sex with women or not. MSMs are also highly vulnerable to HIV and a strategically important group for focusing HIV prevention programmes as some, though not all, MSM sub-populations do have high rates of partner change as well as high number of concurrent sexual partners; and those that often engage in anal sex with multiple partners.

Injecting Drug Users (IDUs)
HIV is highly transmissible through the sharing of needles and other injection equipment as a result of which, it can spread very rapidly amongst IDUs who may inject drugs, then fall back into non-injecting drug use (e.g. oral), or abstinence, and then return to injecting drug use. IDUs are another HRG for which TIs are of critical importance as some IDUs are also sex workers and once HIV prevalence is high in the IDU population, it can expand quickly into the larger high risk sexual networks.

Transgender Groups (TG/ Hijra)
Hijras belong to a distinct socio-religious and cultural group, a ‘third gender’ (apart from male and female). They dress in feminine attire (cross-dress) and are organised  under seven main gharanas (clans). For the purposes of TIs, hijras are covered under the term ‘trans-genders’ or TGs.

B. Bridge Populations: The broader transmission of HIV beyond high-risk groups (FSWs, MSM, Transgenders and IDUs) often occurs through their sexual partners, who also have lower-risk sexual partners in the “general” population. Bridge populations  are formed of people, who, through close proximity to HRGs are at the risk of contracting HIV, particularly clients of sex workers. Truckers and migrant labourers form a major section of bridge populations. They are a  critical group because of their ‘mobility with HIV’.


Trucker
Evidence shows long-distance truck drivers who spend months at a stretch on  highways, being away from their family are  likely to engage in high-risk sexual behaviour and may have multiple sexual partners, including Female Sex Workers (FSWs) and male sexual partners. These may be casual partners on the highways, or other fixed partners en route. Resulting in higher  prevalence of Sexually Transmitted Infections and greater vulnerability to HIV among truckers Because long-distance truckers  move throughout the country, those who are at higher risk of HIV can form transmission “bridges” from areas of higher prevalence  to those of lower prevalence.

Migrants
In developing countries an increasing number of poor illiterate people, mostly single males, are moving from rural areas to work in cities. Earning little money, isolation and a greater sense of anonymity makes them highly vulnerable to patterns of behaviour like alcohol, drug-use and unprotected sex with persons having unknown sexual history, in turn making them vulnerable to HIV infections.Migrants have two major routes of mobility: from rural to urban areas and between rural areas. Along with truckers, they are bridge populations requiring a specific HIV response.

C. Other Vulnerable Populations: Risk groups in rural areas, HIV affected children, youth 15-19 years old and women. This is discussed further in the section on link workers.

. Tasks, Personnel and Structures:
NACP focusses on implementing TIs through NGOs and CBOs. The NACO has developed  NBO/CBO Guidelines and Guidelines on Financial and  Procurement systems for NGOs/CBOs. These guidelines enable SACS/TSUs to establish procedures for applications, partner identification, appraisal and contracting, capacity building of partners, monitoring and evaluation. SACS’ recruit suitable NGOs, CBOs or networks following the processes laid out in the guidelines endeavouring  to saturate coverage of the HRGs mapped and estimated in the State. SACS plans,monitors and manages  TIs through partner organisations. SACS ensures adequate resources to accomplish goals as well as the minimum quality of interventions. SACS provides support and necessary mentoring to achieve its objectives. It reviews and monitors all partner organisations toidentify gaps in TIs  and address them.

TSUs oversee the implementation of TIs in the respective States along with SACS and facilitate its execution along with partner organisations.

III. Services:

Core groups: Through the TIs under NACP Female Sex Workers (FSWs), highrisk Men Who Have Sex With Men and Transgenders (MSM and TGs), and Injecting Drug Users (IDUs) receive a comprehensive package of preventiveservices, including treatment for Sexually Transmitted Infections (STI), distribution of condoms and other risk reduction materials, needle syringe exchange programme, Opioid Substitution Therapy (OST) etc. State AIDS Control Societies (SACS) are expected to saturate coverage of these groupsbefore moving on to cover other groups.

 

Bridge Populations: Interventions for Bridge Populations particularly focus on clients of sex workers who receive acombination of services including condom promotion, referrals to clinical services for STI management and Behaviour Change Communication (BCC). Specific strategies have been outlinedto approach two major populations within the bridge population: truckers and high risk migrants. The HIV prevention program with truckers has 4 major strategies i.e. enhancing their knowledge on the issue and motivating them to adopt safe sexual practices, treatment of STIs among long-distance truckers, promotion of condoms through social marketing, increasing the involvement of CBO in the planning, management, and monitoring of the project program.

 

 

Intervention programmes amongst migrants target both transit and destination points using community-based intervention points at grass-root level, as well as behaviour change through massive awareness creation and increasing the accessibility of condoms at the community level. The Employer-led Model of interventions also helps in building capacity within government, corporate and private institutions, specifically focusing on migrant informal workers.

 

Thematic Area: